Predictors of Follow-Up Appointment No-Shows Before and During COVID Among Adults with Type 2 Diabetes.

Background: The coronavirus disease 2019 (COVID-19) pandemic has rapidly transformed health care delivery into telehealth visits. Attending regular medical appointments are critical to prevent or delay diabetes-related complications. Although telehealth visits have addressed some barriers to in-person visits, appointment no-shows are still noted in the telehealth setting. It is not completely clear how the predictors of appointment no-shows differ between in-person and telehealth visits in diabetes care. Objective: This retrospective study examined if predictors of appointment no-shows differ (1) between pre-COVID (January 1, 2019-March 22, 2020) and COVID (March 23, 2020-December 31, 2020) periods and (2) by health care delivery modes (in-person or telehealth visits) during COVID among adults with type 2 diabetes mellitus (T2DM). Methods: We used electronic health records between January 1, 2019 and December 31, 2020 across four diabetes clinics in a tertiary academic hospital in Baltimore, Maryland. Appointments marked as completed or no-show by established adults with T2DM were included in the analyses. Results: Among 7,276 appointments made by 2,235 patients, overall appointment no-show was 14.99%. Being older and White were protective against appointment no-shows in both unadjusted and adjusted models during both time periods. The interaction terms of COVID periods (i.e., pre-COVID vs. COVID) were significant for when glycated hemoglobin drawn before this visit and for missing body mass index. Telehealth visits during COVID decreased more half of the odds of appointment no-shows. Conclusions: In the context of diabetes care, the implementation of telehealth reduced appointment no-shows. Future studies are needed to address social determinants of health, including access to internet access, to further reduce health disparities among adults with T2DM.

Patient Engagement in Diabetes Care: Missed Appointments Among Adults Living with Type 2 Diabetes

OBJECTIVES/GOALS: Missed appointments (MAs) negatively impact the health outcomes of adults living with type 2 diabetes mellitus (T2DM), causing disruptions in clinic operation and added financial cost to healthcare providers and systems. This study aimed to identify risk factors for MAs in both in-person and telehealth settings among adults living with T2DM. METHODS/STUDY POPULATION: Using a sequential multi-method design guided by the modified Quality-Caring Model, the quantitative phase of this study used electronic health records (EHR) data in Calendar Years 2019 and 2020 with 7,276 encounters made by 2,235 patients with T2DM from four diabetes clinics within a tertiary academic medical center in Baltimore, MD. Multivariable random effect logistic regression were used to examine the association between MAs and included predictors (i.e., patient characteristics [e.g., age, race, health status], health provider factors [e.g., types of provider], and health system factors [e.g., scheduling lag]). Based on the results of the quantitative phase, a purposive sample of 23 adults with T2DM and 10 providers were then interviewed individually via phone or zoom. RESULTS/ANTICIPATED RESULTS: The EHR data found that the following variables decreased the odds of MAs: having an activated patient portal account, patients with age over 46 or with white race. Telehealth was associated with 50% decreased odds of MAs during COVID (after 3/23/2020). On the other hand, longer scheduling lag increased the odds of MAs. Qualitative interviews revealed that MAs were often related to social needs, such as lack of/limited health-related transportation and its associated financial burden. Telehealth helped break these barriers for some adults with T2DM, but technical challenges in telehealth persisted for those with low digital health literacy and people who did not have a digital device and/or with unstable internet connection. Providers worried that these challenges might undermine the quality of diabetes care. DISCUSSION/SIGNIFICANCE: Disparities in MAs by age and race were noted, which might reflect the impact of unmeasured social needs in EHR. Perceived convenient telehealth may reduce MAs in T2DM care. However, the persistent technical challenges of telehealth should be addressed to optimize the quality of diabetes care and to promote care continuity for underserved populations.

The relationship between older adults' technology use, in-person engagement, and pandemic-related mental health.

OBJECTIVE: The objectives of this study are to 1) describe changes in in-person communication/activity and changes in older adult technology use during the COVID-19 pandemic and 2) examine whether less in-person communication/activity mediates the relationship between pandemic-related mental health and technology use. METHOD: Linear regressions (stratified by age and financial strain) and structural equation modeling were employed using a nationally representative, cross-sectional survey of 3,188 older adults from the 2020 National Health and Aging Trends Study's COVID-19 Questionairre. RESULTS: Older adults engaged in more technology-based activity (b = 0.24; p<.001), more technology-based health care communication (b = 0.22; p<.001), and more technology-based food acquisition (b = 0.21; p<.001) during the COVID-19 pandemic, as compared to before the pandemic. Results indicate that adults <80 years old demonstrated greater increases in technology-based activity, technology-based health communication, and technology-based food acquisition, compared to adults ≥80 years old. Change in in-person communication significantly mediated the relationship between pandemic-related mental health and technology-based communication (standardized coefficient= -0.012; p=.005), and change in in-person activity significantly mediated the relationship between pandemic-related mental health and technology-based activity (standardized coefficient= -0.017; p=.020). CONCLUSIONS: This study suggests that older adults are utilizing technology more, and therefore should be considered in technology design and dissemination. Technology use could be an important positive response to help those with pandemic related worries stay safely engaged with friends and family. Technologies should be produced that are modifiable for older adults with disabilities and affordable for older adults with fixed incomes.

EQUIP emergency: can interventions to reduce racism, discrimination and stigma in EDs improve outcomes?

BACKGROUND: Despite a publicly funded system, health care in Canada has been shown to be deeply inequitable, particularly toward Indigenous people. Based on research identifying key dimensions of equity-oriented health care as being cultural safety, harm reduction and trauma- and violence-informed care, an intervention to promote equity at the organizational level was tested in primary health care, refined and adapted, and tested in Emergency Departments (EDs). METHODS: In partnership with clinical, community and Indigenous leaders in three diverse EDs in one Canadian province, we supported direct care staff to tailor and implement the intervention. Intervention activities varied in type and intensity at each site. Survey data were collected pre- and post-intervention from every consecutive patient over age 18 presenting to the EDs (n = 4771) with 3315 completing post-visit questions in 4 waves at two sites and 3 waves (due to pandemic constraints) at the third. Administrative data were collected for 12 months pre- and 12 months post-intervention. RESULTS: Throughout the study period, the participating EDs were dealing with a worsening epidemic of overdoses and deaths related to a toxic drug supply, and the COVID 19 pandemic curtailed both intervention activities and data collection. Despite these constraints, staff at two of the EDs mounted equity-oriented intervention strategies; the other site was experiencing continued, significant staff shortages and leadership changeover. Longitudinal analysis using multiple regression showed non-significant but encouraging trends in patient perceptions of quality of care and patient experiences of discrimination in the ED. Subgroup analysis showed that specific groups of patients experienced care in significantly different ways at each site. An interrupted time series of administrative data showed no significant change in staff sick time, but showed a significant decrease in the percentage of patients who left without care being completed at the site with the most robust intervention activities. CONCLUSIONS: The trends in patient perceptions and the significant decrease in the percentage of patients who left without care being completed suggest potential for impact. Realization of this potential will depend on readiness, commitment and resources at the organizational and systems levels. TRIAL REGISTRATION: Clinical Trials.gov #NCT03369678 (registration date November 18, 2017).

The Association Between Older Adult Technology Use and Mental Health During the COVID-19 Pandemic

Physical distancing during the COVID-19 pandemic may impact the mental health of older adults, but technology use may buffer this impact. This study aimed to 1) examine changes in older adult technology use during the COVID-19 pandemic and 2) determine if technology use moderates the relationships between decreased in-person communication/activity and the mental health of older adults during the pandemic. Data were taken from the NHATS COVID-19 Round 10 (n= 3,188). Older adults engaged in more technology-based activity (b= .237, p<0.001), technology-based healthcare communication (b=.112, p<0.001), and technology-based food acquisition (b= .214, p<0.001) during the COVID-19 pandemic, compared to before. Technology use did not moderate the relationship between decreased in person personal communication (b= .021, p= 0.662)/activity (b= .045, p= 0.749) and mental health during the pandemic. Although older adults are utilizing technology more during the pandemic, it might not be protective against negative mental health outcomes from physical distancing.