Karter Andrew J, Parker Melissa M, Moffet Howard H, Ahmed Ameena T, Ferrara Assiamira, Liu Jennifer Y, Selby Joe V
Division of Research, Kaiser Permanente, Oakland, California 94612, USA.
Med Care. 2004 Feb;42(2):110-5. doi: 10.1097/01.mlr.0000109023.64650.73.
When patients miss scheduled medical appointments, continuity and effectiveness of healthcare delivery is reduced, appropriate monitoring of health status lapses, and the cost of health services increases. We evaluated the relationship between missed appointments and glycemic control (glycosylated hemoglobin or HbA1c) in a large, managed care population of diabetic patients.
Missed appointment rate was related cross-sectionally to glycemic control among 84,040 members of the Kaiser Permanente Northern California Diabetes Registry during 2000. Adjusted least-square mean estimates of HbA1c were derived by level of appointment keeping (none missed, 1-30% missed, and >30% missed appointments for the calendar year) stratified by diabetes therapy.
Twelve percent of the subjects missed more than 30% of scheduled appointments during 2000. Greater rates of missed appointments were associated with significantly poorer glycemic control after adjusting for demographic factors (age, sex), clinical status, and health care utilization. The adjusted mean HbA1c among members who missed >30% of scheduled appointments was 0.70 to 0.79 points higher (P <0.0001) relative to those attending all appointments. Patients who missed more than 30% of their appointments were less likely to practice daily self-monitoring of blood glucose and to have poor oral medication refill adherence.
Patients who underuse care lack recorded information needed to determine level of risk. Frequently missed appointments were associated with poorer glycemic control and suboptimal diabetes self-management practice, are readily ascertained in clinical settings, and therefore could have clinical utility as a risk-stratifying criterion indicating the need for targeted case management.
患者错过预定的医疗预约时，医疗服务的连续性和有效性会降低，健康状况监测缺失，医疗服务成本增加。我们在一个大型的糖尿病患者管理式医疗人群中评估了错过预约与血糖控制（糖化血红蛋白或HbA1c）之间的关系。
2000年期间，在北加利福尼亚凯撒医疗集团糖尿病登记处的84040名成员中，将错过预约率与血糖控制进行横断面关联分析。根据糖尿病治疗方法分层，通过预约遵守情况水平（全年无错过、错过1 - 30%以及错过超过30%的预约）得出HbA1c的校正最小二乘均值估计值。
2000年期间，12%的受试者错过超过30%的预定预约。在调整了人口统计学因素（年龄、性别）、临床状况和医疗服务利用情况后，更高的错过预约率与显著更差的血糖控制相关。错过超过30%预定预约的成员的校正平均HbA1c比参加所有预约的成员高0.70至0.79个百分点（P <0.0001）。错过超过30%预约的患者进行每日血糖自我监测以及口服药物续方依从性差的可能性更低。
未充分利用医疗服务的患者缺乏确定风险水平所需的记录信息。频繁错过预约与较差的血糖控制和次优的糖尿病自我管理实践相关，在临床环境中很容易确定，因此作为一种风险分层标准可能具有临床实用性，表明需要进行有针对性的病例管理。
