Do Public Transportation Barriers Lead to Missed Doctor's Appointments? Empirical Evidence From A Large Health System

Tuesday, June 25, 2019
Exhibit Hall C (Marriott Wardman Park Hotel)

Presenter: Laura Smith

Co-Authors: Zhiyou Yang; Hannah Neprash

Missed or “no-show” doctor’s appointments contribute to disruptions in care, poor patient outcomes, and health system inefficiencies. No-shows are especially frequent among low-income patients, who may live in underserved areas and rely on public transit to travel to and from doctor’s appointments. Research on no-shows has largely been limited to small, observational studies relying on self-reported data from willing participants. In this study, we use a large electronic health record (EHR) database from an integrated delivery system to empirically examine the relationship between public transit availability and no-shows for primary care appointments. We rely on the opening of a large light rail transit line to estimate the effect of increased public transit availability on no-shows. The new light rail line included several stations in close proximity to clinics in our database, and increased rail ridership by an estimated 12 million rides per year. We estimate difference-in-differences models, comparing no-show rates at clinics located near the light rail transit line to those not located near it, before and after the light rail opened to the public. All of our models control for patient demographic (e.g., age), clinical (e.g., chronic conditions), and appointment (e.g., new patient or not) factors. We include clinic fixed effects to account for underlying differences across clinics in rates of no-show appointments and year-month fixed effects to account for seasonal effects related to no-shows.

The analytic sample represents over 6 million appointments, occurring at primary care clinics located throughout a metropolitan area between 2011 and 2017. Approximately 5% of all appointments in our sample are no-shows, but the rate of no-shows varies substantially across clinics-- from 3% to 10% of appointments --and is highest at clinics located in low-income neighborhoods and neighborhoods with lower levels of educational attainment. Preliminary results suggest the opening of the light rail line did not decrease no-show appointments; however, we anticipate adding more clinic locations and more granular measures of public transit availability to future iterations of our analyses.

Our research contributes to the debate surrounding the relationship between transportation and health care utilization. As cities continue to invest in public transit and ride sharing companies develop transportation services specifically aimed at patients traveling to medical appointments, it is particularly important to have quasi-experimental evidence regarding the effect of transportation availability on utilization of scheduled health care services.