Missed Dental Care Appointments in an Urban Safety Net Hospital

Katheryn Goldman, DMD, MPH, ABD; Muath A. Aldosari, BDS, MPH, DMSc; and Keri Discepolo DDS, MPH

ABSTRACT

Background: A paucity of literature has focused specifically on the sociodemographic and concrete resources available to patients who have missed pediatric dental care appointments in the United States. This pilot study aims to assess the factors associated with missing dental care appointments among pediatric patients visiting a hospital-based dental clinic. Specifically evaluated is the association between both the guardian’s adverse childhood experience (ACE) and access to concrete supports to determine how they relate to missed dental appointments.

Methods: This study is a cross-sectional analysis of 150 randomly sampled pediatric patients who visited the dental clinic at a large urban children’s hospital in July 2019. Of those identified, 30 random guardians were interviewed via simple random sampling using the modified ACE questionnaire and surveyed for access to concrete supports.

Results: The average number of missed dental care appointments was 10.6%. The majority of children who missed >10% of dental care appointments were Hispanic (54.6%), non-Hispanic Black (44.4%) utilizing public insurance (41.6%) and living in low-income neighborhoods (46.8%) and within 10 miles from the hospital (43.8%). Of those interviewed, 20% of families were found to have high-risk ACE scores.

Conclusions: This study illustrates a targeted demographic and identifies adverse experiences and access to concrete supports.

Practical implications: The research reinforces the value of identifying vulnerable populations through trends in care utilization and also is suggestive of the benefit of social resource involvement in the dental setting.

Keywords: Health care disparities, oral health, child health services, behavioral risk factor, surveillance system, health knowledge, attitudes, practice, vulnerable populations

AUTHORS

Katheryn Goldman, DMD, MPH, ABD, attended dental school at the University of Pennsylvania. She earned a Master of Public Health degree from SUNY-Albany where she was inducted into the Delta Omega National Public Health Honor Society. She completed her pediatric dental residency at Boston Children’s Hospital- Harvard University and is a diplomate of the American Board of Pediatric Dentistry. Dr. Goldman is currently completing a PhD program in social welfare at the Wurzweiler School of Social Work.

Muath A. Aldosari, BDS, MPH, DMSc, received his Master of Public Health in epidemiological methods and biostatistical analysis from the Johns Hopkins University Bloomberg School of Public Health. Dr. Muath then joined the Harvard School of Dental Medicine for his doctoral degree, where he focused his research on the evaluation of school-based delivery of dental services. He is an assistant professor at King Saud University in Riyadh, Saudi Arabia.

Keri Discepolo, DDS, MPH, is a board-certified diplomate of the American Board of Pediatric Dentistry and a fellow of the American Academy of Pediatric Dentistry. She was awarded her DDS from the New York University School of Dentistry. Dr. Discepolo received her training in pediatric dentistry at the Yale New Haven Hospital/ Yale School of Medicine and was awarded a Master of Public Health from the Mailman School of Public Health, Columbia University. She is a clinical associate professor of pediatric dentistry and acting chair for the department of pediatric dentistry at the Boston University Henry M. Goldman School of Dental Medicine.

An estimated 23% to 34% of outpatient medical care appointments in the United States are missed annually. 1 Missed health care appointments can be a prediction of poorer health outcomes. 1 Investigations have shown risk factors for missed dental care appointments to include forgetfulness, confusion surrounding appointment schedule and utilization of public insurance. 2–4 Health-seeking behaviors can also be subjectively related to perceived need and the patient’s value of care. 5–7 Those of racial minority background are particularly vulnerable to the obstacles of accessing preventive health care and are susceptible to poor oral health outcomes. 8 One study of appointments in the dental setting found patients who were Black and those categorized racially as “other” missed significantly higher numbers of appointments than all other groups of patients, and research that emphasizes health communication with a specific focus on racial minority patients, particularly in the dental setting, is needed. 9,10 In a pediatric dental context, children with a “high” caries-risk assignment during their first dental visit have 1.7 times the odds of missing more than 20% of all scheduled appointments compared to children with “low” caries risk. 2 The causes of missed dental appointments are multifaceted and warrant further investigation.

Existing literature has demonstrated that individuals with high adverse childhood experience (ACEs) scores had more late-canceled and no-show medical appointments than those with no ACE scores. 11 Other research has demonstrated that ACE exposure of mothers is negatively associated with follow-through with preventive health care visits among their children in early life. Because caregivers’ responsibilities are planning and transporting children to dental appointments, it is possible to hypothesize that parental ACEs scores may correlate with missed pediatric dental appointments.

Existing literature focuses on missed medical care appointments and outcomes of those missed appointments. 13 Sociodemographic and concrete resources have not been studied as extensively with respect to missed pediatric dental care appointments in the United States. Studies outside of the United States have shown that low socioeconomic status, young age of the patient, large unstable family structure and previously broken appointments are all significantly correlated with a missed appointment. 11,12 Access to concrete supports can be a useful indicator of some of the socioenvironmental factors that may impact care decisions. Access to concrete supports may also prevent unintentional neglect, such as failure to follow through with dental appointments, when families are unable to adequately provide for their children. 14 While existing studies offer important insight into global trends in care utilization, it is important to evaluate sociodemographic barriers that are specific to the social structures of families living in the United States. Therefore, this study aims to evaluate characteristics of those patients who miss dental care appointments

Methods

This pilot study is a cross-sectional quantitative analysis of patients who visited the dental clinic at a large urban children’s hospital in the Northeast. Institutional review board approval was obtained through the hospital. The sample population consisted of primary caregivers of children of English-speaking families, with children aged 0 to less than 18 years who had a dental appointment scheduled in the month of July 2019 and who had at least one continuity of care visit scheduled in the department in the past two years. The month of July was selected for the temporal frame, as school is not in session during this time. Families may have less conflict in attending dental appointments and trends in missed dental care appointments could be more closely reviewed excluding scheduling conflicts due to school hours. All patients who were scheduled during this time frame were contacted and given the opportunity to decline from participation in the study and chart review via email notification.

Out of 1,140 patients, a random number generator was utilized to contact caregivers to participate in a phone interview until 30 caregivers agreed to participate in order to pilot the desired questionnaires. The caregivers’ children’s charts were also evaluated for review. These participants were utilized to pilot the use of a modified version of the validated Behavioral Risk Factor Surveillance System (BRFSS) survey and the Protective Factors second-edition survey (PFS-2). The sample size was selected to enable us to detect a difference in proportion of missed dental appointments by one standard deviation between groups, with 0.8 power and alpha set at 0.05. An additional 120 charts of patients whose caregivers were not contacted to be surveyed were selected for a clinical chart review by a simple random sample utilizing a random number generator. This chart review was completed in order to understand general trends in care utilization and characteristics of individuals who missed dental appointments and to provide a comparative reference to the specific trends seen in care utilization and characteristics of individuals in the interview group. Interviews were conducted by a single provider in order to maintain consistency and reliability.

Verbal consent was obtained by interviewees and a copy of the consent was emailed to the family after participation. A gift card raffle was used as an incentive to complete the surveys. As previously noted, the study piloted the use of a modified version of the validated BRFSS, consolidating questions specific to in- depth discussions of sexual abuse, which we did not believe were pertinent to this study and the PFS-2. The study was chosen to be a pilot to evaluate the applicability of these surveys in terms of the feasibility of use in a dental setting as well as the ability to acquire participation by parents and caregivers given the sensitive nature of the questionnaire and the lack of surface-level connection to dentistry. The modified BRFSS questionnaire, which asks questions in regard to an individual’s exposure to childhood abuse and neglect, measured caregivers’ ACEs. A higher score represents higher risk for ACEs. Based on their score, we categorized caregivers into low (0-1), medium (2-3) and high (4+) risk for ACEs. The PFS-2 is utilized with caregivers participating in family support and child maltreatment services and evaluates familial protective factors to prevent child abuse. We specifically focused on concrete supports and questions relating to the subject’s ability to pay rent, utilities, child care services, etc. Our modified version of this questionnaire grouped individuals into low (0-3), medium (4-6) and high (7+) accessibility to concrete support. Patients’ attendance and missed dental care appointments (outcomes) were collected from their clinical charts. Based on the proportion of missed dental care appointments, we dichotomized our outcome of interest to children with 10% or less missed dental care appointments and children with more than 10% missed dental care appointments. In addition, we collected information about their nondental care appointments in the hospital for comparison. To quantify oral health, we recorded the presence of untreated dental caries. Demographic and insurance information was collected, and ZIP codes were used to approximate the distance traveled to their appointment and the family median income. Income categories were calculated utilizing data published by the Pew Research Center data for 2018 utilizing the income tiers. 15 Descriptive analysis was done first to report the characteristics of our sample. Then, Fisher’s Exact Test was used to assess if there were differences in these characteristics between the outcome groups: patients who missed 10% or less of their dental care appointments compared to children with more than 10% missed dental care appointments. The Mann–Whitney two-sample nonparametric test was employed to compare the ACE and PFS scores between the outcome groups. The differences deemed statistically significant at p value of 0.05. All statistical analyses were performed using Stata/SE Version 15.1 (StataCorp, College Station, Texas).

Results

For the study, 120 patient charts were reviewed without interviews, and 30 patients consented out of 109 to complete the survey (27.5% response rate) and have their child’s chart reviewed. The average proportion of missed appointments was 10.6% for dental care appointments and 10.5% for medical care appointments. The majority of our sample (44.7%) were adolescents between ages 13-17 with permanent dentition (TABLE 1). Nearly 1 in 5 (17.3%) children had untreated caries and more than half (67%) were covered only by public dental insurance. A third of our sample (30.7%) lived in a neighborhood more than 30 miles away from the hospital, and 41.3% resided in low-income neighborhoods.

table 3One in 5 (20.0%, P = 0.06) of the caregivers were categorized as high-risk for ACE, and 46.7% of caregivers reported at least two or more adverse childhood experiences. On the other hand, 73.3% (P = 0.04) of caregivers had high access to concrete supports. The differences between ACE and concrete support scores were not statistically significant between guardians who missed 10% or less dental care appointments compared to those who missed more than 10% in ACE score (p-value = 0.60) or concrete support score (p value = 0.41). TABLE 2 demonstrates the average ACE and concrete support scores of guardians surveyed. compares the proportion of missed dental care appointments with the children’s sociodemographic characteristics. Children who were less likely to miss their dental appointments were of Asian descent (6.7%), while 54.6% of Hispanic/Latino children missed more than 10% of dental care appointments (p-value < 0.01). Of the patients who missed > 10% of dental care appointments, the majority of them (41.3%) had public dental insurance, followed by the noninsured (33.3%) (p-value < 0.01). In addition, 77.1% of patients with ≤ 10% of missed hospital care appointments had also missed ≤ 10% of all dental care appointments (p-value < 0.01). Two in 5 patients (43.8%) who lived within 10 miles of the hospital missed > 10 of their dental care appointments (p-value = 0.03), and a similar proportion of children living in low-income neighborhoods (46.8%) missed >10 of their dental care appointments (p-value 0.03).

Discussion

The data from this study indicate that Black and Latino, low socioeconomic status families and families living in an urban environment (less than 10 miles from the hospital), represent the largest proportions of patients with > 10% of missed dental care appointments. Utilizing public insurance was also associated with higher missed dental care appointments. In congruence with the public discussion that is currently occurring across the United States, the data is suggestive of structural inequalities in place that inhibit the aforementioned demographic groups from utilizing pediatric dental care to the same capacity as their white, high socioeconomic status, suburban counterparts. It has been noted that the intersectionality of race and socioeconomic status produces complex patterns of inequality in community life and neighborhood norms, and that adverse conditions and stressors at the neighborhood level were found to be more pronounced among low-income Black parents; such stressors may have had a subsequent impact that led to inequities of care utilization. 14 Larger demographic data trends found in the U.S. population support the trends found in our study. As of 2016, 19% of all children in the U.S. live in poverty. 16 By race and ethnicity, this amounts to 34% of Black children and 28% of Hispanic children, compared with 12% of white children.

Out of the children who missed >10% of dental care appointments, 74% of them had untreated caries. This could be related to missing dental appointments and therefore not receiving care, which demonstrates the consequences that barriers to care utilization can have on a child’s oral health. As found in the literature, having a history of broken dental appointments has a significant association with caries outcomes. 2 The relationship between untreated caries and missed dental appointments could also be due to the fact that the populations at risk for missing dental appointments are also at high risk for having untreated caries. Research has shown in one study that non-Hispanic and Black youth had the highest prevalence of untreated caries and that the prevalence of untreated caries increased as the family income level decreased. 17 Missed appointments have been associated with medical complexity and mental illness; emergency room utilization has shown to have a negative correlation to attending appointments. 18 Importantly, access to specialized care or continuity care can be disproportionate for Black or Hispanic patients when compared to their white peers. 3,18 Significant differences in psychosocial stress exposure by race/ethnicity have been demonstrated to also be a predictor in oral health care usage. 12 As these individuals age, it is predicted they will have more instances of undiagnosed conditions with respect to oral health, which can lead to lifelong consequences. 19,20 Furthermore, the demonstration of these trends in a smaller data set such as this one, while limited in generalizability due to its size, follow trends that are reflective of greater national trends demonstrating racial and socioeconomic inequality, indicating how deeply inequity is ingrained into the health care system in the United States. The survey data offered valuable information regarding family resources that could be collected in a dental setting to gain a more comprehensive understanding of a family’s social background. For example, 46.7% of parents reported at least two or more adverse childhood experiences, indicating the importance of trauma-informed care, not only with children but with their caregivers as well. The survey data also indicated that 73.3% of caregivers reported high access to concrete supports. This could demonstrate that the patient families surveyed feel secure in their ability to access basic needs including food, shelter and clothing. However, we must also acknowledge that the families may have overreported access to concrete supports as response bias. For example, families may feel embarrassed to report difficulty paying for groceries or meeting other basic needs and will overreport their ability to meet those needs. Disseminating data in a written format, as opposed to a verbal questionnaire, may change the way families respond to sensitive questions relating to security surrounding concrete supports. It is also important to note that phone survey response rates are declining. In 2018, the Pew Research Center reported 6% as the average response rate for phone surveys. 21 While our survey data had a much higher response rate, 27.5%, we believe this may be due to the fact a dental provider conducted the survey and allowed herself to be identified with her full name and title. Due to the hesitancy of the subjects noted during the collection of these surveys, written questionnaires may be more appropriate in future research, given the national decline in participation in phone surveys. Even though the data set was small, the information gathered about patient families demonstrated that certain questions from modified versions of validated BRFSS and PFS-2 surveys may be useful in family questionnaires to establish a more nuanced understanding of a history of family trauma and resources available to the family that may influence a family’s oral health practices or care utilization. Our dental setting afforded the opportunity to review medical records due to our integrated system. Many institutions throughout the United States are moving toward this type of integration. The nuanced information provides specific information around medical missed appointments and social information that may not be part of the routine discussion in the dental setting. Utilizing more of this information to inform approaches to care or identifying possible barriers to obtaining care should be our goal as a health care system.

This study supports the existing literature that missed dental care appointments are associated with overall incomplete use of health services.

In addition to piloting ways of gaining a more nuanced understanding of a family’s social history, the study evaluated a multitude of characteristics that could impact a family’s dental care utilization. The variables that demonstrated a significant relationship with pediatric dental care utilization were (i) race of the child, (ii) median household income by ZIP code, (iii) distance from the hospital, (iv) missed medical care appointments and (v) insurance. It is important to note that the study did not collect specific socioeconomic variables such as the family’s individual household income. However, the results of the study demonstrate the power of the living environment on health outcomes and further support existing research that has linked community social characteristics with variations in individual-level health.

Missed dental appointments should be evaluated in the context of oral health care and oral health needs. Recently, recommendations have emerged that focus on enhancing health care provider education about the causes of racial and ethnic disparities that affect health care access and delivery. An important goal for providers should be improved understanding of the existence and magnitude of disparities and health care obstacles that patients face. 22,23 Our data suggests that barriers extend beyond just oral health care utilization; furthermore, this study supports the existing literature that missed dental care appointments are associated with overall incomplete use of health services. 4 Therefore, issues of care utilization can impact both a child’s systemic and oral health and subsequently emphasize the importance of an intersectional approach to helping families with care utilization in order to support vulnerable populations and achieve optimal health care use and patient outcomes. The research reinforces the value of identifying vulnerable populations through trends in care utilization and is suggestive of the benefit of social resource involvement in the dental setting. Follow-up research will be required to identify what specific factors prevent dental care utilization in order to target resources to the specific needs of the patient population to increase ease of service utilization.

Limitations

It is important to acknowledge that a small number of patients and families surveyed for this study were sampled from a single hospital in an urban setting in the Northeast, therefore the results cannot infer generalizability. Future research should replicate this study in a larger patient pool within various practice settings to see how, and if, trends change across geographic and care environments. n