"Patient Lost to Follow-up": Opportunities and Challenges in Delivering Primary Care in Academic Medical Centers

Abstract

Background: Academic health centers (AHCs) face unique challenges in providing continuity to a medically and socially complex patient population. Little is known about what drives patient loss in these settings.

Objective: Determine physician- and patient-based factors associated with patient loss in AHCs.

Design: Retrospective cohort study, embedded qualitative analysis.

Setting: Academic health center.

Participants: All visits from 7/1/2014 to 6/30/2019; 89 physicians (51%) participated in a qualitative analysis.

Measures: Physician-based factors (gender, years of service, hours of practice per week, trainee status, and departure during the study period) and patient-based factors (age, gender, race, limited English proficiency, public health insurance, chronic illness burden, and severe psychiatric illness burden) and their association with patient loss to follow-up, defined as a lapse in provider visit greater than 3 years.

Results: We identified 402,415 visits for 41,876 distinct patients. A total of 9332 (22.3%) patients were lost to follow-up. Patient factors associated with loss to follow-up included patient age < 40 (HR 3.12 (2.94-3.33)), identification as non-white (HR 1.07 (1.10-1.13)), limited English proficiency (HR 1.18 (1.04-1.33)), and use of public insurance (HR 1.12 (1.04-1.21)). Provider factors associated with patient loss included trainee status (HR 3.74 (2.43-5.75)) and having recently departed from the practice (HR 1.98, 1.66-2.35). Structured interviews with clinical providers revealed unfavorable relationships with providers and staff (35%), inconvenience accessing primary care (23%), unreliable health insurance (18%), difficulty accessing one's primary care provider (14%), and patient/provider transitions (10%) as reasons for patient loss.

Conclusions: Younger patient age, markers of social vulnerability, and physician transiency are associated with patient loss at AHCs, providing targets to improve continuity of care within these settings.

Keywords: Academic medical centers; Patient loss; Primary care.