by Elizabeth Matsui
I wrote recently about the challenge of getting a prescribed medication into a patient’s hands and focused on the process from the physician prescribing the medication to the patient receiving the prescribed medication. Because I’m a pediatrician, allergist-immunologist, and asthma researcher, the lens through which I view health care is the challenge of providing the standard-of-care to low-income children with asthma, but the observations for this patient population and condition are applicable to all chronic health conditions.
Even when we have systems in place to ensure that a prescribed medication gets into the patient’s hands, if the patient doesn’t come to the clinic visit in the first place, the patient won’t receive the medication. The patient and family must somehow interact with their physician in order to initiate the prescription-to-medication receipt process described above. And we know that low-income populations, which tend to have a higher prevalence of chronic health conditions and greater morbidity associated with these chronic health conditions, have a high no show rate for appointments as pointed out here and here.
So what are we to do? Should we expect children with asthma whose families struggle with transportation and taking time off of work and who often are focused on ensuring shelter and food for their children to be “on their own” to schedule, remember, and make it to their appointments? An answer of “yes” to this question is shortsighted. There are many compelling reasons that we should work to ensure that children have regular follow-up by a physician or other health care provider:
The question is then how do we achieve regular follow-up for children with asthma? There are many potential strategies, but the approach that has worked well for us in the setting of a clinical trial could lend insight into strategies that could be effective outside of a research setting. Our study team does the following:
In addition, families receive a small monetary incentive for each visit and the child gets to choose a toy from our toy bin to take home.
This process is obviously time consuming and resource intensive, but certain aspects are worth exploring outside of a research setting. For example, there’s a growing literature that incentives can be effective, so this approach may be helpful to ensure regular asthma follow-up. Providing transportation also removes a barrier, and in Maryland, Medicaid and local health departments provide transportation to doctor’s appointments, although I’m not sure how many of their patients know about this resource. It would be helpful to know more about who uses this resource, how it is used, and whether using it is associated with improvements in asthma.
But we also need to think outside of the traditional paradigm of the patient traveling to the doctor’s office at regular intervals. Health care providers and workers can, for example, go to the patient. For children, that means providing regular asthma assessment and management in schools, community centers, and/or homes. With recent changes to Medicaid regulations, it is possible for community health workers to be reimbursed for home visits and many groups are working to understand the effectiveness of these programs. Another model is a roving asthma team, such as the Breathmobile.
We also can’t forget that we have ways to communicate remotely with patients about health conditions. Texting has been very effective for some health-related activities in low-income populations and someday apps and telemedicine will be easily accessible to low income populations. For childhood asthma in particular, doing much of the monitoring and medication adjustment by phone, text, or electronically is sufficient for most patients. And undoubtedly far superior to no monitoring.
Although it’s not clear what the best system would be to ensure regular follow-up, and whatever system that is will vary among populations, we have many tools at our disposal and should be actively working to build those systems for the families we serve.