When COVID-19 was declared a public health emergency in the U.S. in March 2020, public health officials advised individuals to stay home unless they had moderate to severe illness. Days before the lockdown began in Massachusetts, the Brigham and Women’s Hospital Diabetes Management Program developed a protocol for reaching out to patients whose routine clinic visits would be abruptly canceled.
Marie E. McDonnell, MD, the director of the program, and colleagues took advantage of this “natural experiment” to determine how outreach from clinicians influences patients’ re-engagement in care. Two-way communication was the key to success, they report in Endocrine Practice. They also found that patients who simply received a message were no more likely to book or keep an appointment than those who could not be contacted.
Between March 16 and June 19, 2020 (14 weeks), an administrative report was run daily in the diabetes clinic to capture all appointments canceled. Patients who canceled and had not been seen at the clinic within the last month were listed in tracking software to be contacted by ambulatory care nurses who were redeployed for this effort.
787 patients were considered to have canceled due to the pandemic and were included in the analysis (average age, 62; range, 18–99). After the intervention period, a chart review was performed to determine whether each patient booked and kept an appointment before October 31, 2020.
648 patients (82%) booked a visit by the end of the study period. There was no significant difference in rates of appointment booking between those who could not be contacted (76%) and those who were left a voicemail or a message in the electronic health records portal (77%).
In contrast, 89% of patients who communicated with the nurse by telephone or the portal booked an appointment (OR, 2.43; P<0.001).
Of the 648 patients who booked an appointment, 519 (80%) attended it. Again, there was no significant difference between those who were not contacted (72%) and those who were left a message (75%). However, 86% of patients who were reached kept their appointment (OR, 2.39; P<0.001).
Patients on insulin were more likely to keep their appointment (OR, 1.70; P=0.008) while patients with a higher hemoglobin A1C level were less likely (OR, 0.87 for each 1.0% increase in HbA1C; P=0.011).
Consequences of Disengagement
Most published guidelines for clinicians during the COVID-19 pandemic addressed inpatient care. Overlooking routine care for patients with diabetes during a natural disaster or pandemic can create a massive burden for years to come, not just from the consequences of poor glycemic control but also missed cancer screenings, delayed surgery, and poor mental healthcare.
This study suggests that targeted outreach is necessary to maintain or regain continuity of care during major disruptions, especially for patients who were already at higher risk.
The outreach initiative was time-consuming and might not be feasible for many practices. A more sustainable approach might be to have text messages sent by a chatbot or a member of the clinical or administrative team.