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Brief communication 389 MASS TRANSIT STRIKE EFFECTS ON ACCESS TO MEDICAL CARE Ambulatory clinic appointment no-shows, who are patients who schedule appointments and then do not present themselves at the clinic, have a significant impact on delivery of, and access to, health care. Patients may delay or not receive adequate care, which can lead to increased morbidity and possibly early mortality.1"5 Similarly, the availability of health care resources to all patients may be affected, as valuable appointment slots are unnecessarily booked. To compensate for expected missed appointments, many clinics use a policy of overbooking time slots. If a larger than expected proportion of patients arrive for their appointments, an increased wait time to see providers at the clinic will result. If the number of failed appointments is greater than expected, the result is an underutilization of resources as physicians, staff, and facilities idle during the gaps between patients. This underutilization has "trickle-down" effects to referral providers (e.g., laboratory, imaging, other physicians) and facility staff as well. A number of factors have been associated with patients missing a scheduled appointment. These barriers can be classified in a number of categories, including patient, provider, disease, therapy, patient-provider interaction, access, institutional, and environmental factors.1 One component of adequate health care access has been identified as the availability of transportation— both public and private—to the clinic.1 Public transportation barriers have adverse effects on the populations most dependent on them for access to health care, namely the elderly and the poor.6,7 In terms of access to care, survey studies have found transportation to be a barrier to prenatal care,8"12 well child visits,13"15 cancer care,16 HIV management ,17 dental visits,1819 and the management of diabetes.5 For patients with diabetes, transportation was a problem not only for provider visits, but also to pharmacies and obtaining insulin.5 In one program designed to provide nocost mammography for low-income women, transportation was the most common reason for failing to receive screening.20 In a more broad-based study of patient access to and use of care, transportation was reported as the third most common reason for not having a regular source of medical care.21 Patients who cited transportation problems were 1.45 (95 percent confidence interval = 1.19-1.77) times more likely to have delayed seeking medical care. In a study of urban and rural areas in North Carolina, 7.7 percent of 4,162 survey respondents reported having put off health care due to transportation Journal ofHealth Care for the Poor and Underserved · Vol. 10, No. 4 · 1999 390 Mass Transit Strike Effects problems.22 Although reports of transportation barriers were slightly higher in the rural respondents (9.8 percent), almost 6 percent of urban participants reported transportation as a barrier despite the cities' mass transit systems. Patients who rated themselves in poor health were almost twice as likely as other respondents to cite problems with transportation. The problem is further complicated by evidence that the distance a patient must travel for health care is another, often-reported barrier. Patients using emergency departments for nonurgent problems report a major reason for doing so was the closeness of the facility to their home.3 Similarly, the elderly clearly state a preference for receiving care at a facility close to home.23 This preference stems from a number of factors, including discomfort with traveling outside the neighborhood into unfamiliar surroundings along with personal safety concerns about using public transportation. Even in younger patients, the combination of distance and transportation difficulties were seen as serious barriers to obtaining needed health care.16 Although the literature consistently suggests that inadequate transportation limits access to medical care, most reports have been the result of survey studies. No report that the author is aware of has examined the actual utilization of mass transit by ambulatory care patients. Such an undertaking would be a laborious and costly initiative. In 1996, a rare, although by no means unique, opportunity for study presented itself in the form of a three-week work stoppage by the mass-transit drivers in Minneapolis, Minnesota. Using computerized administrative data from...


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