Discussion

Our data suggest that children with CHD who come from more disadvantaged neighbourhoods are more likely to miss cardiology appointments, more likely to present to the emergency department, and more likely to be admitted after an emergency department visit. The difference is particularly noticeable when comparing the most disadvantaged areas to the least disadvantaged. While the difference in risk of emergency department visits and admissions between area deprivation index quartiles weakens when controlling for race, area deprivation index remains significant when predicting missed cardiology visits.

When looking at the effect of ≥2 missed cardiology visits on the number of emergency department visits and unplanned admissions, there is a significant difference in the risk for more acute visits. This relationship remains even when controlling for race. Our data suggest that patients from more deprived communities, based on their neighbourhood’s area deprivation index, have more missed cardiology appointments. Additionally, patients with more missed cardiology appointments have a greater number of emergency department visits and unplanned admissions.

The increased risk for missed clinic visits among patients with higher area deprivation index levels is likely multifactorial and based on many known social risk factors for adverse health outcomes and missed visits. Such barriers likely include transportation, childcare, finances, and free time away from work, but these factors can be difficult to identify during routine care. ^{Reference Zuckerman, Perrin, Hobrecker and Donelan1} Both area deprivation index and the social vulnerability index (a measurement of community resilience) have been shown to be related to missed paediatric specialty visits in surgical, haematology, and neurodevelopment patients. ^{5–Reference Catanzarite, Bouck and Matthes8} area deprivation index is already integrated into major electronic health records and could serve as a screening variable to identify patients at higher risk for missed appointments and guide interventions to improve attendance. This would be particularly useful in paediatric cardiology practices that serve rural communities, since prior research has already shown an association between missed cardiology visits and greater distance from clinic. ^{Reference Rosamilia, Williams and Bair3} Improving rates of clinic attendance can help reduce the financial and scheduling burden of missed visits on a practice.

Reducing missed visits could also help improve the care of congenital heart patients. Missed appointments can delay the recognition of early signs of clinical deterioration; they can lead to missed medications, delayed referrals, and missed opportunities for caregivers to understand their child’s health. These factors may be contributing to the increased number of visits to the emergency department seen in patients with ≥2 missed cardiology visits. It has already been shown that gaps in paediatric cardiology care of two or more years have been associated with emergency department visits. ^{Reference Rosamilia, Williams and Bair3} The association between missed visits and emergency department presentation has also been noted in children seen in neurology clinics and among patients who did not have regular health check-ups in the preceding year, which suggests a similar pattern to our specialty cohort. ^{Reference Jarvis, Livingston, Childs and Fraser2,Reference Holland, Varni, Pulcini, Simon and Harder9}

When controlling for Black race, the lack of a significant relationship between emergency department visits and area deprivation index was not entirely surprising, as previous studies have shown that race often confounds area deprivation index associations. Since area deprivation index considers a community’s education, income, and housing quality, this relationship could simply reflect well-documented inequities between Black and non-Black communities. Area deprivation index may not be effective on its own for predicting a patient’s risk of increased emergency department visits, but it may contribute to the overall risk profile. Previous studies have looked at risk factors for visits to the emergency department and have shown that patients with public insurance and lower family educational attainment had more presentations to the emergency department for “low-resource-intensity” visits. These were considered visits that could have potentially been managed as an outpatient visit. ^{Reference Gaffney, Michelson, Monuteaux, Porter and Hudgins10} In a meta-analysis of paediatric emergency department visits, Black race, family income, and deprivation (both individually or in a community) were all associated with higher emergency department utilisation in a mixed paediatric population. ^{Reference Amjad, Tromburg and Adesunkanmi11}

While our results are limited by coming from a single centre as part of a retrospective chart review, our large and diverse patient population allows us to better understand a cohort of some of the highest risk congenital heart patients. Many congenital heart centres serve patient populations already facing significant social barriers to their cardiac care, and missed cardiology visits can further exacerbate this problem. The relationship our data shows between community deprivation and missed cardiology appointments continues to drive home the importance of considering the social factors that often complicate a child’s medical care. The clinical relevance of missed visits was also evident in our data, which showed a relationship between missed visits and emergency department visits and unplanned admissions. Identifying patients with a higher risk for missing visits is a crucial step for eventually developing patient centred interventions to improve clinic attendance. Based on our findings, area deprivation index may be a powerful, accessible component to help identify patients in the greatest need.