Appointment Scheduling Drives Referral Success in Adults with Sickle Cell Disease

Background

Adults with sickle cell disease (SCD) require ongoing care from multiple specialties for preventative and disease-specific care. Evaluating patient and referral-level factors and their relation to appointment outcomes may identify opportunities to strengthen care coordination and access to specialty care.

Methods

We conducted an IRB-approved retrospective cohort study at the Johns Hopkins Sickle Cell Center for Adults (SCCA), examining outpatient referrals placed between July 1, 2022, and July 1, 2023, among adults (≥18 years). Referrals for each patient to other specialties were identified, as were appointments scheduled and whether the patient saw a clinician of the target specialty. Referrals were categorized by whether the specialty is embedded with the SCCA (SCCA hematology and psychiatry), affiliated but not embedded (ophthalmology), or external. Referrals that were completed, meaning there was a completed visit with that specialty, were tabulated. We also examined the scheduling process, including whether an appointment associated with a referral was ever scheduled; and if so, whether the result was a cancellation or no-show. Multivariable logistic regression was used to determine predictors of successful referral. Separate models were then used to evaluate predictors of appointment scheduling and visit completion among specialties embedded within or affiliated with the SCCA (SCCA hematology and psychiatry and Hopkins ophthalmology).

Results

393 referrals from 241 unique patients met inclusion criteria. Several patients had multiple referrals to the same specialty, so referrals were aggregated into 338 referral chains representing the sequence from the first referral through appointment scheduling and final outcome of completion or non-completion (mean 1.16 referrals per chain). Patients in this cohort were 63.9% female, 37.8% were aged 18–30 years, and 51.5% were employed/students. Referrals were to Hopkins Ophthalmology (46.4%), SCCA Psychiatry (21.6%), External specialties (21.3%), and SCCA Hematology (10.7%). Ophthalmology referrals had significantly lower odds of overall referral success (OR 0.23, 95% CI 0.10–0.50) and appointment scheduling (OR 0.10, 95% CI 0.02–0.32) compared to hematology. However, among referrals with a scheduled appointment, completion did not differ significantly by specialty. Age, gender, and employment status demonstrated minimal association with referral success. Ophthalmology specific analysis showed that a greater number of SCCA visits in the 6 months prior to referral was associated with lower odds of success (OR 0.86, 95% CI 0.73–0.97), while unemployment showed a nonsignificant trend toward lower success (OR 0.46, 95% CI 0.19–1.09).

Conclusions

Specialty type and appointment scheduling were the primary drivers of referral success among adults with SCD. Higher scheduling rates within embedded specialties, such as SCCA psychiatry, indicate that integration of specialty care within comprehensive sickle cell centers may improve referral success. Interventions that expand embedded specialty services represent strategies to improve access and continuity of specialty care.

Note: Reference categories: Specialty (SCCA Hematology), Age (18-30 years), Gender (Female), Employment Status (Employed/Student), Referring Pattern (APP only). Prior Clinic Visits modeled as a continuous variable. Significance levels are indicated as follows: *p<0.001.