The Fragmentation of Specialty Care. The Role of Referral Location, Type of Referral, and Demographic Factors in Determining Completion Rates for Uninsured Patients in a Student-Run Free Clinic.

Abstract

Little is known about how location of specialty care affects accessibility for uninsured patients at free clinics. To address this gap, the specialty referral completion rate by location and role of demographic and referral-specific factors were analyzed at an urban-based free clinic. A retrospective review was performed at a single site, student-run free clinic exclusively serving uninsured patients. Referral completion rate and predictors of referral completion were examined including age, race, ethnicity, sex, referral type, and location of referral. Significant predictors (p < 0.05) were included in the adjusted model if the associated odds ratio (OR) was meaningful. A total of 351 referrals met criteria. Completion rate was 53.6%. Co-location of specialty services was associated with a higher completion rate (64.7%, p < 0.001) and counseling referral type had a lower completion rate (11.5%, p < 0.001). Significant predictors of referral completion included sex, ethnicity, location of referral, and referral type (p < 0.001). Hispanic patients had higher rates of completion (68.4%, p < 0.001). On multivariable analysis, non-co-located fee-for-service hospital referrals had lower odds of completion when compared to co-located referrals at the free clinic (OR = 0.25, CI 95% [0.12-0.54], p < 0.001). Also, when compared to other types of referrals, counseling referrals had a 25 times lower odds of referral completion (p < 0.001). There was a higher completion rate of co-located referrals suggesting that multiple locations and health systems may deter patients from seeking necessary care. The lower rate of counseling referral completion indicates that additional efforts are needed to make these services more accessible to uninsured patients.