A pilot study: the impact of clinic-provided transportation on missed clinic visits and system costs among teenage mother-child dyads

Lack of transportation is a major barrier to accessing healthcare, disproportionately affecting teenage parents, racial/ethnic minorities, and socioeconomically disadvantaged populations. Children are particularly vulnerable due to dependence on adults, and infants of teen parents face higher risks of adverse outcomes. Prior estimates suggest 4–9% of children miss healthcare due to transportation barriers, with higher rates among lower-income households. Missed appointments delay treatment and preventive care, worsening morbidity and mortality and increasing costs, and may lead to clinic discharge policies that exacerbate disparities. Non-emergent medical transportation and rideshare-based programs have shown promise in reducing missed visits and costs in some settings. Given the risks and barriers faced by teenage mothers and their children, the study implemented a clinic-provided rideshare intervention at a specialized clinic to assess its impact on missed clinic visits, system costs, and patient satisfaction.

The paper cites extensive literature on transportation barriers to healthcare access and their disproportionate impact on vulnerable groups, including teenagers, racial/ethnic minorities, and low-income populations (Hughes-Cromwick et al., 2005; Wolfe et al., 2020; Syed et al., 2013; Ballantyne and Rosenbaum, 2017). It highlights the heightened vulnerability of children and infants of teen parents and documents missed appointment consequences and associated costs (Tin et al., 1998; Kheirkhah et al., 2016; Triemstra and Lowery, 2018). Prior work on non-emergent medical transportation and rideshare partnerships (including UberHealth) suggests reductions in missed appointments and cost-effectiveness (Surampudi, 2019; Vais et al., 2020; Chaiyachati et al., 2018; Rochlin et al., 2019). One controlled trial noted no decrease in missed appointments when uptake was low (Chaiyachati et al., 2018). The pandemic context introduced telemedicine and altered transportation risk perceptions, affecting appointment patterns (Alexander et al., 2020; Drerup et al., 2021; Ozbilen et al., 2021).

Design: One-arm pre-post time series pilot study comparing missed clinic visits and costs during an intervention period (July 2020–February 2021) to the preceding year (July 2019–March 2020). Setting and population: Teen and Tot clinic at Boston Medical Center, serving pregnant adolescents up to age 20 and adolescent/young adult mothers and their children until the mother's age 23. The clinic population is predominantly racial/ethnic minorities and socioeconomically disadvantaged patients. Intervention: Clinic-offered free rides via UberHealth to scheduled clinic appointments. Eligibility: existing Teen and Tot clinic patients with a cell phone residing within 50 miles. Patients were screened during routine reminder calls 1–2 days before appointments. Initially rides to clinic were offered; as of Oct 1, return rides home were also provided. Clinic staff scheduled rides via a clinic rideshare account using the patient’s cell number and pickup address. Costs (ride fares and no-show fees) were covered by the clinic. Patients received automated text reminders and were surveyed post-appointment about satisfaction and safety. Ethics: Institutional Review Board exemption as a quality improvement project; informed consent not required; patients verbally consented to rides. Measures: - Primary independent variable: number of rides provided. - Process measures: number offered rides, number of completed rides, user/coordinator cancellations, average distance and duration, and ride/cancellation costs; estimated administrative scheduling time. - Clinic measures: total scheduled visits, missed visits without cancellation, visit type (annual exam vs follow-up). - Outcomes: Primary—proportion of missed visits without cancellation; overall cost differences between periods (cost of missed visits pre-intervention vs cost of missed visits during intervention plus intervention costs). Secondary—patient satisfaction from post-ride Likert surveys and any rideshare-related adverse events. Costing approach: Intervention costs included direct ride expenditures and administrative time (estimated 15 h at $28/h, plus time for bi-monthly 30-min meetings and a 30% buffer for variability in estimates). Costs of missed visits were based on clinic administrator estimates: $900 for annual/new patient physical exams and $300 for follow-up visits. Prices were inflation-adjusted to July 2021 using CPI (2019→2021 for comparison period; 2020→2021 for study period). Cost differences were calculated as a range (minimum and maximum); standardized costs per clinic visit were computed to account partially for pandemic-related census changes. Analysis: Chi-square test compared missed-visit proportions between periods. Descriptive statistics summarized rides, cancellations, distances, durations, and costs. Patient satisfaction responses of Agree/Strongly Agree were counted as positive responses; others as negative. Analyses used STATA 15.1.

- Clinic appointments: 97 during intervention (July 2020–Feb 2021) with 29 missed without cancellation (29.9%); 443 during comparison (July 2019–Mar 2020) with 145 missed (32.7%); p = 0.59 (no significant difference). - Rideshare utilization: 153 rides scheduled; 106 completed (69.3%), 34 user-canceled (22.2%), 13 coordinator-canceled (8.5%). Of 97 clinic visits, 56 (57.7%) were via rideshare. Average distance 4.4 miles each way; average duration 13.2 minutes. - Costs per ride: Completed rides $17.38 average; user-canceled $5.82; coordinator-canceled $1.62. - Intervention cost: Total $2,340.67 ($2,060.67 rides + $420.00 administrative time at $28/h for ~15 h). - Total costs (inflation-adjusted to July 2021): Study period (missed visits + intervention) $26,321.00; comparison period (missed visits) $117,151.32; crude net savings $90,830.32. - Standardized costs per clinic visit: $271.35 (study) vs $264.45 (comparison); net excess $6.90 per clinic visit during study. - Patient satisfaction (n=64/106 surveyed): 60 reported the ride increased likelihood of attending; 43 (67.2%) reported they would not have made the appointment otherwise. Among those offered return trips, 38/54 (70.4%) said the return ride was necessary. Safety: 56/64 reported no health or safety concerns; six noted concerns (e.g., difficulty locating ride, lateness/no arrival, driver on phone, difficulty retrieving lost item). No serious adverse events reported.

The rideshare intervention did not significantly reduce missed clinic visits nor clearly lower system costs. The findings are likely confounded by the SARS-CoV-2 pandemic, which reduced clinic census nationwide and increased per-patient operating costs, while the rapid expansion of telemedicine likely decreased transportation-related no-shows. Additionally, some patients may have perceived higher infection risk with ridesharing and avoided the service. Despite these factors, the target population—largely of lower socioeconomic status—may have derived benefits not captured in primary outcomes. Given prior evidence of benefit from rideshare programs and the relatively small standardized cost difference observed, further research is warranted in post-pandemic conditions. Implementation lessons include the value of enhanced reminders and the importance of offering return rides, supported by patient survey feedback.

A clinic-offered rideshare program for teenage mothers and their children was feasible but did not significantly change missed-visit rates or clinic-incurred costs during the pandemic-affected period. Pandemic-related shifts in clinic operations and patient behavior likely influenced outcomes. Considering potential patient benefits and equity implications, additional research on rideshare interventions under more typical clinic conditions is warranted.

- Small sample size limits precision and statistical power. - Single-center study in a specific subpopulation limits generalizability. - One-arm pre-post design without a concurrent control group limits causal inference and susceptibility to confounding (e.g., pandemic effects, telehealth uptake). - Cost estimates were imprecise and relied on administrative assumptions; could not account for changes in punctuality and potential cost savings from on-time appointments. - Reasons for ride cancellations were not captured, limiting process understanding.