Lack of transportation poses a substantial barrier to healthcare access, disproportionately affecting vulnerable populations like teenage parents and their children. These individuals often face challenges related to distance, vehicle access, and return transportation, resulting in missed appointments and compromised health outcomes. Studies show a significant percentage of US children miss healthcare appointments due to transportation issues, with higher rates among low-income families. Missed appointments lead to delayed treatment, worsening health conditions, increased costs for healthcare systems, and the perpetuation of existing health inequities. Teenage parents and their children are especially vulnerable because of their socioeconomic status and the potential for cascading negative effects on both the parent and child's health and well-being. Interventions aimed at addressing transportation insecurity, such as providing rideshare services, hold the promise of improving access to care and reducing disparities. Previous research suggests that clinic-offered rideshare interventions can decrease missed visit rates and improve cost-effectiveness, utilizing technological innovations like partnerships with third-party rideshare vendors. This study sought to evaluate the impact of a rideshare intervention on missed clinic visits, costs, and patient satisfaction within a specialized clinic for teenage parents and their children.

Existing literature highlights the significant problem of transportation insecurity as a barrier to healthcare access, especially for vulnerable populations. Studies such as Hughes-Cromwick et al. (2005) and Syed et al. (2013) demonstrate the substantial number of individuals unable to access healthcare due to transportation limitations. Wolfe et al. (2020) and Ballantyne and Rosenbaum (2017) identify specific populations at higher risk, including teenage parents, racial and ethnic minorities, and those with lower socioeconomic status. The consequences of missed appointments extend beyond patient inconvenience; Tin et al. (1998) and Kheir-khah et al. (2016) emphasize the negative impact on health outcomes and increased healthcare costs. Prior research on rideshare interventions, such as Surampudi (2019) and Vais et al. (2020), shows promising results in reducing missed appointments and enhancing cost-effectiveness. These studies suggest that clinic-provided transportation can be a valuable tool in addressing healthcare disparities.

This pilot study was conducted at the Teen and Tot clinic within Boston Medical Center, a safety-net hospital serving a predominantly minority and low-income population. The intervention involved providing free rideshare transportation via the UberHealth platform to eligible patients (those with cell phones living within 50 miles of the clinic). Eligibility was determined during appointment reminder calls, and both outbound and return rides were offered. The study used a one-arm pre-post time series design, comparing missed visit rates and costs during the intervention period (July 2020-February 2021) with a comparison period (July 2019-March 2020). The primary outcome measures were the proportion of missed visits and the cost difference between the two periods, considering both the cost of missed visits and the intervention costs. Chi-square tests were used to compare missed visit rates. Cost analysis included direct rideshare expenses and administrative time. Patient satisfaction was assessed via post-ride surveys. The study was exempted from full IRB review due to its quality improvement nature. Data analysis was performed using STATA 15.1. The costs of missed clinic visits were adjusted for inflation using CPI data from the Bureau of Labor Statistics. The cost of a physical exam and a follow-up exam were obtained from Boston Medical Center clinic accountants.

During the study period (July 2020-February 2021), 97 clinic visits were scheduled, with 29 (29.9%) missed. The comparison period (July 2019-March 2020) saw 443 visits, with 145 (32.7%) missed (p=0.59). Of 153 rides scheduled, 106 (69.3%) were completed. The average distance per ride was 4.4 miles, and the average duration was 13.2 minutes. The average cost of a completed UberHealth ride was $17.38. The total intervention cost was estimated at $2,340.67 ($2,060.67 for rides and $280.00 for administrative time). The estimated total cost of the intervention and missed visits during the study period (adjusted for inflation) was $26,321.00. The comparison period's cost (adjusted for inflation) was $117,151.32, resulting in a net cost savings of $90,830.32. However, when standardized by the number of clinic visits, the intervention showed a net excess cost of $6.90 per visit. Of 64 post-ride survey respondents, 60 reported that the rides increased their likelihood of attending appointments, and 43 indicated that they would have been unable to attend without the rideshare service. A significant portion reported that the return rides were necessary to make their appointments. Most respondents reported no safety concerns during their rides.

This pilot study aimed to assess the impact of a clinic-provided rideshare intervention on healthcare access for teenage mothers and their children. While previous research has demonstrated the effectiveness of such interventions in reducing missed appointments and improving cost-effectiveness, this study did not find a statistically significant difference in missed visit rates or a clear cost benefit. However, this is likely attributed to several factors. The reduced clinic census during the SARS-CoV-2 pandemic significantly influenced the results, leading to increased per-patient costs. The widespread adoption of telehealth during the pandemic might have also lessened the impact of transportation barriers. Furthermore, the perception of rideshares as potentially higher risk for SARS-CoV-2 infection may have deterred some patients from using the service. Despite the null findings regarding missed visit rates, a substantial number of patients reported that the rideshares were crucial for them to attend their appointments. This suggests that although the direct impact on missed visits might not be statistically significant, the intervention likely still provided significant value.

This pilot study, while not demonstrating a significant impact on missed visit rates or costs due to confounding factors related to the pandemic, highlights the potential value of clinic-provided rideshare interventions for improving access to care for teenage mothers and their children. The high satisfaction rates and the numerous patients reporting the service as essential suggest the continued exploration of such initiatives is warranted. Future research with larger samples, a control group, and adjusted for pandemic-related factors is necessary to fully assess the effectiveness of this intervention and optimize its implementation.

This study had several limitations. The relatively small sample size may have limited the statistical power to detect significant differences. The single-site design limits the generalizability of the findings. The absence of a control group hinders the establishment of causality. The cost estimates may have been imprecise, and the study did not account for potential cost savings from increased on-time appointments. The considerable impact of the SARS-CoV-2 pandemic on clinic census and patient behavior confounds the interpretation of the results. Despite these limitations, the findings suggest the importance of continuing to explore clinic-provided transportation interventions.