Linkage and retention in care soon after HIV diagnosis improves clinical outcomes. Conversely, missed visits after diagnosis are associated with increased mortality in the public care setting. We analyzed mortality among newly diagnosed HIV patients ≥18 years old in a large private care setting between 01/01/1997 and 12/31/2009, comparing patients who missed visits in their first year following diagnosis (index period) with those who did not. Patients who died during the index period were excluded. Hazard ratios (HR) for association of missed visits and mortality were obtained by Cox proportional hazards regression, adjusting for patient demographics, CD4+ counts, and AIDS-defining conditions (CDC, 1993) at diagnosis. We also evaluated risk factors of missed visits by multivariable logistic regression. 2811 patients were included, of whom 65% had ≥1 missed visit, and 226 patients died during follow-up. Patients with ≥1 missed visit had a 71% increased mortality risk (HR=1.71, p=0.001) with 12% increased rate per missed visit (HR=1.12, p<0.001). Factors associated with missed visits were younger age (OR=1.69 compared to 60+ years), Black and Latino race/ethnicity (OR=1.54, 1.48 respectively, compared to Caucasians), injection drug use (OR=2.50 compared to men who have sex with men), and lower CD4+ (OR=1.43 for CD4+ 100–199 cells/μL, OR=1.39 for 50–99 cells/μL, and OR=1.63 for CD4+ <50 cells/μL, compared with CD4+ >500 cells/μL). In an insured patient population, missed visits in the first year of HIV care are common and associated with increased mortality. Early retention in HIV care is critical to improving outcomes.
Get full access to this article
View all access options for this article.
References
1.
MillettGA, CrowleyJS, KohHet al.A way forward: the National HIV/AIDS Strategy and reducing HIV incidence in the United States. J Acquir Immune Defic Syndr, 2010; 55:S144–S147.
2.
HorbergM, HurleyL, TownerWet al.Abstract 484; HIV quality metrics: associations between retention in care and maximal viral control. 49th Annual Meeting of the Infectious Diseases Society of America, Boston, Massachusetts: Infectious Diseases Society of America, 2011.
3.
MugaveroMJ, WestfallAO, ZinskiAet al.Measuring retention in HIV care: the elusive gold standard. J Acquir Immune Defic Syndr, 2012; 61:574–580.
4.
MugaveroMJ, AmicoKR, WestfallAOet al.Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr, 2012; 59:86–93.
5.
MugaveroMJ. Improving engagement in HIV care: what can we do?Top HIV Med, 2008; 16:156–161.
6.
MugaveroMJ, LinHY, WilligJHet al.Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis, 2009; 48:248–256.
7.
AbergJA, KaplanJE, LibmanHet al.Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America. Clin Infect Dis, 2009; 49:651–681.
8.
SmithLR, FisherJD, CunninghamCO, AmicoKR. Understanding the behavioral determinants of retention in HIV care: a qualitative evaluation of a situated information, motivation, behavioral skills model of care initiation and maintenance. AIDS Patient Care STDS, 2012; 26:344–355.
9.
WohlAR, CarlosJA, TejeroJet al.Barriers and unmet need for supportive services for HIV patients in care in Los Angeles County, California. AIDS Patient Care STDS, 2011; 25:525–532.
10.
California Department of Public Health Center for Infectious Diseases Office of AIDS. HIV/AIDS Surveillance In California. California Department of Public Health Office of AIDS. Sacramento, California: California Department of Public Health Office of AIDS, 2011; 10.
11.
HorbergM, HurleyL, TownerWet al.HIV quality performance measures in a large integrated health care system. AIDS Patient Care STDS, 2011; 25:21–28.
12.
California Department of Health Services. Office of AIDS. California AIDS Surveillance Reportcumulative cases as ofDecember31, 2005. 2006.
13.
KriegerN. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health, 1992; 82:703–710.
14.
GordonNP. How does the adult Kaiser Permanente membership in Northern California compare with the larger community?http://www.dor.kaiser.org/external/uploadedFiles/content/research/mhs/_2011_Revised_Site/Documents_Special_Reports/comparison_kaiser_vs_nonKaiser_adults_kpnc(1).pdf. 2012 November 30.
15.
SelbyJV, JohnsonESet al.Kaiser Permanente Medical Care Program. BLS. Pharmacoepidemiology, 4th. New York, New York: Wiley Publishing, Inc., 2005; 241–259.
16.
Center for Disease Control and Prevention. 1993. Revised Classification System for HIV Infection and Expanded Surveillance Case Definition of AIDS among Adolescents and Adults. Morbid Mortal Weekly Rep, 1992; 41:1–19.
17.
BrennanAT, MaskewM, SanneI, FoxMP. The importance of clinic attendance in the first six months on antiretroviral treatment: a retrospective analysis at a large public sector HIV clinic in South Africa. J Int AIDS Soc, 2010; 13:49.
18.
ZhangY, DouZ, SunKet al.Association between missed early visits and mortality among patients of China National Free Antiretroviral Treatment Cohort. J Acquir Immune Defic Syndr, 2012; 60:59–67.
19.
ColubiMM, Perez-EliasMJ, EliasLet al.Missing scheduled visits in the outpatient clinic as a marker of short-term admissions and death. HIV Clin Trials, 2012; 13:289–295.
20.
FleishmanJA, YehiaBR, MooreRD, KorthuisPT, GeboKA. For the HIVRN. Establishment, retention, and loss to follow-up in outpatient HIV care. J Acquir Immune Defic Syndr, 2012; 60:249–259.
21.
HoweCJ, ColeSR, NapravnikS, EronJJ. Enrollment, retention, and visit attendance in the University of North Carolina Center for AIDS Research HIV clinical cohort, 2001–2007. AIDS Res Hum Retroviruses, 2010; 26:875–881.
22.
TobiasCR, CunninghamW, CabralHDet al.Living with HIV but without medical care: barriers to engagement. AIDS Patient Care STDS, 2007; 21:426–434.
23.
AidalaAA, LeeG, AbramsonDM, MesseriP, SieglerA. Housing need, housing assistance, and connection to HIV medical care. AIDS Behav, 2007; 11:101–115.
24.
Antiretroviral Therapy Cohort C. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. Lancet, 2008; 372:293–299.
25.
California Department of Health Care Services Medi-Cal Managed Care Division. Medi-Cal Managed Care Program 2010 CAHPS Summary Report. California Department of Health Care Services Medi-Cal Managed Care Division. Sacramento, California: Health Services Advisory Group, Inc., 2011; 1–100.
26.
California Office of the Patient Advocate. How Does Your Health Plan Measure Up?January2012. Comparisons of health plans and medical groups operating in the state of California. http://www.opa.ca.gov/. 2012 November 30.
27.
CatzSL, McClureJB, JonesGN, BrantleyPJ. Predictors of outpatient medical appointment attendance among persons with HIV. AIDS Care, 1999; 11:361–373.
28.
GiordanoTP, HartmanC, GiffordAL, BackusLI, MorganRO. Predictors of retention in HIV care among a national cohort of US veterans. HIV Clin Trials, 2009; 10:299–305.
29.
HallHI, GrayKM, TangT, LiJ, ShouseL, MerminJ. Retention in care of adults and adolescents living with HIV in 13 US Areas. J Acquir Immune Defic Syndr, 2012; 60:77–82.
30.
MugaveroMJ, LinHY, AllisonJJet al.Racial disparities in HIV virologic failure: do missed visits matter?J Acquir Immune Defic Syndr, 2009; 50:100–108.
31.
YongMK, ElliottJH, WoolleyIJ, HoyJF. Low CD4 count is associated with an increased risk of fragility fracture in HIV-infected patients. J Acquir Immune Defic Syndr, 2011; 57:205–210.
32.
GiordanoTP, GiffordAL, WhiteACJr.et al.Retention in care: a challenge to survival with HIV infection. Clin Infect Dis, 2007; 44:1493–1499.
33.
MagnusM, SchmidtN, KirkhartKet al.Association between ancillary services and clinical and behavioral outcomes among HIV-infected women. AIDS Patient Care STDS, 2001; 15:137–145.
34.
The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States. The White House Office of National AIDS Policy, 2010.
35.
National Quality Forum. Voting Draft Report: National Voluntary Consensus Standards: Infectious Disease Endorsement Maintenance 2012. Washington, DC: National Quality Forum, November19, 2012.
36.
CullyJA, MignognaJ, StanleyMAet al.Development and pilot testing of a standardized training program for a patient-mentoring intervention to increase adherence to outpatient HIV care. AIDS Patient Care STDS, 2012; 26:165–172.
