Annotated Abstracts of Journal Articles
2014, 4th Quarter
Annotations by Oliver Freudenreich, MD, FAPM and Mary Ann Cohen, MD, FAPM
Also of interest:
The Centers for Disease Control and Prevention, in collaboration with several other agencies and partner organizations, updated and expanded their 2003 recommendations regarding HIV prevention in the US. This is one of the available documents on the CDC’s website for clinical providers.
ANNOTATION (Freudenreich & Cohen)
The Finding: Using data from eight Centers for AIDS Research (CFAR) sites that collectively form a clinical cohort (called CNICS), the authors showed an increased in all-cause mortality if patients failed to achieve retention in clinical care (which was operationally defined using measures from IOM and DHHS). In addition, missed visits independently increased mortality risk in those patients considered retained in care.
Strength and Weaknesses: This analysis was novel in that it combined two measures of engagement in care (overall retention in care, which is traditionally based on attended visits, versus missed clinical visits). However, the study follow-up period was rather short (only two years). The study also does not tell us how to prioritize patients who have missed clinic visits.
Relevance: In the US, only a minority of patients (30% based on 2011 data from the CDC) achieve the important surrogate marker goal of viral suppression. While testing will identify patients who are unaware that they are infected, linking patient to care and retaining them are equally critical elements of the HIV care cascade where our system is clearly failing many patients. The current study adds an easily measurable metric (“no-show visits”) that clinicians can use as points of discussion with established patients who miss visits, particularly if there are clinical concerns about the no-show visits (not all no-show visits will be equally concerning).
Background: The continuum of care is at the forefront of the domestic human immunodeficiency virus (HIV) agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Core indicators for retention in care are calculated based on attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value of missed clinic visits for all-cause mortality.
Methods: We conducted a multisite cohort study of 3672 antiretroviral-naive patients initiating antiretroviral therapy (ART) during 2000-2010. Retention in care was measured by the IOM and DHHS core indicators (2 attended visits at defined intervals per 12-month period), and also as a count of missed primary HIV care visits (no show) during a 24-month measurement period following ART initiation. All-cause mortality was ascertained by query of the Social Security Death Index and/or National Death Index, with adjusted survival analyses starting at 24 months after ART initiation.
Results: Among participants, 64% and 59% met the IOM and DHHS retention core indicators, respectively, at 24 months. Subsequently, 332 patients died during 16 102 person-years of follow-up. Failure to achieve the IOM and DHHS indicators through 24 months following ART initiation increased mortality (hazard ratio [HR] = 2.23; 95% confidence interval [CI], 1.79-2.80 and HR = 2.36; 95% CI, 1.89-2.96, respectively). Among patients classified as retained by the IOM or DHHS clinical core indicators, >2 missed visits further increased mortality risk (HR = 3.61; 95% CI, 2.35-5.55 and HR = 3.62; 95% CI, 2.30-5.68, respectively).
Conclusions: Beyond HIV retention core indicators, missed clinic visits were independently associated with all-cause mortality. Caution is warranted in relying solely upon retention in care core indicators for policy, clinical, and programmatic purposes.
Armstrong WS, Del Rio C: Falling through the cracks and dying: missed clinic visits and mortality among HIV-infected patients in care
Clin Infect Dis 2014; 59(10):1480-2