Missed visits and mortality among patients establishing initial outpatient HIV treatment

Abstract

Background: Dramatic increases in the number of patients requiring linkage to treatment for human immunodeficiency virus (HIV) infection are anticipated in response to updated Centers for Disease Control and Prevention HIV testing recommendations that advocate routine, opt-out HIV testing.

Methods: A retrospective analysis nested within a prospective HIV clinical cohort study evaluated patients who established initial outpatient treatment for HIV infection at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic from 1 January 2000 through 31 December 2005. Survival methods were used to evaluate the impact of missed visits during the first year of care on subsequent mortality in the context of other baseline sociodemographic, psychosocial, and clinical factors. Mortality was ascertained by query of the Social Security Death Index as of 1 August 2007.

Results: Among 543 study participants initiating outpatient care for HIV infection, 60% missed a visit within the first year. The mortality rate was 2.3 deaths per 100 person-years for patients who missed visits, compared with 1.0 deaths per 100 person-years for those who attended all scheduled appointments during the first year after establishing outpatient treatment (P = .02). In Cox proportional hazards analysis, higher hazards of death were independently associated with missed visits (hazard ratio, 2.90; 95% confidence interval, 1.28-6.56), older age (hazard ratio, 1.58 per 10 years of age; 95% confidence interval, 1.12-2.22), and baseline CD4+ cell count < 200 cells/mm(3) (hazard ratio, 2.70; 95% confidence interval, 1.00-7.30).

Conclusions: Patients who missed visits within the first year after initiating outpatient treatment for HIV infection had more than twice the rate of long-term mortality, compared with those patients who attended all scheduled appointments. We posit that early missed visits are not causally responsible for the higher observed mortality but, rather, identify those patients who are more likely to exhibit health behaviors that portend increased subsequent mortality.

Figure 1

Short-term (1 year) and long-term vital status of 567 HIV-infected patients establishing initial outpatient HIV care at the UAB 1917 HIV/AIDS Clinic between 1 January 2000 – 31 December 2005. Among the 543 patients who were living one year after their initial attended visit, observed mortality was 2.3 and 1.0 per 100 patient-years follow-up for those with and without a missed visit in the first year, respectively (P=0.02). Only missed visits that patients did not call ahead to notify the clinic that they would not attend their appointment were included in this measure (“no show” visits). Appointments cancelled by a patient in advance, those scheduled while a patient was hospitalized, and those cancelled by the clinic are not included in the missed visit measure. Vital status was determined by query of the Social Security Death Index (SSDI) as of 1 August 2007.

Figure 2

Kaplan-Meier survival plot among patients establishing initial outpatient HIV care at the UAB 1917 HIV/AIDS Clinic between 1 January 2000 and 31 December 2005 catgegorized by missed visit status in the first year of care. Among 567 patients, 543 patients (96%) were living one year after their initial visit; observed mortality was 2.3 and 1.0 per 100 patient-years for those with and without a missed visit in the first year, respectively (P=0.02). Only missed visits that patients did not call ahead to notify the clinic that they would not attend their appointment were included in this measure (“no show” visits). Appointments cancelled by the clinic and those scheduled while a patient was hospitalized are not included in the missed visit measure. Vital status was determined by query of the Social Security Death Index (SSDI) as of 1 August 2007.