Study Finds Factors Linked to Missing Visits for HIV Care

Fran Lowry

June 11, 2012

June 11, 2012 (Miami Beach, Florida) — Being younger, being covered by Medicare or Medicaid insurance, and having a detectable viral load at baseline were significantly associated with missed visits in a study of retention in HIV primary care.

The findings were presented here at the 7th International Conference on HIV Treatment and Prevention Adherence.

"Retaining patients in HIV primary care promotes viral suppression, which reduces risk of HIV transmission," said first author Jason Craw, MPH, from ICF International in Atlanta, Georgia.

"Evaluating the demographic and behavioral variables, barriers to care, and patient unmet needs may enhance our understanding of retention and help target interventions to improve patient outcomes," Craw said.

In their study, Craw and his associates assessed retention in primary care among 611 patients enrolled in the control group of a trial conducted by the Centers for Disease Control and Prevention and the Health Resources and Services Administration, which involved 6 HIV clinics in the United States.

Retention in care was examined using electronic clinic visit records. Two measures of retention were assessed. One was 4-month visit constancy, which measures the regularity of being seen for care and was defined as keeping at least 1 primary care visit in each of 3 consecutive 4-month intervals. The second was multiple missed visits, defined as having 2 or more missed (no-show) visits in 12 months after enrolment.

To be included in the study, patients had to be at least 18 years of age. They also had to have missed 1 or more primary care visits in the previous 12 months, had to have failed to make at least 1 primary care visit in each 6-month period in the previous 12 months, or had to be a new patient to HIV care or a new patient at the clinic.

Participants completed a computer survey at study entry to provide information on demographic and behavioral variables, unmet needs, and barriers to care.

Study Results

Of the cohort, 37% were female, 67% were black, 18% were Hispanic, and 12% were white. Mean age was 44 years.

More than half of the participants (54%) failed to keep at least 1 visit in all 3 of the 4-month intervals. In addition, 43% missed 2 or more visits in a 12-month period.

On multivariate analyses, factors significantly associated with missing 2 or more visits were being younger (18 to 39 years) as opposed to older (50 years and older), being insured with Medicare or Medicaid as opposed to private insurance, and having a detectable baseline viral load (at least 200 copies/mL) as opposed to an undetectable baseline viral load (below 200 copies/mL), Craw reported.

Patients 18 to 29 years of age were 35% more likely than those 50 years or older to miss 2 or more visits, and patients 30 to 39 years were 26% more likely than those 50 years and older to miss 2 or more visits.

Patients covered by Medicare were 42% more likely and patients covered by Medicaid were 36% more likely than privately insured patients to miss 2 or more visits.

Patients with a detectable baseline viral load were 43% more likely to miss 2 or more visits than patients with an undetectable viral load at baseline.

No significant associations were found for the 4-month visit constancy outcome, Craw reported.

"These 2 retention measures captured different aspects of care-seeking behavior. There are patients who can be seen regularly for care but who still do not show up for a lot of visits, and then you have patients who may not miss many visits, but they also may not be seen regularly for care because they schedule appointments so erratically that they end up having a large gap in care," he said.

More Research Needed to Determine Retention Gold Standard

"We need additional research to investigate whether or not there is a clear gold standard for measuring retention in care. It needs to be tied to which retention measures best predict suppressed viral load; ultimately, the goal is to not only retain patients in care, but also to have a suppressed viral load so that risk of transmission is lower," he said.

"This large study analyzed factors that predicted retention in care," José M. Zuniga, PhD, MPH, from the International Association of Physicians in AIDS Care in Washington, DC, and cochair of the conference, told Medscape Medical News.

"The results help identify patients in care who are at risk for poor retention — younger people, people with needs, and those with detectable viral loads. Care programs should focus attention to these at-risk populations," Dr. Zuniga said.

Mr. Craw and Dr. Zuniga have disclosed no relevant financial relationships.

7th International Conference on HIV Treatment and Prevention Adherence: Abstract 79940. Presented June 4, 2012.


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