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Beyond Core Indicators of Retention in HIV Care: Missed Clinic Visits are Independently Associated with All-cause Mortality
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......[from Editorial: this study by Mugavero et al with the CFAR Network of Integrated Clinical Systems (CNICS) investigators highlights the importance of finding meaningful measures that are associated with outcomes (8).....While the association between missed visits and death intuitively seems to be associated with loss of virologic control of HIV, this has not been established.....Accurately defining who is out of care or lost to care is vital and will also limit using scarce resources to track patients who have transferred care elsewhere or have died. The current shift in insurance status due to the Affordable Care Act complicates this picture as patients are more likely to change care providers than ever before. Combining state or municipality data with clinic level data by building close collaborations with Departments of Public Health (DPHs) will improve the ability to correctly classify patients who appear non adherent to visits at the clinic level......a number of obstacles prevent people with HIV from experiencing optimal health. Among these are late diagnosis, delayed access to care, breaks in care, delayed prescription and intermittent use of antiretroviral therapy, untreated mental health and substance use disorders and unmet basic needs].......Our findings suggest that the additional inclusion of missed clinic visits in HIV policy, clinical and public health planning is prudent to optimize classification, risk stratification, and resource allocation to those in greatest need.....cost and time-intensive peer mentor, patient navigation, and intensive case management programs are among the few evidenced-based approaches to enhancing HIV care engagement [15, 23]. Such programs could be targeted to those with missed clinic visits......At 24-months following ART initiation, 64% and 59% of patients met the IOM and DHHS retention core indicators, respectively, with an average of 2.1 missed (no show) visits accrued. Subsequently, 332 patients (9.0%) died during 16,102 person-years follow-up (20.6 deaths per 1,000 person-years). Mortality rates were lower among patients classified as retained by the IOM indicator, DHHS indicator and with zero missed visits (16.0, 15.3, and 11.3 deaths per 1,000 person years, respectively) com pared to those classified as not retained or experiencing missed clinic visits.......older age, black/African American race, and lower baseline CD4 count were consistently associated with increased mortality.
Clinical Infectious Diseases Advance Access published August 4, 2014
Michael J. Mugavero1, Andrew O. Westfall1, Stephen R. Cole2, Elvin H. Geng3, Heidi M. Crane4, Mari M. Kitahata4, W. Christopher Mathews5, Sonia Napravnik3, Joseph J. Eron3, Richard D. Moore6, Jeanne C. Keruly6, Kenneth H. Mayer7,8, Thomas P. Giordano9,10, James L. Raper1, on behalf of CFAR Network of Integrated Clinical Systems (CNICS)
1University of Alabama at Birmingham
2University of North Carolina, Chapel Hill
3University of California, San Francisco
4University of Washington
5University of California, San Diego
6Johns Hopkins University
7Fenway Community Health Center
8Harvard University
9Michael E. DeBakey VA Medical Center
10Baylor College of Medicine
The continuum of care is at the forefront of the domestic HIV agenda, with the Institute of Medicine (IOM) and Department of Health and Human Services (DHHS) recently releasing clinical core indicators. Retention in care core indicators are calculated based upon attended HIV care clinic visits. Beyond these retention core indicators, we evaluated the additional prognostic value missed clinic visits for all-cause mortality.
Methods. We conducted a multi-site cohort study of 3,672 antiretroviral-naïve patients initiating ART from 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-month post-ART initiation.
Results. Among participants, 64% and 59% met the IOM and DHHS retention core indicators at 24-months. Subsequently, 332 patients died during 16,102 person-years follow-up. Failure to achieve the IOM and DHHS indicators through 24 months post-ART initiation increased mortality (HR=2.23;95% 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.

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