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Early Missed Office Visits Post-HIV Diagnosis and Mortality in a Large Healthcare System
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Reported by Jules Levin
CROI 2012
Michael Horberg1,2, Leo Hurley1,3, Daniel Klein1,4, Michael Silverberg 1,3, Charles Quesenberry3, Michael Mugavero5
1- Kaiser Permanente HIV Interregional Initiative, Oakland, CA, 2-Mid-Atlantic Permanente Research Institute, Rockville, MD, 3- Kaiser Permanente Northern California Division of Research, Oakland, CA
4- Kaiser Permanente Northern California, Hayward, CA , 5- University of Alabama Birmingham, Birmingham, Alabama
'increased mortality associated with any missed office visit and missed visits associated with being black or latino, IDU, 18-29 yrs old, low CD4, public insurance'
DISCUSSION
Our heterogeneous patient population and extensive clinical databases afford us the opportunity to explore various health outcomes and the factors associated with poor outcomes.
Even in an insured population, missed outpatient visits in the first year post-HIV diagnosis are associated with increased mortality after the first year post-HIV diagnosis.
Several patient-level factors also are associated with increased mortality beyond the first year post-HIV diagnosis, including:
· Older age, injection drug use, initial CD4+ count <100/μL, and if the patient were diagnosed earlier in the combination antiretroviral era
Various patient-level factors are associated with missed outpatient visits in the first year, even in an insured population with multidisciplinary HIV care, including:
· Younger age, Black race, Latino, injection drug users, lower CD4+ count, and if the patient were diagnosed earlier in the combination antiretroviral era
CONCLUSIONS
Missing any visit in the first year post-HIV diagnosis is significantly associated with subsequent mortality, even in an insured patient population.
· Special attention is warranted for older populations, injection drug users, severely immunosuppressed, and patients diagnosed early in the potent antiretroviral era.
Missed outpatient visits early in care are common.
Fostering early retention in care is critical to improving health outcomes. Such efforts should be targeted for youth, racial/ethnic minorities, IDU and patients with advanced HIV infection at diagnosis.
BACKGROUND
The year following HIV diagnosis and entry to care can be a bellwether for subsequent care challenges. 1
Prior research in a more public care setting demonstrated an association between missed visits in the first year post-HIV diagnosis and subsequent mortality. 1
As the US strives to achieve the goals of the National HIV/AIDS Strategy, including increased linkage and retention in
care, understanding the implications of missed visits and the predictors of such missed visits will be crucial.
We explored the association between missed visits in the 1st year post-diagnosis and subsequent mortality risk in an
insured healthcare setting and examined which factors might lead to missed visits.
METHODS
We performed an observational cohort analysis of all newly diagnosed HIV+ patients >18 yrs old from 1/1/1999 through 12/31/2007 in the Kaiser Permanente Northern California healthcare system.
We excluded patients who died during the first year post-diagnosis (index period).
We identified all outpatient appointments (kept or missed) in the index period to a physician or nurse practitioner.
We determined mortality any time after the index period, censoring follow-up as of 12/31/2009 ( deaths were ascertained even for those who have left the system using state and national death sources).
Statistical Analysis
We employed Cox proportional hazards modeling to examine the association between missed visits and mortality, adjusting for gender, age, year of diagnosis, race/ethnicity, HIV risk behavior, AIDS status, CD4 level and insurance type (commercial or Medicare/Medicaid).
We also employed logistic regression, adjusting for the same factors and clustered by medical center and provider, to identify factors predicting missed visits.
STRENGTHS/LIMITATIONS
Strengths: Insured patient population, heterogeneity of patient-level and clinic-level factors, completeness of appointment records (though nearly 100% and would be non-differential) and mortality outcome data,
Limitations: Retrospective design, potential residual confounding, lack of documentation of reasons for missed visits
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