Methods: We obtained de-identified, patient-level medical records data from a large, urban, HIV/AIDS clinic in southeastern United States. The sample included 1,159 adults (≥ 18 years old) living with HIV who received HIV primary care services at the clinic. A primary care addresses routine medical care and is scheduled in advance (emergency, walk-in visits or specialty care not included). The primary outcome was retention (specifically, lack of retention), measured by the number of missed HIV primary care visits (0, 1-2, or 3+ missed visits). A missed visit is one that was not cancelled at any point prior to the scheduled visit. Predictors included: sex, age, race, education level, Ryan White HIV/AIDS Program (RWHAP) support services (yes/no), primary healthcare payer type (RWHAP, public insurance, private insurance, none), and poverty (based on monthly income). Multivariable multinomial logistic regressions compared factors associated with missing 1-2 vs. 0 visits, 3+ vs. 0 visits, and 3+ vs. 1-2 visits.
Results: In the full multivariable model, socioeconomic and demographic characteristics remained significantly associated with missing either 1-2 or 3+ visits (versus 0 missed visits--100% retention), including poverty, lack of RWHAP support services, not having at least a high school degree, and younger age. Compared with uninsured patients, those with private insurance had half the risk of missing 1-2 versus 0 visits (risk ratio [RR]=0.48, 95% confidence interval [CI]=0.28-0.83). Only poverty remained predictive of missing 3+ versus 1-2 visits (RR=2.70, 95% CI =1.49-4.88).
Conclusions and Implications: Patients at risk for missing 3+ visits, and who may have been at higher mortality risk, were not so different from patients who missed 1-2 visits. This finding is particularly relevant in terms of its potential to inform clinical interventions to improve retention in care. Social workers are well-suited to helping patients attend their appointments by supporting them to access support services and health insurance/healthcare assistance and, therefore, fulfill a vital role in HIV care.
Mugavero MJ, Westfall AO, Cole SR, Geng EH, Crane HM, Kitahata MM, et al. Beyond core indicators of retention in HIV care: missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis. 2014;59(10):1471-9.