HIV Patients Who Miss Office Visits at Higher Risk of Death

Initial office visits in the first year after diagnoses of HIV are crucial to establish care, offer counseling, and to start antiretroviral therapy in a timely manner.¹ A 2012 single-site study in an underinsured population showed that missing office visit in the first year correlated with increased mortality.¹

A new study published in the journal AIDS Patient Care and STDs, examined the impact of missing office appointments in the Kaiser Permanente Northern California health system, which provides HIV care to more than 20 000 insured HIV-positive patients. The investigators analyzed the database for missed office visits by patients who missed visits in the first year following diagnosis. A visit was recorded as missed if the patient failed to keep the appointment and if neither the provider nor the patient had canceled it. The investigators also examined the demographics and clinical parameters associated with missed visits.²

Out of 2811 patients eligible for analysis, 1844 patients (66 %) had at least one missed visit and of those patients, 11.9 % had missed more than 5 visits. The results showed a significant correlation between the number of missed visits and mortality, with mortality increasing substantially as the number of missed visits increased.²  Patients with more than a single missed office visit had a 71% increased risk of mortality (HR=1.71, p=.001) with a 12% increased rate per missed visit (HR=1.12, p <.001). The corresponding risk of death over 12 years was 9.4%, 12.6%, 17.5%, and 25.6% for patients with 0, 1 to 2, 3 to 5, and more than 5 missed visits, respectively. The differences were highly statistically significant across these categories (p <.001).² Among the demographic factors examined, the investigators found that younger age, Black or Latino race/ethnicity, intravenous drug use, heterosexuality, and CD4+ count <200 cells/µL were associated with missed visits.²

This data from an insured population confirms previous single-site studies in an underinsured population and suggests that the association of missed visits and increased mortality in HIV-infected patients is related to factors other than access to care. Early retention in HIV care is essential. Missed office visits are lost opportunities to start and monitor antiretroviral therapy and to provide critically needed services to a highly vulnerable population. 

References
1. Mugavero MJ, Amico KR, Westfall AO, et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr 2012;59:86–93.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237801/pdf/nihms330945.pdf (Full text)
2. Horberg MA, Hurley LB, Silverberg MJ, Klein DB, Quesenberry CP, Mugavero MJ. Missed Office Visits and Risk of Mortality Among HIV-Infected Subjects in a Large Healthcare System in the United States. AIDS Patient Care STDS. 2013 Aug;27(8):442-9. doi: 10.1089/apc.2013.0073 http://www.ncbi.nlm.nih.gov/pubmed/?term=AIDS+Patient+Care+STDS.+2013+Aug%3B27(8)%3A442-9.+doi%3A+10.1089%2Fapc.2013.0073 abstract