Missed visits common in early HIV care linked to death in US
By Mark Mascolini
In a private healthcare system in the United States, two thirds of people diagnosed with HIV missed at least one visit during their first year of care, and missing visits raised the risk of death 71 percent. Missed clinic visits have been linked to higher mortality among HIV patients in public care in the United States, but research has not addressed the clinical impact of missed visits on privately insured US patients until this study. To address that question, researchers working in the Kaiser Permanente Northern California system analyzed mortality among newly diagnosed adults entering care between January 1997 and the end of 2009.
The investigators compared mortality in people who missed a visit in their first year after HIV diagnosis with patients who kept all visits. They excluded people who died during their first year of care and determined the association between missed visits and mortality with a Cox proportional hazards regression model that adjusted for patient demographics, CD4 count, and AIDS conditions at HIV diagnosis.
Among 2811 patients evaluated, 1827 (65 percent) missed one or more visits during their first year of care and 226 (8 percent) died during follow-up. People who missed one or more visits in the first year had a 71 percent greater risk of death (adjusted hazard ratio [aHR] 1.71, P = 0.001). Mortality risk rose 12 percent with each visit missed (aHR 1.12, P < 0.001).
Missed visits were more common among younger people (odds ratio [OR] 1.69 compared with people 60 or older), Blacks and Latinos (OR 1.54 and 1.48 compared with whites), injection drug users (OR 2.50 compared with men who have sex with men), and people with a lower CD4 count (OR 1.43 for 100-199 cells/ul, OR 1.39 for 50-99 cells/ul, and OR 1.63 for less than 50 cells/ul, compared with more than 500 CD4 cells/ul).
“In an insured patient population,” the researchers conclude, “missed visits in the first year of HIV care are common and associated with increased mortality.” They stress that “earlt retention in HIV care is critical to improving outcomes.”