title: Missed office visits and risk of mortality among HIV-infected subjects in a large healthcare system in the United States.
abstract: Linkage and retention in care soon after HIV diagnosis improves clinical outcomes. Conversely, missed visits after diagnosis are associated with increased mortality in the public care setting. We analyzed mortality among newly diagnosed HIV patients ≥18 years old in a large private care setting between 01/01/1997 and 12/31/2009, comparing patients who missed visits in their first year following diagnosis (index period) with those who did not. Patients who died during the index period were excluded. Hazard ratios (HR) for association of missed visits and mortality were obtained by Cox proportional hazards regression, adjusting for patient demographics, CD4+ counts, and AIDS-defining conditions (CDC, 1993) at diagnosis. We also evaluated risk factors of missed visits by multivariable logistic regression. 2811 patients were included, of whom 65% had ≥1 missed visit, and 226 patients died during follow-up. Patients with ≥1 missed visit had a 71% increased mortality risk (HR=1.71, p=0.001) with 12% increased rate per missed visit (HR=1.12, p<0.001). Factors associated with missed visits were younger age (OR=1.69 compared to 60+ years), Black and Latino race/ethnicity (OR=1.54, 1.48 respectively, compared to Caucasians), injection drug use (OR=2.50 compared to men who have sex with men), and lower CD4+ (OR=1.43 for CD4+ 100-199 cells/μL, OR=1.39 for 50-99 cells/μL, and OR=1.63 for CD4+ <50 cells/μL, compared with CD4+ >500 cells/μL). In an insured patient population, missed visits in the first year of HIV care are common and associated with increased mortality. Early retention in HIV care is critical to improving outcomes.
authors.affiliation: Mid-Atlantic Permanente Research Institute, Rockville, MD 20852, USA. michael.horberg@kp.org
authors.forename: Michael A
authors.initials: MA
authors.lastname: Horberg
authors.forename: Leo B
authors.initials: LB
authors.lastname: Hurley
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Silverberg
authors.forename: Daniel B
authors.initials: DB
authors.lastname: Klein
authors.forename: Charles P
authors.initials: CP
authors.lastname: Quesenberry
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Mugavero
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D001071:Appointments and Schedules; D018791:CD4 Lymphocyte Count; D003695:Delivery of Health Care; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care; D016016:Proportional Hazards Models; D012307:Risk Factors; D012959:Socioeconomic Factors; D015996:Survival Rate; D014481:United States / Q000453:epidemiology; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents