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In Newly Diagnosed Patients, Watch Out for Missed Appointments!

Summary and Comment |
September 12, 2013

In Newly Diagnosed Patients, Watch Out for Missed Appointments!

  1. Paul E. Sax, MD

In a privately insured patient population, missing an office visit was among the strongest predictors of mortality.

  1. Paul E. Sax, MD

Several studies have demonstrated that patients who miss scheduled appointments have unfavorable clinical outcomes. A recent study extends this observation to privately insured patients.

The study involved adults who received a diagnosis of HIV infection between 1997 and 2007 at Kaiser Permanente Northern California, excluding those who died <1 year after diagnosis. Follow-up was conducted through the end of 2009. In all, 2811 patients (88% male, 50% white, 21% black, 18% Latino) were eligible for analysis; 62% reported being a man who has sex with men as their HIV risk factor. Only 2% had public insurance. At diagnosis, the median CD4 count was 310 cells/mm3, and the median viral load was 39,984 copies/mL

Sixty-six percent of the participants had at least one missed visit during the first year after diagnosis. There were 226 deaths during the 12-year follow-up period, with mortality risk increasing significantly as more visits were missed. Specifically, the risk for death was 9%, 13%, 18%, and 26% for patients with no, one or two, three to five, and more than five missed appointments (P<0.001). Compared with individuals not missing any visits, those who did miss visits had a hazard ratio for death of 1.71 (P=0.001). CD4-cell count aside, this factor was the single strongest predictor of mortality. Each missed visit increased the risk for death by an additional 12%.

Comment

Although these findings may be intuitively obvious to experienced HIV clinicians, the study nicely quantifies a patient group at high risk for poor outcome — individuals who miss appointments. That this phenomenon has been observed across multiple payors and also in other countries emphasizes the importance of steady engagement in care to maximize survival. One suspects that having regular clinic visits strongly correlates with antiretroviral therapy adherence — an analysis these investigators could do in the future, because most of the patients received their medications through internal Kaiser Permanente pharmacies.

  • Disclosures for Paul E. Sax, MD at time of publication Consultant / Advisory board Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Janssen; Merck Grant / research support NIH; Bristol-Myers Squibb; Gilead; GlaxoSmithKline; Merck Editorial boards Medscape; UpToDate Leadership positions in professional societies Mass ID Society (Vice President)

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