Abigail Zuger, MD

A pattern of making and missing appointments confers additional mortality risk.

Taking good care of patients who never show up is impossible, but translating this self-evident truth into numerical terms has not been easy. Several formal metrics for measuring “retention in care” for HIV-infected patients have been proposed, and a large study now evaluates their validity.

Researchers correlated patterns of clinic attendance with mortality among 3672 antiretroviral therapy (ART)-naive HIV-infected patients (80% male, 53% white; mean baseline CD4 count, 220 cells/mm3) starting combination ART at one of five clinics in the U.S. between 2000 and 2010. Two years after enrollment, about 60% met at least one of two slightly different accepted definitions of retention in care, both of which require at least four clinic visits spaced out over a 2-year period.

After a median 6-year follow-up, overall mortality in the cohort was 9%. Mortality was more than twice as high among those not retained in care as defined by either metric than among those retained in care. However, quantity of missed visits over the initial 2-year period was also an independent predictor of mortality, increasing risk both among those considered retained in care and among those considered not retained in care.

Citation(s):

Mugavero MJ et al. Beyond core indicators of retention in HIV care: Missed clinic visits are independently associated with all-cause mortality. Clin Infect Dis 2014 Aug 28; [e-pub ahead of print].

Armstrong WS and Del Rio C.Falling through the cracks and dying: Missed clinic visits and mortality among HIV-infected patients in care. Clin Infect Dis 2014 Aug 28; [e-pub ahead of print].