In a large geographically diverse sample of patients engaged in routine HIV primary care, past HIV appointment attendance emerged as the most powerful predictor of future attendance, according to a study published in AIDS and Behavior.
Recently, considerable attention has focused on the HIV care continuum. Approximately half of individuals diagnosed with HIV infection in the United States are not engaged in regular medical care, and transmission from these individuals accounts for an estimated 61% of new HIV cases. Therefore, improving HIV care engagement represents an enormous opportunity to maximize both the treatment and public health prevention benefits of antiretroviral therapy. Despite the many approaches used to measure engagement and retention in HIV care, no clear gold standard has been established. Because missed clinical visits are immediately actionable by clinic staff, proactive identification of patients at high risk for future no shows and intervention to prevent drop out holds promise as a cost-effective approach. Therefore, this study used demographic, clinical, and behavioral data from a network of nationally distributed clinics in the United States to develop a clinically relevant prediction model for identifying patients currently engaged in care who are at risk for missing their subsequent visit.
Data came from the Center for AIDS Research Network of Integrated Clinical Systems (CNICS), a collaboration of 8 geographically diverse, academically affiliated HIV primary care clinics. All CNICS patients with ≥2 attended HIV primary care appointments in 2002 through 2015 at 6 CNICS sites were included. The unit of analysis was each attended visit, and for each attended visit, the outcome was defined as whether the subsequent scheduled visit was attended or a no-show. The primary aim of this study was to develop a predictive model for whether a patient would attend vs miss (no-show) a scheduled HIV primary care appointment. Potential predictors of missed visits were defined a priori from 3 categories: demographic and contextual, clinical, and psychosocial characteristics.
The most dramatic bivariate variation in no-show risk across subgroups was for past-year missed visits. Patients who had not missed any appointments in the previous year at the time of an attended visit had a 9% no-show risk for the next scheduled appointment. Patients who had missed 4 or more visits had a no-show risk of 31% for the next visit. Past-year missed visits had a strong predictive strength compared with the relatively minor additional predictive benefit of other demographic, clinical, and psychosocial characteristics. Those classified in the “high-risk” no-show group based solely on past missed visits were on average of younger age, more likely to be uninsured, less likely to be on antiretroviral therapy or reporting nonadherence, less likely to have viral suppression, more likely to have moderate to severe symptoms of depression and anxiety, and more likely to report current illicit drug use than those in the low or moderate risk groups.
Overall, the investigators concluded that, “Clinic-based strategies to risk stratify patients based upon past visit attendance with targeted deployment of evidence-informed retention interventions should be evaluated in an effort to meaningfully address the largest gap on the HIV care continuum, an area of urgent need.”
Pence BW, Bengston AM, Christopoulos KA, et al. Who will show? Predicting missed visits among patients in routine HIV primary care in the United States [published online July 13, 2018]. AIDS Behav. doi: 10.1007/s10461-018-2215-1