D\u27Aversa, J

Faulkner, Dorothy, PhD

Friel, Timothy J, MD

Nagel, Lynn

Nerino, Anthony

Strobel, Anthony

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineFactors Associated with Loss to Follow-up amongHIV-Infected Patients at an Urban, Hospital-BasedOutpatient HIV ClinicTimothy J. Friel MDLehigh Valley Health Network, Timothy.Friel@lvhn.orgAnthony NerinoLehigh Valley Health NetworkLynn NagelLehigh Valley Health Network, Lynn.Nagel@lvhn.orgJ D'AversaLehigh Valley Health NetworkAnthony StrobelLehigh Valley Health Network, Anthony.Strobel@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Community Health and Preventive Medicine Commons, Immune System DiseasesCommons, Infectious Disease Commons, Medical Sciences Commons, and the Statistics andProbability CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtFriel,T., Nerino, A., Nagel, L., D'Adversa, J., Strobel, A., & Faulkner, D. (2012). Factors associated with loss to follow-up among hiv-infectedpatients at an urban, hospital-based outpatient hiv clinic.AuthorsTimothy J. Friel MD, Anthony Nerino, Lynn Nagel, J D'Aversa, Anthony Strobel, and Dorothy Faulkner PhDThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/medicine/142References:1	 	Centers	for	Disease	Control	and	Prevention.	MMWR	2011;	60:	1618-23.	2	 Berg	MB,	Safren	SA,	Mimiaga	MJ,	et	al.	AIDS	Care	2005;	17:902-907.3	 	Mugavero	MJ,	Amico	KR,	Westfall	AO,	et	al.	J	Acquir	Immune	Defic	Syndr	2012;	59:86-93.4	 	Mugavero	MJ,		Lin	HY,		Allison	JJ,	et	al.	J	Acquir	Immune	Defic.	2009;	50:100-108.	5	 	Park	WB,	Choe	PG,	Kim	SH,	et	al.	J	Intern	Med.	2007	Mar;	261(3):268-75.6	 	Giordano	TP,	Hartman	C,	Gifford	AL,	et	al.	HIV	Clin	Trials.	2009	Sep-Oct;10(5):299-305.	Factors Associated with Loss to Follow-up among HIV-Infected Patientsat an Urban, Hospital-Based Outpatient HIV Clinic Timothy Friel1, A. Nerino2, L. Nagel1, J. D’Aversa1, A. Strobel1, J. Sabino1, D. Faulkner2(1) AIDS Activities Office of Lehigh Valley Health Network, Allentown, PA, (2) Department of Community Health and Health Studies, Lehigh Valley Health Network, Allentown, PennsylvaniaAbstract (#1058)BACKGROUND:  Loss to follow-up (LTF) from HIV care has been linked to multiple negative health outcomes, including virologic failure, disease progression and reduced survival. We sought to elaborate the primary epidemiologic factors associated with LTF among patients newly enrolled in an urban, hospital-based outpatient HIV program.  METHODS:  We completed a retrospective medical record review of all new patients presenting for care between 2005 and 2008. LTF was defined as an interruption between medical visits of more than 180 days. Alpha was set at <0.05 with a 95% CI.  Bivariate analyses were performed using SPSS 15.0 (IBM, Inc., Chicago, IL).   RESULTS:  Among the 321 patients included in the analysis, three groups were identified: patients without lapses in medical visits (No LTF; 37%); patients intermittently LTF who later returned to care (ILTF; 30%), and patients permanently lost to follow-up (PLTF; 33%). Demographic variables associated with PLTF included younger age (p=0.033) and residence in a medical, corrections or rehabilitation facility (p=0.012). Other significant risk factors included prior incarceration (p=0.012), reported use of alcohol and/or recreational drugs (p=0.015), and evidence of anxiety or depression on routine screening at program intake (p=0.016 and 0.005, respectively). A transmission risk factor of injection drug use (IDU) was associated with PLTF (p=0.002), while a CD4 count less than 100 at program entry correlated with increased retention in care (p=0.035). Conditioned bivariate analyses demonstrated reduced engagement occurring more commonly among young African Americans (p=0.026), White, non-Hispanic IDU (p<0.001) and women with histories of arrest (p=0.036) and incarceration (p=0.036). Conditioned bivariate analyses demonstrated reduced engagement occurring more commonly among young Black/African Americans (p=0.026), White, non-Hispanic IDU (p<0.001) and women with histories of arrest (p=0.036) and incarceration (p=0.036). CONCLUSION:  LTF is an all-too-common phenomenon in HIV care with potentially significant consequences for patients. Multiple clinical, demographic and psychosocial factors are associated with suboptimal retention in care. Special strategies to enhance the engagement of patients at highest risk for LTF are warranted.  •	 Loss to follow-up is an all-too-common phenomenon among patients newly enrolled in care, with more than half of these individuals exhibiting unexplained absences greater than 180 days during six years of observation.•	 Since LTF has been associated with multiple detrimental health outcomes, special strategies to enhance the engagement of HIV patients at highest risk for LTF are warranted.  •	 Prospective studies assessing the impact of programmatic interventions to improve patient retention rates are desperately warranted. ConclusionsBackground•	 Many HIV-infected Americans have failed to reap the benefits of current HIV therapies because of suboptimal rates of diagnosis, linkage, engagement and retention.1 •	 Non-adherence with medical visits has been associated with multiple undesirable outcomes:	 	 	 –	 	lower	CD4	counts	and	higher	viral	loads2		 	 	 –	 	delays	in	virologic	suppression	and	increased	HIV	viral	load	burden3		 	 	 –	 	virologic	failure4		 	 	 –	 the	development	of	AIDS-defining	illnesses5		 	 	 –	 	reduced	survival5-11	•	 Previous studies have coupled several clinical, demographic and psychosocial factors with the phenomenon of patient loss to follow-up (LTF). •	 We aimed to establish the incidence of LTF and identify the correlates of LTF among patients newly enrolled in care at the AIDS Activities Office (AAO) of Lehigh Valley Health Network, an urban, multidisciplinary primary care practice for almost 800 HIV-infected patients in Allentown, PA.Methods•	 Completed retrospective chart review of medical and case management records of all new patients enrolling into care between January 2005 and June 2008 (n=321)•	 Calculated number of days between consecutive medical visits from 2005 to 2010•	 “Loss to Follow-up” (LTF) defined as any unexplained interrruption between medical visits of greater than 180 days.•	 Potential correlates of LTF examined through bivariate and conditioned bivariate analyses using SPSS 15.0 (IBM, Inc., Chicago, IL). 	 	 	 –	 	Alpha	set	at	<0.05	with	a	95%	CI.	•	 Study approved by Institutional Review Board of Lehigh Valley Health Network. •	 More than 60% (201/321) of newly enrolled patients had at least one episode of LTF during the six years of observation. (Table I)	 	 	 –	 48%	(96/201)	were	ultimately	reengaged	in	care	(ILTF).	 	 	 –	 	Patients	with	a	single	medical	visit	accounted	for	43%	of	the	PLTF	group.•	 Several factors increased the risk of interrupted patient engagement (p<0.05). (Table II)	 	 	 –	 Demographic:	Age	<	43	years	 	 	 –	 Psychosocial:		 	 	 	 	 •	 	Reported	use	of	alcohol,	recreational	drugs	and	nicotine	 	 	 	 	 •	 	History	of	incarceration	 	 	 	 	 •	 	Temporary	residence	in	a	medical,	corrections	or	rehabilitation	facility	(almost	80%	with	some	visit	gap	and	59%	with	PLTF)	 	 	 	 	 •	 	Screening	indicating	significant	anxiety	or	depression	at	program	intake	(enrollment	in	psychiatric	services	was	not	predictive).	 	 	 –	 Clinical:	HIV	transmission	via	injection	drug	use•	 Low baseline CD4 count (<100 cells/mL) was associated with sustained retention in care. •	 Surprisingly, patients with lower incomes were less likely to have visit interruptions.Results7	 	Girodano	TP,	Gifford	AL,	White	Jr.	AC,	et	al.	Clin	Infect	Dis	2007;	44:1493-99.	8	 	Mugavero	MJ,	Lin	HY,	Willig	JH,	et	al.	Clin	Infect	Dis.	2009	Jan	15;48(2):248-56.9	 	Ndiaye	B,	Ould-Kaci	K,	Salleron	J,	et	al.	Antivir	Ther	2009;	14:	567-75.	10	 	Helleberg	M,	Engsig	FN,	Kronborg	G,	et	al.	AIDS	2012;	26:	741-48.	11	 	Horberg	M,	Hurley	L,	Klein	D,	et	al.	CROI	2012.	Abstract	1129.	•	 The following factors were not statistically correlated with LTF:	 	 	 –	 Baseline	Viral	Load	 	 	 –	 	New	HIV	or	AIDS	Diagnosis	 	 	 –	 Zip	Code/Proximity	to	Practice	 	 	 –	 	Method	of	Transportation	 	 	 –	 Marital	Status	 	 	 –	 	Children	Age	<18	years	at	Home	 	 	 –	 Education	Level	 	 	 –	 	Employment	Status	 	 	 –	 History	of	Arrest	 	 	 –	 	Insurance	Status	 	 	 –	 Enrollment	in	Mental	Health	Program	 	 	 –	 	Learning	Impairments	 	 	 –	 	Probation	or	Parole	at	Intake•	 Conditioned bivariate analysis revealed unique sub-groups with heightened risk for LTF: (Table III)	 	 	 –	 Non-Hispanic	White	Females	 	 	 –	 	Non-Hispanic	Blacks	<43	years	 	 	 –	 	Non-Hispanic	Whites	with	a	history	of	drug/alcohol	use	 	 	 –	 Females	with	histories	of	arrest	or	incarceration	 	 	 –	 	Non-Hispanic	Whites	with	histories	of	arrest	or	incarcerationPatient Categories Abbreviation DefinitionNo Loss to Follow-up No LTF Patients without any unexplained lapse in medical care >180 daysIntermittent LTF ILTF Patients intermittently lost to follow-up (>180 days) who later return to carePermanent LTF PLTF Patients permanently lost to follow-up during analysis* 45/105 PLTF patients (42.8%) only had a single medical visit. Table I. Frequency of Loss to Follow-up Among Newly Enrolled PatientsN PercentNo LTF 120 37.4%ILTF 96 29.9%PLTF 105* 32.7%TOTAL 321 100%**HADS=Hospital Anxiety and Depression ScaleTable II. Analysis of Factors Potentially Associated with Loss to Follow-up Among New Patients Variables N No LTF ILTF PLTF p Value% N % N % NGender 319            Female  38% 38 27% 27 35% 35 .670    Male  37.4% 82 31.5% 69 31.1% 68Age (Quartiles) 321    16-37 36% 32 24.7% 22 39.3% 35 .033    38-43 27.6% 21 32.9% 25 39.5% 30    44-49 39.5% 30 39.5% 30 21.1% 16    50-73 46.3% 37 23.8% 19 30% 24Race/Ethnicity 316    White Non-Hispanic 43.5% 47 24.1% 26 32.4% 35 .280    Black Non-Hispanic 34.4% 30 35.6% 31 29.9% 26    Hispanic  32.2% 39 31.4% 38 36.4% 44Initial CD4 Count 309    <=100 55.4% 41 27.0% 20 17.6% 13 .035    101 - 200  32.3% 10 25.8% 8 41.9% 13    201 - 350 29.0% 18 38.7% 24 32.3% 20    351 - 500 33.9% 19 30.4% 17 35.7% 20    501 + 33.7% 29 30.2% 36 36.0% 31Transmission Status 309    Heterosexual 37.4% 58 29.7% 46 32.9% 51 .002    MSM 47.9% 45 31.9% 30 20.2% 19    IDU 21.7% 13 28.3% 17 50% 30Drug/ETOH Use (Not Nicotine) 243    Yes 30.6% 48 31.8% 50 37.6% 59 .046    No  39.5% 34 38.4% 33 22.1% 19Drug/ETOH Use (Inc. Nicotine) 245    Yes 30.1% 53 32.4% 57 37.5% 66 .015    No 43.5% 30 37.7% 26 18.8% 30Living Situation 230    With Parents or Family 34.6% 27 41.0% 32 24.4% 19 .012    With Spouse/Partner 40.0% 26 36.9% 24 23.1% 15    Alone/Roommate 32.1% 17 34.0% 18 34.0% 18    Institution/Treatment Ctr 20.6% 7 20.6% 7 58.8% 20Poverty Status 280    < Federal Poverty Level 42.1% 96 30.3% 69 27.6% 63 .009    100-200% Poverty Level 57.7% 15 42.3% 11 0% 0    >200% 26.9% 7 50.0% 13 23.1% 6History of Incarceration 216    Yes 23.5% 19 33.3% 27 43.2% 35 .012    No 40.0% 54 34.1% 46 25.9% 35Anxiety Score (HADS)** 252    Low (0 - 7) 42.4% 50 42.4% 50 15.3% 18 .016    Moderate (8 - 10) 41.3% 19 37.0% 17 21.7% 10    High (11 - 21) 40.9% 36 25.0% 22 34.1% 30Depression Score (HADS) ** 252    Low (0 - 7) 38.6% 61 39.9% 63 21.5% 34 .005    Moderate (9 - 10) 62.0% 31 22.0% 11 16.0% 8    High (11 - 21) 29.5% 13 34.1% 15 36.4% 16Table III. Conditioned Bivariate Analysis of LTF Among New HIV Patients Variables N No LTF ILTF PLTF p Value% N % N % NGender* Race/Ethnicity 314            White Non-Hispanic      Female  30.0% 6 10.0% 2 60.0% 12 .012    Male  46.6% 41 27.3% 24 26.1% 23    Black Non-Hispanic Not Significant    Hispanic Not SignificantAge* Race/Ethnicity 316    White Non-Hispanic Not Significant    Black Non-Hispanic    16-37 23.8% 5 38.1% 8 38.1% 8 .026    38-43 19.0% 4 33.3% 7 47.6% 10    44-49 33.3% 7 52.4% 11 14.3% 3    50-73 58.3% 14 20.8% 5 20.85 5    Hispanic  Not  SignificantTransmission Status* Gender 309    Female        Heterosexual 44.4% 32 26.4% 19 29.2% 21 .042        IDU 19.0% 4 23.8% 5 57.1% 12    Male        Heterosexual 31.3% 26 32.5% 27 36.1% 30 .005        MSM 48.9% 45 32.6% 30 18.5% 17        IDU 23.1% 9 30.8% 12 46.2% 18Transmission Status* Race/Ethnicity 309    White Non-Hispanic                Heterosexual 30.8% 12 28.2% 11 41% 16 .001        MSM  57.9% 33 24.6% 14 17.5% 10        IDU 10.0% 1 10.0% 1 80.0% 8    Black Non-Hispanic  Not Significant    Hispanic Not Significant Drug/Alcohol Use* Race Ethnicity (exc. Nicotine) 239          White Non-Hispanic                 Yes 36.4% 16 18.2% 8 45.5% 20 .014        No 45.8% 11 41.7% 10 12.5% 3    Black Non-Hispanic Not Significant    Hispanic Not SignificantArrest or Incarceration* Gender 244    Female                Prior Arrest 23.8% 10 33.3% 14 42.9% 18 .036        No Prior Arrest 51.4% 18 25.7% 9 22.9% 8    Male Not Significant    Female        Prior Incarceration 20.0% 4 25.0%  5 55.0% 11 .036        No Prior Incarceration 47.6% 20 28.6% 12 23.8% 10    Male Not SignificantArrest or Incarceration* Race/Ethnicity 213    White Non-Hispanic               Yes 24.4% 10 31.7% 13 43.9% 18 .012        No 57.5% 15 26.9% 7 15.4% 4    Black Non-Hispanic Not Significant    Hispanic Not Significant

Factors Associated with Loss to Follow-up among HIV-Infected Patients at an Urban, Hospital-Based Outpatient HIV Clinic

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Factors Associated with Loss to Follow-up among HIV-Infected Patients at an Urban, Hospital-Based Outpatient HIV Clinic

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