Missed Initial Medical Visits: Predictors, Timing, and Implications for Retention in HIV Care

Abstract

HIV disproportionately affects racial/ethnic minorities and individuals living in the southern United States, and missed clinic visits account for much of this disparity. We sought to evaluate: (1) predictors of missed initial HIV medical visits, (2) time to initial visit, and (3) the association between initial visit attendance and retention in HIV care. Chart reviews were conducted for 200 consecutive HIV-infected patients (100 in Dallas, 100 in San Antonio) completing case management (CM) intake. Of these, 52 (26%) missed their initial visit, with 22 (11%) never presenting for care. Mean age was 40 years, 85% were men, >70% were of minority race/ethnicity, and 28% had a new HIV diagnosis. Unemployment (OR [95% CI] = 2.33 [1.04-5.24], p = 0.04) and lower attendance of CM visits (OR = 3.08 [1.43-6.66], p = 0.004) were associated with missing the initial medical visit. A shorter time to visit completion was associated with CD4 ≤ 200 (HR 1.90 [1.25-2.88], p = 0.003), Dallas study site (HR = 1.48 [1.03-2.14], p = 0.04), and recent hospitalization (HR = 2.18 [1.38-3.43], p < 0.001). Patients who did not complete their initial medical visit within 90 days of intake were unlikely to engage in care. Initial medical visit attendance was associated with higher proportion of visits attended (p = 0.04) and fewer gaps in care (p = 0.01). Missed medical visits were common among HIV patients initiating or reinitiating care in Texas. Employment and CM involvement predicted initial medical visit attendance, which was associated with retention in care. New, early engagement strategies are needed to decrease missed visits and reduce HIV health disparities.

Improving HIV Care Engagement in the South from the Patient and Provider Perspective: The Role of Stigma, Social Support, and Shared Decision-Making

“…In particular, they requested interventions that would enhance their sense of a trusting relationship with their providers and a safe, supportive clinic environment. We previously demonstrated that more frequent case management appointments were associated with improved attendance at the IMV in this setting, 24 and patient participants in this study expressed the important role case managers play in their ability to engage in care. This aligns with many existing evidence-based care engagement interventions, which emphasize the role of support from case managers and patient navigators.…”

“…First, patient participants who were interviewed were contactable and willing to be interviewed, so the perspectives of those who are unreachable are not included. However, data from our study and other investigations on engagement in care over time suggest that many people who miss their initial provider visit go through cycles of engagement, 24,33 and we captured many of those perspectives. The study design is cross sectional, and we did not capture changes in individuals' perspectives over time.…”

“…Reduced wait times for the initial medical visit, a second structural intervention suggested by providers in this study, has been shown to be associated with engagement in care in our prior work and in other settings. 24,35 However, patient participants also emphasized the need for relational interventions. In particular, they requested interventions that would enhance their sense of a trusting relationship with their providers and a safe, supportive clinic environment.…”

“…In two large safety net clinics serving majority African Americans and Hispanics living with HIV in Dallas and San Antonio, Texas, 26% of individuals who linked to clinic through an initial case management visit missed their initial medical provider visit (IMV). 24 Patients with less case management contact and those who were unemployed were more likely to miss their IMV. Attending the IMV was associated with increased overall engagement in care and fewer gaps in care, while patients who did not complete their IMV within 90 days of case management intake were unlikely to ever engage in care in the clinic.…”

“…Attending the IMV was associated with increased overall engagement in care and fewer gaps in care, while patients who did not complete their IMV within 90 days of case management intake were unlikely to ever engage in care in the clinic. 24 To adapt interventions to the needs of majority/minority clinics in the south, we conducted a cross-sectional qualitative study to examine facilitators and barriers to attending HIV medical care from patient and provider perspectives in these same two large Texas safety net clinics. Our goal was to ascertain differences in perspective between those who engaged in care and those who did not and to solicit clinic provider perspectives to more effectively embed interventions in the context of these two clinics.…”