August 20, 2019

HIV patients who missed medical visits within the past year are more likely to be no-shows in the future, according to new research from the UNC Gillings School of Global Public Health. This finding offers insight on how providers can proactively identify patients at risk of missing visits and take steps to support their appearance at future appointments.

Missing medical visits can result in negative health outcomes for patients with HIV, and research shows that 61% of new HIV cases are transmitted from HIV-positive individuals who are not currently engaged in medical care. By finding ways to spot patients who may miss future visits and dedicating special efforts to keep them in care, researchers say providers can prevent harmful outcomes for HIV patients and lower the likelihood of future virus transmission.

Dr. Brian Pence

Dr. Brian Pence

“Having patients fall out of HIV care is a big problem, both for the patients themselves and for the effort to end the HIV epidemic,” says Brian Wells Pence, PhD, professor of epidemiology at the Gillings School and lead author of the study. “Clinicians can predict whether a patient they are seeing in clinic today is likely to be a no-show for their next HIV appointment using a pretty simple metric, which allows the clinic to focus support on those most likely to fall out of care. This permits clinics to focus their resource-limited supportive services on those patients most at risk.”

The study, “Who Will Show? Predicting Missed Visits Among Patients in Routine HIV Primary Care in the United States,” was published online July 13 in AIDS and Behavior. Using data from the Center for AIDS Research Network of Integrated Clinical Systems — a collaboration of large, geographically diverse, academically affiliated HIV primary care clinics — researchers developed a predictive model for whether a patient would show up or not for their next scheduled HIV primary care appointment.

From the sample, the team flagged attended appointments and measured whether each patient showed up for the next scheduled visit, not counting appointments that were intentionally canceled or rescheduled. The overall no-show risk for the next appointment was 17%. Only 9% of patients who had missed zero appointments in the past year failed to show up for the next scheduled appointment, whereas 31% of patients who had missed four or more visits in the past year failed to show up for their next appointment.

Frequently missing care appointments also interferes with medication adherence and clinical outcomes, says Pence. Previous research suggests that patients who miss HIV appointments have worse clinical outcomes and substantially higher mortality rates than those reliably engaged in care.

“If you don’t have a car, or a job, or a stable place to live, or if you are in an abusive relationship or struggling with mental illness or substance use, making it to a medical appointment can be a challenge,” he explains. “That’s why it’s particularly important to be able to identify patients at elevated risk while they are still in the clinic and mobilize the clinic’s supportive services — such as social work and financial counseling — to help address whatever that particular patient’s challenges are and help them remain engaged in care.”

Based on other recent studies, such strategies could involve focusing a “light touch” outreach effort to patients at moderate risk of future missed visits and a more comprehensive case management approach to those at the highest risk.  Future research could examine whether implementation of this simple predictive metric allows clinics to channel their resources with greater impact than their current standard operations, adds Pence.

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