Comparative Value of Four Measures of Retention in Expert Care in Predicting Clinical Outcomes and Health Care Utilization in HIV Patients

This study compared the ability of four measures of patient retention in HIV expert care to predict clinical outcomes. This retrospective study examined Veterans Health Administration (VHA) beneficiaries with HIV (ICD-9-CM codes 042 or V08) receiving expert care (defined as HIV-1 RNA viral load and CD4 cell count tests occurring within one week of each other) at VHA facilities from October 1, 2006, to September 30, 2008. Patients were >= 18 years old and continuous VHA users for at least 24 months after entry into expert care. Retention measures included: Annual Appointments (>= 2 appointments annually at least 60 days apart), Missed Appointments (missed >= 25% of appointments), Infrequent Appointments (> 6 months without an appointment), and Missed or Infrequent Appointments (missed >= 25% of appointments or > 6 months without an appointment). Multivariable nominal logistic regression models were used to determine associations between retention measures and outcomes. Overall, 8,845 patients met study criteria. At baseline, 64% of patients were virologically suppressed and 37% had a CD4 cell count > 500 cells/mm(3). At 24 months, 82% were virologically suppressed and 46% had a CD4 cell count > 500 cells/mm(3). During follow-up, 13% progressed to AIDS, 48% visited the emergency department (ED), 28% were hospitalized, and 0.3% died. All four retention measures were associated with virologic suppression and antiretroviral therapy initiation at 24 months follow-up. Annual Appointments correlated positively with CD4 cell count > 500 cells/mm(3). Missed Appointments was predictive of all primary and secondary outcomes, including CD4 cell count <= 500 cells/mm(3), progression to AIDS, ED visit, and hospitalization. Missed Appointments was the only measure to predict all primary and secondary outcomes. This finding could be useful to health care providers and public health organizations as they seek ways to optimize the health of HIV patients.