Higher Risk Of Loss To Follow-up Research Articles

Are trajectories of depressive symptoms during the first half of drug-sensitive pulmonary tuberculosis treatment associated with loss to follow-up? A secondary analysis of longitudinal data

ObjectiveThe objective of this study was to identify trajectories of depressive symptoms (DSs) during the first half of drug-sensitive pulmonary tuberculosis (PTB) treatment and examine their association with loss to...

The effect of TB patient delay on loss to follow-up in Portugal.

BACKGROUND: Early identification of TB cases, followed by treatment to completion, are essential for controlling and preventing the disease. Previous studies have found some factors associated with both loss to follow-up (LTFU) and patient delay. We aim to build a causal model to investigate the association between TB patient delay and LTFU.METHODS: Pulmonary TB cases were identified using the national surveillance system in Portugal between 2008 and 2017. A directed acyclic graph was used to identify the minimal set of variables to adjust for when studying the association between delay (exposure) and LTFU (outcome). Crude and adjusted hazard were estimated using Cox regression.RESULTS: Nearly 4% of the patients did not follow up treatment. There was no association between patient delay and LTFU, even after adjustment with the minimal set of covariates. Factors associated with a higher risk of LTFU were being younger, being unemployed, living in urban areas, having HIV and the abuse of alcohol and drugs.CONCLUSION: Patient delay was not associated with LTFU, while social conditions were. Future research should investigate the underlying reasons why patients discontinue TB treatment and use these findings to develop targeted interventions that can support patients in completing their treatment regimen.

Functional Status and Incidence of Loss to Follow-up after Antiretroviral Therapy Initiation

Taking medication for lifetime puts Human Immunodeficiency Virus (HIV)-infected patients in challenging situations. The loss to follow-up (LTFU) is a major problem arising from their non-compliance. Information about functional status as a predictor of LTFU is limited. Therefore, this study was aimed to identify the association between the functional status and the incidence of LTFU among HIV patients at Saiful Anwar General Hospital, Indonesia. A retrospective cohort study was conducted in the tropical diseases and infections division of the Saiful Anwar General Hospital by observing 148 HIV patients who were diagnosed in 2015. Data were collected based on existing data in medical records. The log-rank test was used to compare the time of LTFU between groups. Cox proportional hazard was used to determine the effect of functional status after being controlled by other variables. This study found that 65.9% of HIV patients were able to retain on antiretroviral therapy for 39 months. Functional status had a significant association with the time LTFU occurred. Ambulatory patients had a higher risk of experiencing LTFU than working functional status (AHR = 2.289; 95% CI 1.106–4.738; p-value = 0.026). Identifying the patient’s characteristic that has a higher risk of LTFU helps to determine the right strategy to ensure treatment adherence.
 Keywords: antiretroviral therapy (ART), functional status, HIV, loss to follow-up (LTFU), Indonesia

Abstract PS7-57: Patient risk factors for loss to breast oncologic follow up

Abstract For patients who complete treatment for breast cancer, national oncologic guidelines recommend yearly mammography surveillance and oncology follow-up especially during the first five years of survivorship. Some studies have shown that older age and insurance type may be risk factors for timely initial follow up after abnormal mammogram however the role in which racial and socioeconomic disparities may contribute to long term non-adherence or loss to follow-up (LTFU) is not known. Investigation into causes of LTFU or non-receipt of recommended surveillance are crucial in improving health care delivery and targeting interventions that prevent LTFU in high-risk patients. An ongoing study at Lifespan Breast Oncology aims to evaluate this issue further among patients treated for stage 1-3 breast cancer. We have completed data collection on 139 of 300 eligible patients diagnosed in 2014 and for whom 5 years of follow up have been completed. We measured adherence to yearly mammography, visit with breast oncologist, continuation of ET, and LTFU in each year of survivorship. LTFU was defined as patient without any further contact with the Lifespan Breast Oncology clinic. We then examined the association between these adherence measures and age, ECOG performance status at diagnosis, Medicaid insurance status, socio-economic factors, and specific adjuvant therapies, using univariate and multivariate generalized estimating equation models for longitudinal data. The models reported odds ratios (OR) for non-adherence or LTFU, with 95% confidence intervals (CI). Patients who experienced relapse or death were removed from the pool in the year of event. Adherence decreased for all measures between year 1 and year 5 of survivorship: from 99% to 82% for oncology visits, 92% to 80% for mammography, and 86% to 71% from ET. LTFU increased from 0% to 17%, respectively (OR per year, 1.96; 95%CI, 1.55-2.48). In univariate analysis, patients age >70 (compared with age ≤50) had a significantly higher risk of LTFU (Table), non-adherence to visits (OR=6.64 versus age ≤50, P=.002), mammography (OR=4.18, P=.020), or ET (OR=5.42, P=.002). Patients with performance status ECOG ≥2 had significantly lower adherence to all measures. Medicaid insurance was associated with significantly higher LTFU, non-adherence to mammography (OR=5.58, P=.008) or oncology visits (OR=6.53, P=.002). Marital, employment, or parenting status were not significantly associated with the risk of LTFU, but employed patients had a higher adherence to mammography and ET. Cancer stage, ER, or HER2 status were not associated with any adherence measure. LTFU was lower among recipients of ET, but not recipients of chemotherapy. In a multivariable model, Medicaid insurance (OR=3.99, P=.027) and receipt of ET (OR=0.32, P=.027) retained significant association with LTFU. Our findings show that Medicaid patients represent a high risk group with potential need for increased resources to ensure adequate follow-up. We plan to continue to expand this cohort and analyze more patients at our institution. Interventions to change barriers and circumvent financial limitations that these patients face in obtaining care could potentially decrease rates of recurrence and potentially impact overall survival. This data could be utilized in future studies to create a risk stratification tool to identify patients who would be at high risk for LTFU. Table. Factors associated with loss to follow-up.N (%)% LTFU at 5yOR95%CIPAll13917Age ≤5032 (23)161.00351-7070 (50.4)120.890.27-2.90>7037 (26.6)223.511.19-10.4ECOG 015 (10.8)71.0071108 (77.7)153.650.43-31.1> 214 (10.1)2920.281.90-216Insurance: private78 (56.1)91.001Medicaid15 (10.8)466.762.03-22.5Medicare45 (32.4)195.131.98-13.3Children: no70 (50.4)121.34yes66 (47.5)191.710.56-5.22Married: no56 (40.3)171.68yes83 (59.7)160.840.38-1.88Employed: no70 (50.4)201.32yes66 (47.5)150.660.29-1.49Stage:187 (62.6)181.66239 (28.1)120.640.24-1.69313 (9.4)220.80.19-3.46ER-23 (16.5)261.27ER+115 (82.7)150.580.22-1.54No ET38 (27.3)291.033ET101 (72.7)120.410.18-0.93No chemotherapy87 (62.6)171.25Chemotherapy52 (37.4)160.60.25-1.43 Citation Format: Rani Chudasama, Adam Olszewski, Don Dizon, Mary Anne Fenton. Patient risk factors for loss to breast oncologic follow up [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-57.

Nearly one in every six HIV-infected children lost from ART follow-up at Debre Markos Referral Hospital, Northwest Ethiopia: A 14-year retrospective follow-up study.

Although antiretroviral therapy (ART) significantly improves the survival status and quality of life among human immunodeficiency virus (HIV)-infected children, loss to follow-up (LTFU) from HIV-care profoundly affecting the treatment outcomes of this vulnerable population. For better interventions, up-to-date information concerning LTFU among HIV-infected children on ART is vital. However, only a few studies have been conducted in Ethiopia to address this concern. Thus, this study aims to identify the predictors of LTFU among HIV-infected children receiving ART at Debre Markos Referral Hospital. An institution-based retrospective follow-up study was done among 408 HIV-infected children receiving ART at Debre Markos Referral Hospital between 2005 and March 15, 2019. Data were abstracted from the medical records of HIV-infected children using a standardized data abstracted checklist. We used Epi-Data Version 3.1 for data entry and Stata Version 14 for statistical analysis. The Kaplan-Meier survival curve was used to estimate the survival time. A generalized log-rank test was used to compare the survival curves of different categorical variables. Finally, both bi-variable and multivariable Cox proportional hazard regression models were used to identify the predictors of LTFU. Of 408 HIV-infected children included in the final analysis, 70 (17.1%) children were LTFU at the end of the study. The overall incidence rate of LTFU among HIV-infected children was found to be 4.5 (95%CI: 3.5-5.7) per 100-child years of observation. HIV-infected children living in rural areas (AHR: 3.2, 95%CI: 2.0-5.3), having fair or poor ART drug adherence (AHR: 2.3, 95%CI: 1.4-3.7), children started ART through test and treat approach (AHR: 2.7, 95%CI: 1.4-5.5), and children started protease inhibiter (PI)-based ART regimens (AHR: 2.2, 95%CI: 1.1-4.4) were at higher risk of LTFU. This study found that one in every six HIV-infected children lost form ART follow-up. HIV-infected children living in rural areas, having fair or poor ART drug adherence, started ART based on test and treat approach, and taking PI-based ART regimens were at higher risk of LTFU.

Short-term outcomes of rapid initiation of antiretroviral therapy among HIV-positive patients: real-world experience from a single-centre retrospective cohort in Taiwan

ObjectivesRapid initiation of antiretroviral therapy (ART) engenders faster viral suppression but with suboptimal rates of durable viral suppression and engagement in care, as reported by clinical trials in resource-limited settings....

Risk factors for loss to follow‐up, transfer or death among people living with HIV on their first antiretroviral therapy regimen in Mali

Risk factors for loss to follow-up (LTFU) were assessed for people living with HIV (PLHIV) at various reference out-patient clinics (expertise level II) and hospitals (expertise level III) in Mali. HIV-1-positive adults starting antiretroviral therapy (ART) in 2006-2013 were eligible for inclusion. Risk factors for LTFU, defined as no visit in the 6 months preceding the last database update, were assessed with the Cox model, taking into account the competing risks of transfer and death. Potential risk factors at the start of ART were demographic and socioeconomic variables, World Health Organization (WHO) stage, CD4 count, period of ART initiation, type of ART, region of care, expertise level and distance from home. We included 9821 PLHIV, 33% of whom were male, starting ART at nine out-patient clinics and seven hospitals [five and two in the capital Bamako and four and five in the 'regions' (i.e. districts outside the capital), respectively] with a median (interquartile range) CD4 count of 153 (56-270) cells/μL. Five-year cumulative incidences of LTFU, transfer and death were 35.2, 9.7 and 6.7%, respectively. People followed at Bamako hospitals >5km from home, at regional hospitals or at regional out-patient clinics <5km from home were at higher risk of LTFU than people followed at Bamako out-patient clinics, whereas people followed at regional out-patient clinics 5-50km away from home were at lower risk for LTFU. Deaths were less frequent at hospitals, whether in Bamako or in the regions, than at Bamako out-patient clinics, and more frequent at regional out-patient clinics. Expertise level and distance to care were associated with LTFU. Stigmatization may play a role for PLHIV living close to the centres in the regions.

Outcomes among HIV-infected children initiating HIV care and antiretroviral treatment in Ethiopia.

To describe pediatric ART scale-up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection. A descriptive analysis of routinely collected HIV care and treatment data on HIV-infected children (<15years) enrolled at 70 health facilities in four regions in Ethiopia, January 2006-September 2013. Characteristics at enrollment and ART initiation are described along with outcomes at 1year after enrollment. Among children who initiated ART, cumulative incidence of death and loss to follow-up (LTF) were estimated using survival analysis. 11695 children 0-14years were enrolled in HIV care and 6815 (58.3%) initiated ART. At enrollment, 31.2% were WHO stage III and 6.3% stage IV. The majority (87.9%) were enrolled in secondary or tertiary facilities. At 1year after enrollment, 17.9% of children were LTF prior to ART initiation. Among children initiating ART, cumulative incidence of death was 3.4%, 4.1% and 4.8%, and cumulative incidence of LTF was 7.7%, 11.8% and 16.6% at 6, 12 and 24months, respectively. Children <2years had higher risk of LTF and death than older children (P<0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF. Over the last decade large numbers of HIV-infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.

Loss to follow-up and HIV incidence in female sex workers in Kaiyuan, Yunnan Province China: a nine year longitudinal study.

BackgroundLongitudinal studies of female sex workers (FSWs) are vulnerable to loss to follow-up (LTFU) due to this population’s high mobility and low willingness to self-identify as FSWs. LTFU in cohort studies is a critical problem and may lead to bias in estimation of incidence and exposure-outcome associations. The aim of this study was to analyze LTFU and HIV incidence and their associated factors in a 9-year longitudinal study of FSWs in Kaiyuan, Yunnan Province, China.MethodsThis analysis includes all HIV-1 seronegative FSWs who were recruited into a prospective study in Kaiyuan with at least one follow-up visit after enrollment from March 2006 to November 2013. Participants were visited in 6-month intervals after enrollment. Their demographic and behavioral data and blood specimens for HIV and sexual transmitted disease testing were collected at enrollment and at each follow-up visit. The administrative censoring date was December 31, 2014. Participants were considered LTFU if their last visit occurred 1 year or more before the administrative censoring date. Univariate and multivariable Cox regression models with time-independent variables were used to investigate the hazard ratios (HR) and 95 % confidence intervals (CI) of the factors associated with LTFU and HIV acquisition.ResultsOf the 1158 FSWs, 950 were defined as LTFUs (LTFU rate: 29.69, 95 % CI: 27.85–31.62 per 100 person years [PYs]), and 33 experienced HIV seroconversions (cumulative incidence: 1.06, 95 % CI: 0.74–1.47 per 100 PYs). After adjustment, we found that FSWs who used drugs were less likely to be LTFU compared with non-drug users (adjust hazard ratio [AHR]= 0.62, 95 % CI: 0.51–0.76), though FSWs who used drug were associated with a higher risk of HIV acquisition (AHR = 3.06, 95 % CI: 1.49–6.30). Also, FSWs who always used condoms with clients in the previous month were associated with a higher risk of LTFU (AHR = 1.51, 95 % CI: 1.15–1.97), while they were negative associated with new HIV infection (AHR = 0.28, 95 % CI: 0.12–0.61).ConclusionsA high LTFU rate exists in the Kaiyuan FSW cohort study, and LTFU did not occur at random. Participants retained in the cohort tended to be at higher risk of HIV acquisition, which may result in an overestimate of the incidence of HIV infection from the Kaiyuan FSW cohort.

Implementation and Operational Research: Early Tracing of Children Lost to Follow-Up From Antiretroviral Treatment: True Outcomes and Future Risks.

Loss to follow-up (LTFU) challenges the success of antiretroviral therapy (ART) scale-up among pediatric patients. Little is known about children who drop out of care. We aim to analyze risk factors for LTFU among children on ART, find their true outcomes through tracing, and investigate their final outcomes after resuming ART. This is a descriptive, retrospective, cohort study of children on ART between April 2006 and December 2010 in 2 clinics in urban Malawi. Routine data from an electronic data system were used and matched with information obtained through routine tracing procedures. Of 985 children (1999 child-years) on ART, 251 were LTFU: 12.6/100 child-years. At ART initiation, wasting [adjusted hazard ratio (AHR) 1.58 and 95% confidence interval (CI): 1.02 to 2.44] was independently associated with higher risk of LTFU. Of 201 LTFU children traced, 79% were found: 11% died, 25% stopped, 26% transferred-out, and 37% were still on ART. Median time between last visit and first tracing was 84 days (interquartile range: 64-101 days). Tracing reduced risk of LTFU by 38% (AHR 0.62 and 95% CI: 0.42 to 0.91) and decreased LTFU from 23.2% to 8.5%. Additional outcomes of stop, death, and transfer-out increased 4.4-fold, 1.8-fold, and 1.3-fold, respectively. Traced children with gaps in ART intake who resumed ART had higher risk of stopping (AHR 4.92 and 95% CI: 1.67 to 14.5) and transfer out (AHR 2.70 and 95% CI: 1.75 to 4.17) as final outcome. Early tracing substantially reduces LTFU; approximately one-third presumed LTFU was found to be still on ART. Children with wasting at initiation and those traced and found to have irregular ART intake require targeted interventions.

Incidence Rate of and Factors Associated with Loss to Follow-up in a Longitudinal Cohort of Antiretroviral-Treated HIV-Infected Persons: An AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) Analysis

Purpose: Examine incidence and factors associated with loss to follow-up (LTFU) in the AIDS Clinical Trials Group (ACTG) Longitudinal Linked Randomized Trials (ALLRT) cohort.Method: ALLRT is a prospective cohort of HIV-infected persons randomized to antiretroviral (ARV) regimens/strategies in ACTG trials and followed long-term after the trial ends. Person-years were calculated from ALLRT entry until loss to follow-up (LTFU; defined using off-study reasons or ≥3 consecutive missed visits), death/ severe debilitation/site closures, or June 2009 (censored). Poisson regression was used to examine LTFU factors separately among participants who were ARV naïve or ARV experienced at trial entry.Results: Among 4,630 participants (22,524 person-years), 1,140 were lost to follow-up, 237 died, 29 were severely debilitated, and 443 were at sites that closed. The LTFU incidence was 5.5 and 4.2 per 100 person-years among previously ARV-naïve and ARV-experienced participants, respectively. In both groups, age ≤50, site location, being off ARVs, and viral load ≥400 copies/mL were associated with a higher risk of LTFU. Among ARV-naïve participants, male sex, education <16 years, intravenous drug use, and cigarette smoking were also associated with LTFU.Conclusion: Knowledge of differential LTFU can help researchers identify participants at risk of LTFU in longitudinal HIV cohorts and design retention strategies, thereby limiting study bias. The identified factors should be included in inverse probability of weighting models to account for LTFU.

Correcting for Mortality Among Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A Cohort Analysis

BackgroundLoss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.Methods and FindingsWe included 6411 patients enrolled on ART between March 2001 and June 2007. Patients LTF with available civil identification numbers were matched with the national vital registration system to ascertain vital status. Corrected mortality and true LTF were determined by weighting these patients to represent all patients LTF. We used Kaplan-Meier estimates and Cox regression to describe LTF, mortality among those LTF, and true LTF. Of 627 patients LTF, 85 (28.8%) had died within 3 months after their last clinic visits. Respective estimates of LTF before and after correction for mortality were 6.9% (95% confidence interval [CI] 6.2–7.6) and 4.3% (95% CI 3.5–5.3) at one year on ART, and 23.9% (95% CI 21.0–27.2) and 19.7% (95% CI 16.1–23.7) at 5 years. After correction for mortality, the hazard of LTF was reversed from decreasing to increasing with time on ART. Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF. Mortality of patients LTF at 1, 12 and 24 months after their last visits was respectively 23.1%, 30.9% and 43.8%; 78.0% of deaths occurred during the first 3 months after last visit and 45.0% in patients on ART for 0 to 3 months.ConclusionsMortality of patients LTF was high and occurred early after last clinic visit, especially in patients recently started on ART. Correction for these misclassified deaths revealed that the risk of true LTF increased over time. Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.