Missed Clinic Appointments Research Articles

Treatment of HIV in Outpatients with Schizophrenia, Schizoaffective Disorder and Bipolar Disease at Two County Clinics

Despite a high prevalence of HIV in patients with serious mental health disorders, there is little information in the literature regarding details of their HIV treatment. The objective of this paper is to assess factors associated with the success of HIV therapy in people with schizophrenia, schizoaffective, and bipolar disease. The methods used are retrospective, post-study chart review, and clinician questionnaire at two HIV county clinics. Forty-nine (4.8%) study patients were identified, 51% of whom achieved an undetectable HIV viral load. These patients tended to have less drug use (42% vs. 68%), more ongoing psychiatric visits (70% vs. 58%) and were more apt to take psychiatric medicines (70% vs. 40%) than patients with detectable HIV viral loads. Both groups had many missed appointments. We were surprised to find that many patients were successful with HIV treatment despite substance abuse, uncontrolled psychiatric symptoms, and lack of psychiatric care. Missing clinic appointments had little influence on treatment outcome.

Family Perceptions of Barriers and Facilitators of Treatment Protocols for Secondary Stroke Prevention in Children with Sickle Cell Disease

AbstractAbstract 4805Children with sickle cell anemia (SCA) and a primary overt stroke are at high risk of recurrent (secondary) stroke. Chronic blood transfusion (CBT) dramatically reduces but does not eliminate this high risk, and results in transfusion-related hemosiderosis. We previously reported the use of hydroxyurea/phlebotomy as an alternative to CBT to reduce the risk of secondary stroke and improve management of iron overload (Ware et al. J Pediatr 2004). This study examines the caregiver and child experience with secondary stroke prevention. Individual semi-structured interviews were conducted with primary caregivers and children/adolescents (age > 5 years) recruited from the Duke Pediatric Sickle Cell Program. The interviewer (E.P.) asked about perceptions of risk of recurrent stroke and iron overload with and without therapy and facilitators and barriers of therapy. Interviews were coded and analyzed independently by two investigators (E.P and C.T.). The sample included 14 youth (10 males) with a median age of 12.5 years (range 3–17). All primary caregivers were female. Twelve children had a history of overt stroke and 2 had a history of silent stroke. All children had experience with CBT and 9 were receiving CBT at the time of the interview. Eleven children had experience taking hydroxyurea and 5 were taking hydroxyurea at the time of the interview. All caregivers agreed that their child was at risk of recurrent stroke, identified benefit of current treatment and reported high motivation to adhere to treatment protocols. They noted significant impact that stroke had on school functioning, attention, personality, participation in sports and overall quality of life. Caregiver-reported barriers to CBT and hydroxyurea fell into three main categories: (1) missed work and school and related consequences; (2) unexpected resource-related challenges; and (3) inconvenience of clinic appointments, all of which contributed to burden on the family and sometimes missed clinic appointments and treatments. There were higher levels of concern expressed by caregivers of children on CBT related to the higher frequency and longer length of medical appointments compared with those taking hydroxyurea. The primary child-reported barrier was dislike of needles or shots (although this decreased with age as expected); those taking hydroxyurea also noted that they sometimes forgot to take the medication if they were busy with other activities or fell asleep. Caregiver-reported facilitators of CBT and hydroxyurea included: (1) understanding importance of stroke prevention and connection to consistent treatment; (2) ancillary benefits of treatments in addition to stroke prevention; (3) link between treatment and long-term benefits. Caregivers were able to overcome treatment barriers via the following: (1) logistical supports including appointment and medication reminders; (2) shared responsibility with other family members including the child; (3) trust in medical staff; and (4) faith. Although children disliked needles and shots, many enjoyed the clinic visits due to fun activities in the clinic setting and rewards. In addition, iron overload was a significant concern for caregivers. For those with children on CBT, knowledge of the risks of iron overload motivated adherence with oral iron chelation. Automatic refills facilitated adherence with chelation therapy, but the taste of the medication was a major barrier to adequate iron chelation. Caregivers of children taking hydroxyurea noted the benefit of avoiding iron overload. Of those who had undergone phlebotomy, in-home phlebotomy was noted as a facilitator, though requirement for IV contributed to negative perception. In summary, as clinicians review options for secondary stroke prevention with families, they should discuss family perceptions and individual barriers and facilitators which may impact adherence with therapy and long-term outcome. Future research should also investigate whether these family perceptions predict actual adherence to protocols and treatment outcomes. Disclosures:Off Label Use: Hydroxyurea for secondary stroke prevention in sickle cell disease.

Using Mobile Phones to Improve Clinic Attendance Amongst an Antiretroviral Treatment Cohort in Rural Uganda: A Cross-sectional and Prospective Study

We aimed to assess the patterns and dynamics of mobile phone usage amongst an antiretroviral treatment (ART) cohort in rural Uganda and ascertain its feasibility for improving clinic attendance. A cross-sectional study of clients on ART exploring their access to mobile phones and patterns of use was employed. Clinic attendances for antiretroviral drug refills were then monitored prospectively over 28 weeks in 176 patients identified in the cross-sectional survey who had access to mobile phones and had given consent to be contacted. Patients were contacted via voice calls or text messages to remind them about their missed clinic appointments. Of the 276 patients surveyed, 177 (64%) had access to mobile phones with all but one were willing to be contacted for missed visits reminders. Of the 560 total scheduled clinic appointments, 62 (11%) were missed visits. In 79% of episodes in which visits were missed, patients presented for treatment within a mean duration of 2.2 days (SD = 1.2 days) after mobile phone recall. Access to mobile phones was high in this setting. Privacy and confidentiality issues were not considered deterrents. Mobile phones have a potential for use in resource-constrained settings to substantially improve the clinical management of HIV/AIDS.

The Performance of a Glucose-Ketone Meter in the Diagnosis of Diabetic Ketoacidosis in Patients with Type 2 Diabetes in the Emergency Room

Diabetic ketoacidosis (DKA) is a serious metabolic complication. One of its precipitating causes is insulin omission. DKA requires early diagnosis and strict glucose control, which increases the use of glucose meters in the Emergency Room (ER). We aimed to determine the performance of a glucose-ketone meter in the diagnosis of DKA. From 450 type 2 diabetes mellitus insulin-treated patients attending the ER with a capillary glucose level >13.9 mmol/L, 50 patients (26 men and 24 women, mean age 60.2 +/- 8.2 years) had DKA. Capillary glucose and beta-hydroxybutyrate (beta-OHB) were measured with the Precision-Xtra device (Abbott Laboratories, Abingdon, UK). Serum glucose and biochemical parameters were measured on an automatic analyzer; serum beta-OHB was determined using an enzymatic end-point spectrophotometric method. Urine ketones were determined using a semiquantitative assay (Ketodiastix, Bayer Diagnostics, Stoke Poges, Slough, UK). Serum and capillary beta-OHB values were highly correlated (r = 0.99, P < 0.001), and the mean difference between them was 0.49 mmol/L (95% confidence interval [CI], 0.35-0.95 mmol/L; P = 0.81). Similarly, serum and capillary glucose values were significantly correlated (r = 0.86, P < 0.001), and the mean difference between them was 0.43 mmol/L (95% CI, 0.82-0.93 mmol/L; P = 0.71). Patients with DKA were inadequately treated with insulin and missed clinic appointments: 80% of patients with DKA compared to 20% of patients without DKA. In all cases, DKA was attributed to insulin omission. Capillary ketonemia (beta-OHB >3.0 mmol/L) had the highest performance (sensitivity 99.87%, specificity 92.89%, positive predictive value 92.89%) for the diagnosis of DKA compared with serum ketonemia (sensitivity 90.45%, specificity 88.65%, positive predictive value 87.76%) or ketonuria (sensitivity 89.89%, specificity 52.73%, positive predictive value 41.87%). Implementation of measures such as home glucose and ketone monitoring can possibly decrease the number of hospital admissions due to DKA.

Factors Associated with Increased Hospital Utilization in Patients with Heart Failure and Preserved Ejection Fraction

To determine whether controlling systolic blood pressure (SBP), pulse pressure, and heart rate in the outpatient setting is associated with decreased hospital utilization in patients with heart failure and preserved ejection fraction (PEF). Retrospective medical record review. University-affiliated medical center and outpatient clinics. One hundred forty adults admitted between January 1, 2003, and October 31, 2005, for an exacerbation of heart failure with PEF and followed for 2 years after their index admission. Outpatient SBP, pulse pressure, and heart rate, and the percentage of clinic visits for which patients had each vital sign at a certain level were used for correlations and comparisons. These vital signs and percentages of clinic visits were varied until maximum significant differences were observed in total hospital utilization for each parameter. These values were then analyzed for differences based on age, race-ethnicity, and sex. When comparing patients whose vital signs were in control for at least 80% of clinic visits versus those whose were in control for less than 80% of clinic visits, significantly lower hospital utilization was associated with clinic SBP less than 140 mm Hg (median hospital utilization 3 vs 5 visits, p=0.0252), pulse pressure less than 65 mm Hg (3 vs 5 visits, p=0.0113), and heart rate of 55-70 beats/minute (2 vs 4 visits, p=0.0311). Among the 140 patients, 78 (56%) were Caucasian, 48 (34%) were Hispanic, and 14 (10%) were African-American. The African-American patients were significantly younger (p=0.0218) and had significantly poorer SBP control (< 140 mm Hg for >/= 80% of clinic visits: 14.3% vs 43.8%, p=0.0446) and higher hospital utilization (> 4 visits: 78.6% vs 43.8%, p=0.0218) than the Hispanic patients, despite similar percentages of missed clinic appointments (25% for each group). Controlling SBP at less than 140 mm Hg, pulse pressure at less than 65 mm Hg, and heart rate at 55-70 beats/minute for at least 80% of clinic visits were factors associated with decreased hospital utilization. African-American patients with heart failure and PEF were younger, had more poorly controlled SBP, and had higher hospital utilization despite similar percentage of missed clinic visits as their Hispanic counterparts.

The Limited Value of Sequencing Cases Based on Their Probability of Cancellation

Case cancellations on the day of surgery reduce operating room (OR) and anesthesia group productivity. One strategy to reduce the impact of case cancellations on productivity is to assign high-risk cases to start last in the OR workday. To evaluate the utility of this intervention, we used a database of canceled cases to model the process of identifying high-risk cases and resequencing them to be the surgeons' last cases of the day. Descriptive information was prospectively collected on 1 year of canceled cases. A comparison group of completed cases served as controls. Predictors of case cancellation were identified and used to calculate the number of cases that would require resequencing for 1 cancellation to occur at the end of the day. The proportion of total OR hours relevant to each predictor was assessed. To assess the desirability of this strategy, surgeons were surveyed regarding their scheduling preferences for patients at high risk for cancellation. During the study period, 946 of 12,253 cases were canceled. Strong predictors of cancellation included percentage of missed clinic appointments (number of cases requiring resequencing = 5.27) and insurance status (number of cases requiring resequencing = 8.87 for Medicaid). The predictor accounting for the most scheduled time was residence in Chicago (5.1% of total hours). No predictor both required the resequencing of 5 or fewer cases to prevent 1 cancellation in the middle of the day and accounted for >4% of scheduled time. Survey results demonstrated that in addition to cancellation probability, factors such as case complexity also influenced surgeons' sequencing preferences. Highly sensitive predictors of case cancellation are impractical for sequencing purposes because they account for too few hours of scheduled OR time. Effort invested in identifying and resequencing cases at high risk for cancellation likely has limited value.

Early active follow‐up of patients on antiretroviral therapy (ART) who are lost to follow‐up: the ‘Back‐to‐Care’ project in Lilongwe, Malawi

To determine the proportion of patients returning to antiretroviral treatment (ART) and factors associated with their return in a resource-limited setting. Between September 2006 and March 2009, at two ART-providing facilities in Lilongwe, Malawi, we identified patients who had missed clinic appointments by more than 3 weeks and therefore would have run out of antiretroviral drugs. We traced these individuals, documented reasons for missed appointments and, where appropriate, arranged another ART clinic appointment. Between April 2006 and March 2009, 2653 patients on ART had missed 3098 scheduled appointments. We successfully traced 85%, of whom 30% had died. Of the 1580 patients found alive, 25% had transferred to another ART clinic, 21% had collected drugs from other sources, 11% had treatment gaps; 40% had stopped taking drugs, 1% had not started taking drugs despite collecting them and 2% refused to be interviewed. Of the 1158 LTFU patients who had not died, transferred out or declined to be interviewed, 89% promised to return to their ART clinic and 74% actually did. The probability of returning to the clinic was significantly associated with being women, aged over 39 at ART initiation and having either treatment gaps or uninterrupted therapy. The B2C project reduced the proportion of patients finally classified as LTFU by 59%. Early active follow-up of LTFU patients resulted in marked improvement in known patient outcomes and improved retention in the treatment programme.

Emergency Room Visits by Pediatric Fracture Patients Treated With Cast Immobilization

The purpose of this review was to determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care. Retrospective chart review of patients initially seen in a busy urban pediatric orthopaedic clinic identified those who had an ER visit because of a cast-related problem over a 5-year period. Patients were included only if they were seen for their initial visit and cast application in our fracture clinic. Of 168 ER visits made by 155 children treated with cast immobilization, 29% were because of a wet cast; 10%, a damaged cast; 23%, a tight cast; 13%, a loose cast; and 10%, pain. In addition to wet and damaged casts, compliance issues included a missed clinic appointment (5%) and being told by medical personnel to return to the ER for a cast check (8%). Several groups with a high risk for return to the ER were identified: the younger the patient, the more likely that the cast was too loose or wet, and the older the patient, the more likely the cast was too tight. Cast type also played a role: a significantly higher rate of return to the ER was found with long arm, long leg, and hand casts. There were no major complications and no child required hospitalization. All 168 ER visits required only a cast change or reassurance, which could have been done during regular fracture clinic hours; no child required hospitalization or surgery. From these results, a program has been instituted that includes patient education, triage, and follow-up in our fracture clinics to not only improve the quality of patient care but to decrease the financial burden on physicians and the healthcare system. Economic and decision analysis, Level III.

Brief report: trajectories of glycemic control over early to middle adolescence.

To identify distinct patterns of glycemic control over early to middle adolescence, and to determine whether psychosocial variables predicted those patterns. We used trajectory analysis to examine glycemic control over 5 years among adolescents with type 1 diabetes who were of age 12 on average at study start (n = 132). Well-being, relationships, and self-care behavior were assessed with in-person interviews. Blood glucose testing was determined from blood glucose meters, and missed clinic appointments and glycosolated hemoglobin were obtained from medical records. We identified two distinct clusters of individuals, a stable good glycemic control group and a poorer deteriorating glycemic control group. Individuals in the deteriorating control group were characterized by higher peer conflict, more negative diabetes emotions, fewer blood glucose tests, and more missed clinic appointments. Psychosocial variables and behavioral markers of self-care may predict the course of glycemic control over early to middle adolescence.

Addressing social determinants of health to improve access to early breast cancer detection: results of the Boston REACH 2010 Breast and Cervical Cancer Coalition Women's Health Demonstration Project.

The Boston Racial and Ethnic Approaches to Community Health (REACH) 2010 Breast and Cervical Cancer Coalition developed a case management intervention for women of African descent to identify and reduce medical and social obstacles to breast cancer screening and following up abnormal results. We targeted black women at high risk for inadequate cancer screening and follow-up as evidenced by a prior pattern of missed clinic appointments and frequent urgent care use. Case managers provided referrals to address patient-identified social concerns (e.g., transportation, housing, language barriers), as well as navigation to prompt screening and follow-up of abnormal tests. We recruited 437 black women aged 40-75, who received care at participating primary care sites. The study was conducted as a prospective cohort study rather than as a controlled trial and evaluated intervention effects on mammography uptake and longitudinal screening rates via logistic regression and timely follow-up of abnormal tests via Cox proportional hazards models. A significant increase in screening uptake was found (OR 1.53, 95% CI 1.13-2.08). Housing concerns (p < 0.05) and lacking a regular provider (p < 0.01) predicted poor mammography uptake. Years of participation in the intervention increased odds of obtaining recommended screening by 20% (OR 1.20, 95% CI 1.02-1.40), but this effect was attenuated by covariates (p = 0.53). Timely follow-up for abnormal results was achieved by most women (85%) but could not be attributed to the intervention (HR 0.95, 95% CI 0.50-1.80). Case management was successful at promoting mammography screening uptake, although no change in longitudinal patterns was found. Housing concerns and lacking a regular provider should be addressed to promote mammography uptake. Future research should provide social assessment and address social obstacles in a randomized controlled setting to confirm the efficacy of social determinant approaches to improve mammography use.

Can we predict future improvement in glycaemic control?

To determine the factors responsible for poor glycaemic control in diabetes and whether any such factors are associated with likely improvement in glycaemic control. A prospective cohort study of 130 diabetic patients with poor glycaemic control (HbA(1c )> or = 10.0%) with 1-year follow-up in a teaching hospital Diabetes Clinic. Changes in HbA(1c) were measured after 1 year. Poor glycaemic control was attributed to one of 15 possible causes. Those cases due to recent diagnosis of diabetes, inadequate treatment with diet, oral glucose-lowering agents or insulin, exacerbation of co-existent medical problems, recent stressful life-events and missed clinic appointments were all associated with significant improvement in HbA(1c) at 12 months. Patients with low mood or alcohol excess, inadequate blood glucose monitoring, poor exercise/sedentary lifestyle, refusal to take tablets or underdosing and refusal to take insulin at all or to increase the dose were all associated with continuing poor glycaemic control at 12 months. The patients were divided almost equally between the two groups. In patients with poor glycaemic control, it is possible by simple features identified at clinic to predict which individuals are likely to show improvement in control and which will not. These findings have not been reported previously and suggest that about half of individuals with poor control will improve within our current diabetes clinic practice. Additional strategies will be required to address those individuals who are not likely to respond.

Self-reported reasons among HIV-infected patients for missing clinic appointments

Although adherence to clinic visits is important for successful clinical outcome in HIV treatment, little is known about the reasons patients with HIV miss appointments. We prospectively monitored the self-reported reasons for missed clinic appointments among HIV patients at a university hospital in South Korea from June through December 2006. Of the 1562 scheduled clinic visits, 131 (8%) of appointments were missed. Work schedule, forgetfulness and lack of motivation were the primary reasons given for missed appointments. Considering these factors when scheduling appointments may improve adherence to clinic attendance among HIV-infected patients.

Attitudes toward directly administered antiretroviral therapy (DAART) among HIV-positive inpatients in an inner city public hospital

Directly administered antiretroviral therapy (DAART) is one approach to improve adherence among HIV-positive individuals. DAART has been assessed for confined participants such as prisoners and for patients enrolled in methadone clinics but community-based voluntary DAART programs are not well studied. We examined the attitudes toward DAART among 47 HIV-positive inpatients in an inner city public hospital, a population difficult to engage in conventional self-administered highly active antiretroviral therapy (HAART). This study found that 83% of participants prefer self-administered therapy (SAT) and only 17% elect for DAART. A significant proportion of participants think the approach is intrusive or impractical and few are willing to meet with providers daily. A proportion of our patients, however, struggle with medication non-adherence and fragmented medical care, evident in the high rates of missed clinic appointments, frequent emergency department visits and repeated hospitalizations. These data can inform the development of DAART programs and suggest that considerable effort is needed to ‘sell’ the idea of DAART to this patient population. It is likely that such patients will greatly benefit from a clinic that can provide intensive counseling, frequent follow-up, home visits and DAART. Patient education regarding the merits of such an approach will be key to success.

Patients′ assessment of quality of eye care in a nigerian teaching hospital

Patients' assessment of quality of health care despite its importance in uptake of available services is not frequently examined in developing countries.This descriptive cross-sectional study was conducted at the Eye clinic in a Tertiary health facility to find out patients' perception of quality of care received in the facility. A questionnaire instrument was used, and it included patients' socio-demographic data, patients' perception of waiting time, charges, supportive services such as ease of movement from one service point to the other and pharmacy. Respondents' suggestions on any area of service rendered to them were also captured.A total of 124 respondents were interviewed. Majority (89.4%) reported long waiting time particularly for doctors' consultation. Missed clinic appointment was mostly due to health workers strike. Two-thirds of patients procured their prescribed drugs outside the Hospital due to hospital bureaucracy. However, most patients reported having received adequate explanation on their ailment from the health workers. Despite the shortcomings in services received most of the patients expressed satisfaction with the quality of care received.There is need to frequently examine the quality of health care received by patients in developing countries with the aim of identifying areas of services that should be improved. Key words: patients' assessment, eye care, quality.

Determinants of adherence to highly active antiretroviral therapy (HAART) in Chinese HIV/AIDS patients.

Drug adherence is crucial to the success of highly active antiretroviral therapy (HAART) in the treatment of HIV disease. Adherence to HAART and its determinants may, however, differ across HIV/AIDS populations. We retrospectively studied drug adherence by self-report in HIV-1 infected Chinese patients who have been on HAART for at least 1 year as at the end of year 2000. HAART is defined as three or more antiretrovirals with at least one protease inhibitor or non-nucleoside analogue reverse transcriptase inhibitor. The last drug adherence level assessed by self-report in 161 Chinese patients were: grade A (100%) - 130, 80.7%; grade B (95-99%) - 25, 15.5%; grade C (90-94%) - three, 1.9% and grade D (< 90%) - three, 1.9%. Patients with full adherence were more likely to have undetectable (< 500 copies/mL) plasma virus level (adjusted OR, 4.22; 95% CI, 1.75-12.33). Patients' demographics, HIV disease status and antiretroviral regimen did not affect adherence. Partial drug adherence was, however, independently associated with the psychosocial factors of missing clinic appointments (adjusted OR, 3.13; 95% CI, 1.23-8.33), forgetfulness (adjusted OR, 4.55; 95% CI, 1.64-12.5) and a busy work life (adjusted OR, 6.67; 95% CI, 1.75-25). There were similarities and differences in determinants affecting HAART adherence in Chinese compared with other patients. Psychosocial factors rather than HIV disease or treatment were more important factors in our Chinese patients. The relevance of patient populations and care setting for adherence to HAART shall be further studied.

Clinical predictors of mucormycosis in children with type 1 diabetes mellitus.

Mucormycosis is an acute, often rapidly fatal fungal infection that is an important cause of death in young patients with diabetes mellitus (DM) who have poor glycemic control and acute ketosis. Despite the importance of this condition, the clinical predictors of mucor infection are not well defined. A retrospective chart review was carried out for five patients, age 14-19 years, diagnosed with mucormycosis at the University of Florida between 1984 and 1999. For the three patients for whom adequate information was available, two randomly selected, age-matched case controls were selected and compared to affected patients for the following variables: average HbA1c concentrations, number of missed clinic appointments, and the number of hospital and Diabetes Project Unit (DPU) admissions. HbA1c levels were similar in affected patients and controls, indicating glycemic control is not the principal factor predisposing to mucor infection. African-American race and poor compliance, as evidenced by poor clinic attendance, risk-taking behaviors and high admission rate to the DPU, were predictors of increased susceptibility to infection with mucormycosis.

Comparison of Single-Mother and Two-Parent Families on Metabolic Control of Children With Diabetes

To understand the impact of family structure on the metabolic control of children with diabetes, we posed two research questions: 1) what are the differences in sociodemographic, family, and community factors between single-mother and two-parent families of diabetic children? and 2) to what extent do these psychosocial factors predict metabolic control among diabetic children from single-mother and two-parent families? This cross-sectional study included 155 diabetic children and their mothers or other female caregivers. The children were recruited if they had been diagnosed with diabetes for at least 1 year, had no other comorbid chronic illnesses, and were younger than 18 years of age. Interviews and self-report questionnaires were used to assess individual, family, and community variables. The findings indicate that diabetic children from single-mother families have poorer metabolic control than do children from two-parent families. Regression models of children's metabolic control from single-mother families indicate that age and missed clinic appointments predicted HbA1c levels; however, among two-parent families, children's ethnicity and adherence to their medication regimen significantly predicted metabolic control. This study suggests that children from single-mother families are at risk of poorer metabolic control and that these families have more challenges to face when raising a child with a chronic illness. Implications point to a need for developing strategies sensitive to the challenges of single mothers.

Highly active antiretroviral therapy in a large urban clinic: risk factors for virologic failure and adverse drug reactions.

In clinical trials, highly active antiretroviral therapy (HAART) reduces plasma HIV-1 RNA levels to less than 500 copies/mL in 60% to 90% of patients with HIV-1 infection. The performance of such therapy outside of the clinical trial setting is unclear. To determine factors associated with failure to suppress HIV-1 RNA levels and adverse drug reactions in a cohort of patients in whom protease inhibitor-containing therapy was begun in a large urban clinic. Retrospective cohort study. Johns Hopkins HIV Clinic in Baltimore, Maryland. 273 protease inhibitor-naive patients began taking a protease inhibitor regimen containing at least one other antiretroviral drug to which the patients had not previously been exposed. Demographic variables, plasma HIV-1 RNA levels, CD4+ lymphocyte counts, and adverse drug reactions. Levels of HIV-1 RNA were undetectable in 42% of the cohort at 1 to 90 days, in 44% at 3 to 7 months, and in 37% at 7 to 14 months. Factors associated with failure to suppress viral load at two or more time points included higher rates of missed clinic appointments, nonwhite ethnicity, age 40 years or younger, injection drug use, lower baseline CD4+ lymphocyte count, and higher baseline viral load. In a multivariate model, only higher rates of missed clinic appointments were independently associated with viral suppression at 1 year. Ritonavir was associated with adverse drug reactions about twice as frequently as indinavir or nelfinavir, and women experienced significantly more adverse effects than men. Unselected patients in whom HAART is started in a clinic setting achieve viral suppression substantially less frequently than do patients in controlled clinical trials. Missed clinic visits were the most important risk factor for failure to suppress HIV-1 RNA levels. Studies are needed to identify interventions that maximize the performance of HAART in inner-city clinics.

Predictors of outpatient medical appointment attendance among persons with HIV

Non-adherence to medical regimens is a critical threat to the health of HIV-infected individuals. Patients who do not adhere to routine medical care cannot fully benefit from the increasingly efficacious treatments available to them. Consistent attendance at medical appointments plays a central role in both prolonging life and enhancing quality of life for persons living with HIV/AIDS. By identifying why many patients do not reliably attend medical services, interventions can be undertaken to improve appointment-keeping. The primary purpose of the present study was to identify factors predictive of HIV-related medical appointment attendance. One-hundred-and-forty-four outpatients in a public hospital ambulatory care HIV clinic were followed for seven months. Demographic, medical care and psychosocial factors were measured in order to prospectively predict the percentage of missed clinic appointments by persons with HIV disease. Greater outpatient appointment non-attendance was associated with younger age, minority status, less severe illness and lower perceived social support. Treatment duration, provider consistency, hopelessness and religious coping did not emerge as significant predictors of outpatient appointment-keeping in this sample. Practical and theoretical implications of these findings are discussed in light of recent medical advances in HIV/AIDS care.

Reasons for nonattendance for the treatment of venous ulcers in an inner-city clinic

Purpose: This study examined the reasons that people attending an inner-city wound clinic gave for missing appointments and compared these reasons with those of people who did not have chronic wounds. Methods: Thirty-six patients with venous ulcers and 115 people without leg ulcers responded to a survey that queried the reasons for missing clinic appointments. Consecutive sampling was used to obtain participants. The Clinic Attendance Questionnaire was developed for the study and consisted of a demographic section and the Reasons for Nonattendance Questionnaire, which has 45 Yes/No items. Items in the Reasons for Nonattendance Questionnaire were sorted by the investigators into 5 subscores (Personal, Clinic Problem, Illness, Mental Health, and Social). Questionnaires were read to participants. Data were not collected from patients who kept all appointments or from new patients. Results: The primary reasons that patients seeking wound care gave for missing appointments were no ride, no money, out of town, forgot, and in too much pain. People with leg ulcers had significantly more Social, Illness, Personal, and Total reasons, but fewer Clinic Problem reasons, for missing appointments than did the people without leg ulcers. The two groups did not differ in their rating of health, importance of health, or age. Most of the people with leg ulcers had a history of illicit drug abuse. Conclusions: Nonattendance for clinic appointments may delay healing of venous ulcers and decrease the efficiency of the clinic. Reasons for missing wound clinic appointments are numerous and may vary with the patient's condition and background.