Transcript Document

Patient Retention:
A Perspective from the Literature
Elizabeth Horstmann
AIDS Institute
March 9, 2006
What can the literature tell us?
• How are others measuring patient retention?
• How many patients are not retained?
• What patients are not retained?
• Why are they not retained?
What can the literature tell us?
• What are the costs of not retaining patients?
• What are effective strategies for keeping
people in care?
• What can we learn from work with other
chronic diseases?
• What questions still haven’t been answered?
How is patient retention measured?
• Missed appointments
• Visits at defined intervals over time
• Usage of health care system
Missed Appointments
• The number of “no-show” (missed but not
cancelled or rescheduled) appointments /
the total number of patient appointments
• One inconsistency: which appointments
should be included (Only visits that involve
a physician or nurse? Only primary care
visits (no subspecialty appts.?)?
Missed Appointment Rates Data
HIV Specific No-Show Studies
Population
144 patients, public
hospital ambulatory
HIV clinic in Baton
Rouge
671 patients,
outpatient county
(northern CA)
treatment facility
114 patients,
ambulatory HIV
clinic of a public
hospital
Type of Appointment No-Show Rate*
Included
Appts. with doctors or
nurses
25.5%
(Catz, 1999)
Appts. including: intake
assessments, routine
checkups, medication
checks and blood draws
12 months after the
initial appt.
* Appts. not cancelled or rescheduled prior to appt.
25.5%
(Israelski, 2001)
35%
(McClure, 1999)
Percentage of Patients Who Miss
Appointments
Proportion of HIV Patients Who Miss Appts.
Population
Time
Appt. Type % Missing Appointment
213 women
3 month
Northern CA period
Primary care -37% missed ≥ 1 appt.
appts.
(Palacio, 1999)
1680 patients 1-year and
2-year
Italy
periods
“Follow-up” -25% missed ≥ 1 visit in 1st
visit, every 4 year
months
- 34% in 2nd year
(Arici, 2002)
354 patients,
urban clinic
6-months of “Clinic visit” -44.4% missed ≥ 2 visits in
follow-up
6 months
-13.6% were lost to followup after first physician visit
(Giordano, 2003)
1972 patients 6-month
Brazil
period
“Pre-booked -14.0% missed 1 appt.
medical
-13.7% missed ≥ 1 appt.
appointment” (Nemes, 2004)
Unanswered Questions…
• How many patients missing appointments
return to care?
• In what time period do they return to care?
Value of Focusing on Missed
Appointments
• Loss in revenue
• Loss in time
• Easy to measure and then generate list of
patients to follow-up with
Another Way of Measuring Patient
Retention in HIV Care
Population
Definition of
Retention
Retention Rate
29,153 patients (includes ≥ 1 medical care visit -18% were retained
children)
during each of 4 6-55% received ≥ 1
month periods
Multi-site
primary care service
in the 2-year period
(Ashman, 2002)
999 patients, 99% Male, ≥ 1 primary care visit -61% were retained
Community Health
within every 6
Center Boston (Lo, 2002) months, for 2 years
2,647 patients
Chicago
(Sherer, 2002)
Presence of regular
care in all 6-month
periods, for 2 years
-55% were retained
Another Measurement Approach
161 HIV+ Patients in DC Metro
Area
• Regular User (24.8%)
– Completes phlebotomy/medical
appointments at minimum
every 6 months
– Zero no-shows on all scheduled
primary medical appts.
– All cancelled primary medical
visits are rescheduled and
completed
Dekker, 2003
• Sporadic User (31.7%)
– Completes ≥1 phlebotomy
and/or medical appts./year
– No-shows ≥2 primary
medical appointments/year
– Utilizes HIV-urgent care
clinic ≥1 time/yr
• Non-Engager (43.5%)
– Completes initial
phlebotomy and/or primary
medical appointment and
does not return after that
Value of Focusing on Patient
Retention
• Better captures real concern – patients at
risk of falling out of care
Which patients are we concerned
about?
• Which patients miss appointments?
• Which patients are not retained?
Who misses appointments?
• Demographic
– Minority (African American specifically)
(Catz, 1999; Lucas, 1999; Israelski, 2001; Kissinger, 1995)
– Younger Age (Israelski, 2001; Catz, 1999; Lucas, 1999;
Poole, 2001)
–
–
–
–
Heterosexual Orientation (Israelski, 2001)
Education (less than high school) (Poole, 2001)
Lack of health insurance (Palacio, 1999)
Lower household income (Israelski, 2001)
Who misses appointments?
• Clinical
– Higher CD4 count (Catz, 1999; McClure, 1999; Arici, 2002)
– Not having an AIDS diagnosis (Israelski, 2001; Arici, 2002)
– Detectable viral load and AIDS-defining CD4 count (Berg,
2005)
• Other
– History of or current IDU (McClure, 1999; Arici, 2002;
Kissinger, 1995; Lucas, 1999)
– Lower perceived social support (Catz, 1999)
– Less engagement with health care provider (Bakken, 2000)
– Shorter follow-up since baseline (Arici, 2002)
Who doesn’t come for care regularly?
• Demographic
– African American
(Dekker, 2003)
– Female gender
• Clinical
– Higher VL (Sherer, 2002)
– Psychiatric Illness
(Ashman, 2002)
(Sherer, 2002)
– Younger Age (Sherer,
2002; Ashman, 2002)
– Self-pay status (Sherer,
2002; Lo, 2002)
– Unemployed
(Dekker, 2003)
• Other
– IDU (Sherer, 2002;
Ashman, 2002; Dekker,
2003)
Why do HIV patients not come?
• Patients at a community based clinic: conflicts with
work schedules, lack of child care, no transportation,
family illness and hospitalization (Norris, 1990)
• Women patients: forgetting the appointment, having a
conflicting appointment and feeling too sick to attend
the visit (Palacio, 1999)
• NYC clinic: no specific explanation, forgot, meant to
cancel, unexpected social reasons (Quinones, 2004)
Why do patients not come?
Why do patients come?
S
E
P
N
O
R
A
Health Literacy
Stigmas
Connectedness
Obstacles
A
G
D
E
I
C
G
D
Mallinson et al., 2005
Why do patients not come?
• Not HIV disease-specific studies
– Forgetting the appointment
– Feeling too ill to attend
– Resolution of symptoms
(Cashman, 2004; Moore, 2001; Waller, 2000; Barron, 1980)
Patients Lost to Follow Up:
Who are they? Why have they
fallen out of care?
Patients Lost to Follow Up
• Client Advocate hired to locate 503 patients who
had been out of care for at least one year (Dallas)
• 53% of patients lost to follow up were located
• Reasons for leaving care: incarceration,
relocation, fear, frustration with health systems,
death and health insurance issues
• Conclusion: Personal contact is an essential
element of successful return strategies
Waelder, 2002
One-Visit Study – Queens General Hospital
– Exclude those who moved, transferred or died
– 15 patients not “retained”:
• Unable to contact 7
• Contacted 8:
–
–
–
–
–
2 reported active substance abuse, 1 returned to care
1 fear of recognition, referred to other HIV clinic
1 psychiatric history, attends multiple HIV clinics
1 looking for a job, returned to care
1 refused outpatient treatment despite extensive outreach
efforts (frequent QHC hospitalizations)
– 2 feeling well, are early in HIV and refused frequent
medical visits
Jazila Mantis, MD, Jean Fleischman, MD, Kathleen Aratoon, NP, Maria Szczupak,
RPh, Diana Jefferson, RN, Terri Davis, MSW, Maria Bucellato
What are the costs of not retaining
patients?
Clinical Concerns
• Patients with missed appts. are less likely to
receive HAART (Giordano, 2003)
• Greater the number of missed appts., the
less adherent to taking ARVs (Nemes, 2004)
Clinical Outcomes Related to
Missed Appointments
Health Outcomes Associated with No-Shows
Population
Appointments
Health Outcome
123 patients, primary
care clinic
(Rastegar, 2003)
Not specified which
appts. included
Missed appts.
associated with VL>
500 copies/mL
273 patients, large
urban clinic
(Lucas, 1999)
Nursing, psychiatry,
dermatology,
neurology and
gastroenterology
Missed appts.
associated with failure
to suppress VL
195 patients, JHU
outpatients center
(Sethi, 2003)
“Scheduled clinic
visit”
Missed appts.
associated with viral
rebound and clinically
significant resistance
366 patients, HIV
clinic in Cleveland
(Valdez, 1999)
“Clinic visit”
Missing <2 appts.
associated lower VL
(<400 copies/mL)
Clinical Outcomes and Health Resource Utilization Stratified by
Percentage of Missed Visits
Percentage of Visits that were Missed because the
Client failed to keep scheduled appointment with
provider or social worker
(N=1500)
< 25%
> 25%
Using HAART
78%
64%*
Viral Load suppressed
(< 400 copies/ml)
65%
31%*
+68 cells/mm3
-36 cells/mm3*
2.2 days
3.2 days*
3.2
6.8*
Clinical Outcomes
Change in CD4 from Baseline
Health Resource Utilization
Hospital Admissions per year
(mean)
ED visits per year (mean)
*All comparisons are significant with p <0.01 Johns Hopkins AIDS Service Data
Base 1999-2000
Clinical Concerns
• Berg, 2005
– 946 individual with HIV in primary care at an urban
community health centre in Boston
– Included only patients with 2 appts. “made” over the
12-month span
– “Appointment nonadherence over the previous year
was a significant predictor of having an AIDS-defining
CD4 count over and above the significant effects of
number of kept appointments, and whether or not the
patient was taking HAART.”
Strategies for Improving Retention
in HIV Patients
• Reducing missed appointments
• Supportive services data
Retention at Brooklyn Hospital Center
– Population: 800 HIV+ patients
– Intervention
• Reminder calls before appts. (3 attempts)
• Updated patients’ phone number and address at each visit
• Attempted to reach no-shows through emergency contacts
and community agencies
• Peer educators phoned patients missing 3 consecutive appts.
– Outcome:
• Reached more patients by reminder calls 69% vs. 80%
• Patients rescheduling after missed appt. improved 52% vs.
60%
Sendzik, 2004
Ongoing Whitman-Walker Study
• Ongoing 5-year federally funded study
• 100 HIV+ patients paired with “retention care
coordinators” (RCCs)
• RCCs make reminder calls about appts., ensure
transportation to clinics and accompany patients
to appts. making sure they understand the
information provided
• Preliminary data suggest the intervention is
effective in reducing no-shows (16 vs. 25%)
Ukman, 2005
Clinic/Facility Factors
• Mail survey of 138 HIV treatment facilities
in the US
• Clinics with less than 4 providers and that
offer mental health services have fewer
patients missing appointments
Wohler-Torres, 2002
Supportive Services Improve
Patient Retention
Population
Definition of
Retention
Services Associated
w/Retention
29,153 patients ≥1 medical care visit
during each of 4 6multisite
month periods
(Ashman, 2002)
Mental health* , Substance
abuse* , Transportation*,
Advocacy*
999 patients,
≥1 primary care visit
community
within every 6
health center in months, for 2 years
Boston
Mental health**, Case
management*, HIV drug
assistance program*,
Food/nutrition**,
Complementary services**
(Lo, 2002)
2,647 patients,
HIV primary
care center in
Chicago
Presence of regular
care in all 6-month
periods, for 2 years
(Sherer, 2002)
* p ≤ 0.05
** p ≤ 0.005
Case management,
transportation, mental health
and chemical dependency
were significantly more likely
to receive any care, regular
care and had more visits than
patients with no services.
Supportive Services and Specific Groups
• Retaining HIV+ and At-Risk Youth
– For both males and females, ≥ 2 outreach contacts or
case management at ≥3 visits improved retention
– For males, ≥ 2 mental health counseling sessions
increased retention
(Harris, 2003)
• Retaining homeless clients (in substance abuse
treatment)
– Providing housing improved retention
– Making midcourse adjustments (Orwin, 1999)
Lessons from Other Chronic Diseases
• Engagement with health care and associated
health outcomes
• Strategies to keep patients in care
Lessons from Diabetes
Population
Engagement
Measurement
Health Outcome
1347 diabetic patients Regular provider
belonging to an HMO for diabetes
for at least a year
(O’Connor, 1998)
Patients with a regular
provider were more likely
to receive recommended
elements of care and had
better glycemic control
260 Type II Finnish
diabetic adults, under
65 (Hanninen, 2001)
Regular care:
Check-ups ≥ 2
times/year
Health related quality of
life better for those with
regular care
1400 diabetic adults
in the NHANES
survey (Mainous,
2004)
Usual site of care
and/or usual
provider when
you get “sick”
Glycemic control was
better for those with either
a usual site or usual
provider
Reducing Missed Appointments
• Reminders (Maxwell, 2001; Hashim, 2001; Moser, 1994; BenjaminBauman, 1984)
• Open access scheduling system (Kennedy, 2003; Cascardo,
2005)
•
•
•
•
•
Exit interviews (Guse, 2003)
Patient orientation to the clinic (Macharia, 1992; Barry, 1984)
Contracting with patients (Macharia, 1992)
Increasing social support (Tanner, 1997)
Case manager involvement (Blank, 1996)
Ideas for Interventions: Diabetes
Griffin et al. (1998) reviewed studies on diabetes
and missed appointments, “defaulters”, and
recommended that the “focus of the research
should move away from appointment reminders
towards interventions targeting the delivery of
health care and the health professional-patient
relationship which are more likely to be stronger
predictors of default”
Questions about Conceptualizing
Patient Retention
• Much of the literature is focused on missed
appointments. What is the relationship
between missed appointments and patient
retention?
Questions about Conceptualizing
Patient Retention
• Is continuity of care the same thing as
patient retention?
What We Know…
• A significant number of patients are not
retained
• Not being retained has important
consequences for both individual and public
health
• Strategies most likely to be effective for
improving patient retention are ones
focused on improving the process of care
Acknowledgements
• Bruce Agins
• Johanna Buck
• HHC AI Quality Learning Network
For more HIV-related resources,
please visit www.hivguidelines.org