Patient Tracking as a Tool to Improve Retention in Care: Is the Juice Worth the Squeeze?
Patient Tracking as a Tool to Improve Retention in Care: Is the Juice Worth the Squeeze?
Wendy S. Armstrong 1 2
Carlos del Rio 0 1 2
0 Hubert Department of Global Health, Rollins School of Public Health, Emory University , Atlanta , Georgia
1 Emory University Center for AIDS Research
2 Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
retention in care; viral suppression; patient tracking; community health workers; hard-to-reach populations
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Long-term viral suppression is a
critical part of the Joint United Nations
Programme on HIV/AIDS (UNAIDS)
90-90-90 goals; however, accomplishing
90-90-90 requires successful retention in
care. Poor retention in care has
important consequences for individual as well
as public health. While many effective
strategies to achieve high rates of
diagnosis and to develop pathways for rapid
initiation of antiretroviral therapy have been
developed, few interventions are proven
to improve retention. One particularly
challenging subset of patients is those
who are lost to follow-up and require
reengagement in care as they have
already failed “standard care” at least once.
Development of a cost-effective toolbox of
options optimized for retention, allowing
a personalized approach to patients and
their own specific barriers to care, is
desperately needed. Interventions utilizing
patient navigators, text messaging, phone
call reminders, and contingency
management have been studied, with variable
degrees of success [
1, 2
]. Another
intervention that has been proposed and
frequently implemented is patient tracking,
yet there is a scarcity of data evaluating
its effectiveness. In the current issue of
Clinical Infectious Diseases, Bershetyn
et al report on a post hoc evaluation of
patient tracking in 14 clinics in 3 Eastern
African countries: Uganda, Kenya, and
Tanzania [3]. The investigators identified
patients who had visited each one of the
participating clinics at least once in the
last 2.5 years and had been lost to care for
>90 days. Among nearly 6000 eligible
patients, 991 (17%) patients were
randomly selected for tracking by community
health workers, initially in an attempt to
better characterize the death rate in the
cohort. Although the intervention was
not standardized, patient trackers were
asked to contact the patient or if not
available, a surrogate, to determine their
vital status, whether they were in care at
an alternate site, and if out of care, were
encouraged to return to clinic. The
interaction was brief, lasting <15 minutes. The
rate of return to clinic was then evaluated
post hoc, with the group not traced
serving as a control. Among those patients
selected for tracking, nearly a quarter had
died and 21% had transferred care to
another clinic. The rest of the patients were
not in care (15%), could not be reached
but were known to be living (27%), or
no information could be found (13%).
At 1 year, 13.3% of the total number of
patients selected for tracking compared
with 10% of control patients had returned
to care, a small but statistically significant
difference; however, among those known
to be alive and out of care, the
probability of returning to clinic increased to 37%
with a number needed to treat of between
4 and 5. The effect of tracking on return
to clinic was more pronounced in the first
several weeks after contact was initiated.
The findings of this study are
significant. The positive effect of tracking on a
select population adds another proven
intervention to the retention toolbox.
In addition, it underscores the need to
appropriately identify patient
populations that will respond to particular
interventions. Implementing patient tracking
for all patients lost to follow-up in large
clinical settings is an effort-intensive
intervention with a small impact and
would therefore be an inefficient use of
resources. With the correct population,
this study suggests that patient tracking
can have a significant impact that might
have been even greater had the study
been designed to optimize return to
clinic rates.
The authors of the current study
conclude that this intervention is one that
could be useful in low- and
middleincome countries (LMICs), but retention
in care is equally challenging in the areas
of the United States most impacted by the
ongoing human immunodeficiency virus
(HIV) epidemic. As physicians who care
for patients in the southeastern United
States, challenges of transportation,
poverty, poor healthcare access, stigma,
and life circumstances also threaten
long-term retention in our population.
EDITORIAL COMMENTARY • CID 2017:64 (1 June) • 1555
In a recent study, our group identified
younger age, crack cocaine use, food
insecurity, financial and housing
instability, and phone number changes in the
past year as significantly more likely to be
present in those not retained in care [
4
].
US data demonstrate that the majority
of new infections are transmitted from
those diagnosed but no (...truncated)