Patient Tracking as a Tool to Improve Retention in Care: Is the Juice Worth the Squeeze?

Clinical Infectious Diseases, Jun 2017

Armstrong, Wendy S., del Rio, Carlos

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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 - 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)


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Armstrong, Wendy S., del Rio, Carlos. Patient Tracking as a Tool to Improve Retention in Care: Is the Juice Worth the Squeeze?, Clinical Infectious Diseases, 2017, pp. 1555-1556, Volume 64, Issue 11, DOI: 10.1093/cid/cix196