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Background The financial burden of cleft-craniofacial team care is substantial, and high costs can hinder successful completion of team care. Solution Collaboration with multiple stakeholders including providers, insurers, and patient guardians, as well as hospital administrators, is critical to increase patient retention and improve final clinical outcomes. What We Do That is New At our cleft and craniofacial center, charges for a team care visit fall into one of three categories—hospital fees, professional fees, or external fees. There are four types of hospital fees depending on (1) whether the patient is new or returning, and (2) whether the patient saw ≤4 or ≥5 providers. To further elucidate the financial burden (out-of-pocket costs) directly borne by families of children with cleft lip and/or palate, we conducted a retrospective review of billing records of team care visits made between September 2019 and March 2020. Out-of-pocket costs for a single team care visit (on a commercial insurance plan) ranged from $4 to approximately $1220 and had a median (IQR) of $445 ($118, $749). more...

A retrospective observational study was conducted for patients 18 years or older presenting to a Midwestern emergency department (ED) in the United States during February 2019–January 2020 to characterize associated subsequent care utilization in patients who left the ED without being seen. Patients were classified as left without being seen (LWBS) based on documented ED disposition. The healthcare system’s records were reviewed for any associated utilizations within 3 weeks following the initial ED encounter. During the study period, 45,456 patients presented to the ED, with 2269 (5.0%) classified as LWBS. The median documented time until patients left the ED was 112 min. Of these patients, 1257 (55.4%) had a subsequent encounter within the health system within 3 weeks and 920 (73.2%) of these visits were determined to be related to the LWBS chief complaint. These visits included 67.5% of patients returning to ED or hospital, 27.5% to primary care or an urgent care clinic, and 5.0% to a specialty or other provider appointment. Of patients returning to ED, 78.1% did so within 72 h. Patients without a subsequent health system associated encounter tended to be younger, female, non-White, and present with possible lower-acuity chief complaints. At least one-half of LWBS patients sought care related to the concerns by a health system provider within 3 weeks of the initial encounter within the same system. The high prevalence of ED returns within a narrow turnaround window highlights a missed opportunity to provide services to these patients during their initial encounter. Supplementary Information The online version contains supplementary material available at 10.1007/s11739-021-02775-z. more...

Despite the availability of effective medication, blood pressure control rates are low, particularly in low‐ and middle‐income countries. Adherence to medication and follow‐up visits are important factors in blood pressure control. This study assessed the effectiveness of reminder telephone calls on follow‐up visits and blood pressure control among hypertensive patients as part of the Mumbai Hypertension Project. This project was initiated by PATH with the support from Resolve to Save Lives from January 2019 to February 2020. The study included hypertensive patients attending 164 private practices in Mumbai, India; practitioners screened all adults visiting their clinic during the project period. Among 13 184 hypertensive patients registered, the mean age was 53 years (SD = 12.38) and 52% were female. Among the 11 544 patients that provided phone numbers and gave consent for follow‐up calls, 9528 responded to phone calls at least once and 5250 patients followed up at least once. Of the 5250 patients, 82% visited the clinic for follow‐up visit within one month after receiving the phone call. The blood pressure control rate among those who answered phone calls and who did not answer phone calls increased from 23.6% to 48.8% (P more...

Purpose: Opioid use disorder is a prevalent and chronic condition that can lead to adverse outcomes if untreated. Medication-assisted treatment (MAT) with buprenorphine in a primary care setting has the potential to increase availability of treatment and reduce harm; however, retention in MAT is key for patient success. This study’s purpose was to examine predictors of retention in a MAT program for OUD in a family medicine residency clinic. Methods: A retrospective chart review was conducted for 238 patients diagnosed with OUD and receiving MAT at a family medicine residency clinic between 2015 to 2017, with visit and prescription data collected through December 2018. Cox-proportional hazards models were used to examine the length of time in treatment. Results: Over three-fourths of our patients were retained for at least 3 months, 69% for at least 6 months, and 48% retained for at least 1 year. Physician continuity of care and having insurance coverage significantly predicted retention and longer duration of treatment. Conclusions: Continuity of care and having health insurance were key predictors of patient retention in MAT care. Our findings emphasize the clinical significance of maintaining physician continuity of care to improve retention of patients with OUD in MAT programs. Future research could explore what aspects of continuity of care lead to retention in OUD treatment. more...

Background Cancer outcomes in sub-Saharan Africa (SSA) remain suboptimal, in part due to poor patient retention. Many patients travel long distances to receive care, and transportation costs are often prohibitively expensive. These are well-known and established causes of delayed treatment and care abandonment in Malawi and across SSA. Methods We sent visit reminder texts and offered upfront money to cover transportation costs through a mobile money transfer (MMT) platform to lymphoma patients enrolled in a prospective cohort in Malawi. The primary aim was to test the feasibility of upfront MMTs. Results We sent 1034 visit reminder texts to 189 participating patients. Of these texts, 614 (59%) were successfully delivered, with 536 (52%) responses. 320/536 (60%) MMTs were sent to interested patients and 312/320 (98%) came to their appointment on time. Of 189 total patients, 120 (63%) were reached via text and 84 (44%) received MMTs a median of three times (IQR 2–5). Median age of reachable patients was 41 (IQR 30–50), 75 (63%) were male, 62 (52%) were HIV+ and 79 (66%) resided outside of Lilongwe. Conclusion MMTs were a feasible way to cover upfront transportation costs for patients reachable via text, however many of our patients were unreachable. Future studies exploring barriers to care, particularly among unreachable patients, may help improve the efficacy of MMT initiatives and guide retention strategies throughout SSA. more...

The goal of scheduling within an ambulatory enterprise is to appropriately accommodate patients; extending capacity to fulfill this aim in a large health care organization requires the management of a complex scheduling process. Understanding and handling the appointment lead time, referred to as the scheduling horizon, can positively influence capacity management. The analysis demonstrated an increased chance of nonarrived appointments of 16% for a specialty practice and 11% for a primary care practice for every 30-day delay in the scheduling horizon. By incorporating the management of the scheduling horizon, health care organizations can optimize the capacity of their ambulatory clinics. more...

SETTING: Multidrug-resistant TB (MDR-TB) clinical trial in Lima, Peru and Cape Town, South Africa.OBJECTIVE: To identify baseline factors associated with screening failure and study withdrawal in an MDR-TB clinical trial.DESIGN: We screened patients for a randomized, blinded, Phase II trial which assessed culture conversion over the first 6 months of treatment with varying doses of levofloxacin plus an optimized background regimen (ClinicalTrials.gov: NCT01918397). We identified factors for screening failure and study withdrawal using Poisson regression to calculate prevalence ratios and Cox proportional hazard regression to calculate hazard ratios. We adjusted for factors with P < 0.2.RESULTS: Of the 255 patients screened, 144 (56.5%) failed screening. The most common reason for screening failure was an unsuitable resistance profile on sputum-based molecular susceptibility testing (n = 105, 72.9%). No significant baseline predictors of screening failure were identified in the multivariable model. Of the 111 who were enrolled, 33 (30%) failed to complete treatment, mostly for non-adherence and consent withdrawal. No baseline factors predicted study withdrawal in the multivariable model.CONCLUSION: No baseline factors were independently associated with either screening failure or study withdrawal in this secondary analysis of a MDR-TB clinical trial. more...

Pre-exposure prophylaxis (PrEP) for HIV in Wales was launched in July 2017. We set up a PrEP service delivered via our integrated sexual reproductive health service in Aneurin Bevan University Health Board (ABUHB), south east Wales. Public Health Wales (PHW) data show a 22% ‘lost to follow-up’ rate amongst Welsh PrEP patients. Over 18 months, 278 patients booked into ABUHB PrEP clinics. Of these, 275 were men who have sex with men (MSM). One hundred and ninety-three patients commenced PrEP, 5 were diagnosed with HIV at baseline, 42 did not attend their first appointment. The remainder declined PrEP. Of those commenced on PrEP, 51.7% had reduced clinic attendances; all were MSM. Patients with reduced attendances were more likely to be younger (mean age 33 vs. 37 years), reside outside ABUHB catchment area (56.4% vs. 49.6%) and have mental health issues (28.6% vs. 18.8%), but were less likely to disclose substance misuse (24.2% vs. 27.1%) than those attending in line with operational guidance. Of the 63 patients who stopped attending the PrEP clinic, 32.3% (21) had documented reasons, the most common being reduced self-perceived risk. This is the first evaluation of reasons why patients stop attending as well as risk factors associated with those lost to follow-up in PrEP services in Wales. more...

Patients with overactive bladder (OAB) become discouraged with medication therapy because of the side effects, minimal subjective improvement and costs of therapy. With the implementation of a patient navigation pathway there is increased communication, subsequently leading to increased patient retention rates and utilization of third-line therapies. This was a quality improvement study carried out over a 17-month period comparing utilization of a navigation pathway versus patients without navigation. The data were obtained using an online database (PPS Analytics) to compare medication use, cystoscopy, urodynamic studies, use of third-line therapy, and return visits. A total of 535 patients were included in the analysis and broken down into two respective groups. Group 1 were those placed on the navigation pathway and able to be reached via telephone (n = 431). Group 2 were those started on the navigation pathway who were not able to be reached via telephone, but were chart reviewed by a navigator (n = 104). Third-line therapy usage for groups 1 and 2 was 24% and 11% respectively. Return visits for additional OAB management for groups 1 and 2 were found to be 71% and 50% respectively. Patient retention levels and utilization of third-line therapies are significantly improved when utilizing a navigation pathway. With 24% of the patients included in this study opting for third-line therapy, this represents a 600% increase in third-line therapies over national averages. more...

Objective: Meeting recommended provider contact hours in multicomponent pediatric weight management (PWM) programs is difficult when patient retention is low. Our objective was to examine associati... more...

The aims of this study were to assess the rate of subsequent diagnostic chest CT examinations in a lung cancer screening (LCS) program and examine the effect on retention of patients in the program.Patients who underwent LCS CT between June 2011 and August 2018 were included. The occurrence of patients' being subsequently imaged with diagnostic CT versus LCS CT and the effect this had on patients' returning for LCS CT (patient retention) were evaluated. Multivariable logistic regression was used to evaluate variables associated with undergoing diagnostic CT and risk factors associated with loss of patient retention.Of the 5,912 patients who underwent LCS CT, 2,756 underwent subsequent diagnostic or LCS chest CT. Increasing Lung-RADS® score was more likely to lead to subsequent diagnostic chest CT (P.0001). A total of 1,240 patients underwent at least three chest CT examinations in the time interval. For the 711 patients whose subsequent CT studies were for LCS, 585 (82%) were retained, whereas of the 529 patients who underwent subsequent diagnostic CT, only 208 (39%) were retained (P.0001). For the 197 subsequent diagnostic CT examinations performed for pulmonary nodule or screening indications, 81 patients (41%) returned for LCS CT, compared with 498 of 612 patients (81%) who underwent subsequent LCS CT (P.0001). In multivariable analysis, subsequent diagnostic chest CT and increasing Lung-RADS score were associated with loss of retention.A higher Lung-RADS score is a risk factor for subsequent diagnostic chest CT, and this is an independent risk factor for loss from the LCS program. more...

Background A minority of the U.S. population comprises a majority of health care expenses. Health system interventions for high-cost populations aim to improve patient outcomes while reducing costly over-utilization. Missed and inconsistent appointments are associated with poor patient outcomes and increased health care utilization. PEAK Health— Mount Sinai’s intensive primary care clinic for high-cost patients— employed a novel behavioral economics-based intervention to reduce the rate of missed appointments at the practice. Behavioral economics has accomplished numerous successes across the health care field; the effect of a clinic-based behavioral economics intervention on reducing missed appointments has yet to be assessed. Methods This was a single-arm, pre-post trial conducted over 1 year involving all active patients at PEAK Health. The intervention consisted of: a) clinic signage, and b) appointment reminder cards containing behavioral economics messaging designed to increase the likelihood patients would complete their subsequent visit; appointment cards (t1) were transitioned to an identical EMR template (t2) at 6 months to boost provider utilization. The primary objective, the success of scheduled appointments, was assessed with visit adherence: the proportion of successful over all scheduled appointments, excluding those cancelled or rescheduled. The secondary objective, the consistency of appointments, was assessed with a 2-month visit constancy rate: the percentage of patients with at least one successful visit every 2 months for 1 year. Both metrics were assessed via a χ2 analysis and together define patient retention. Results The visit adherence rate increased from 74.7% at baseline to 76.5% (p = .22) during t1 and 78.0% (p = .03) during t2. The 2-month visit constancy rate increased from 59.5% at baseline to 74.3% (p = .01) post-intervention. Conclusions A low-resource, clinic-based behavioral economics intervention was capable of improving patient retention within a traditionally high-cost population. A renewed focus on patient retention— employing the metrics described here— could bolster chronic care efforts and significantly improve the outcomes of high-cost programs by reducing the deleterious effects of missed and inconsistent appointments. more...

Clinical trials are often designed to include homogenous, highly specific patient populations with many resources to reduce patient dropout. Results may not translate to real-world settings. We evaluated discontinuation and loss to follow-up (LTFU) rates in clinical trials of anti-vascular endothelial growth factor (anti-VEGF) injections for diabetic macular edema (DME), age-related macular degeneration (AMD), and retinal vein occlusion (RVO). Retrospective meta-epidemiological study. The authors queried ClinicalTrials.gov for all completed trials of anti-VEGF injections for DME, AMD, or RVO. Of 658 trials identified, 582 were excluded for being non-interventional more...

BACKGROUND It is believed that combination treatment with both neuromodulators (NM) and hyaluronic acid soft-tissue fillers (HA) results in superior aesthetic results and increased patient satisfaction compared to either treatment alone. AIMS To determine whether combined treatment with NM and HA leads to greater patient retention than treatment with NM or HA alone. PATIENTS/METHODS This is a large, multi-center, retrospective review of patient retention rates from 7 aesthetic practices across 5 continents, incorporating over 2600 patients. Patient retention is interpreted as a surrogate marker for overall patient satisfaction. Retention rates were compared at 1, 3, and 5 years for patients who received NM only, HA only, or combination treatment with both NM and HA. RESULTS Combination therapy significantly increased the probability of retention for each time point (1, 3, and 5 years) compared with NM alone (P more...

Background People with HIV (PHIV) with limited access to health services often experience suboptimal antiretroviral therapy (ART) adherence. We investigated whether a daily text messaging intervention improves ART adherence and retention in early HIV care in PHIV in a south Florida hospital-based clinic. Methods ART-naïve PHIV receiving care through the clinic’s Ryan White HIV/AIDS Program were enrolled and randomly assigned to the intervention or control groups with a 1:1 ratio. The intervention group received a 1-way text message daily and the control group received standard care without receiving text message reminders for 6 months. HIV RNA and CD4 cell count were measured at baseline and post-intervention. Adherence to ART was defined as a visual analog scale of ≥ 90%. Retention in care was defined as continued engagement at study end. Results 94 ART-naïve patients were randomized and 83 (85.6%) completed the study, of which 44 were in the intervention group and 39 were in the control group. At the end of the 6-month study period, adherence to ART was 84.4% in the intervention group versus 73.5% in the control group (OR, 1.9; 95% CI 0.7–5.0; p = 0.194). Retention in care significantly improved in the intervention group compared to the control group with the odds of retention increasing by 20% (OR, 1.2; 95% CI 1.1–1.5; p = 0.006). Undetectable HIV RNA (p = 0.112). A significant increase in CD4 cell count and a decrease in HIV RNA were found at study end, with no differences between the two groups. Conclusions In this pilot study, a one-way daily text messaging intervention did not improve ART adherence over a 6-month study period, but significantly enhanced patient retention in early HIV care. Implementation of interventions to improve adherence in this population is required. more...

There is a growing, global burden of patients with end-stage kidney disease (ESKD) requiring renal replacement therapy. Although peritoneal dialysis (PD) is considered to be the most cost-effective dialysis modality, its utilization has been declining in some regions. The first year after starting PD is thought to be a vulnerable period for technique failure, which in turn contributes to poor patient retention. Improved understanding of the risk factors for technique failure during this period may help the development of targeted strategies to lower its incidence and improve both the utilization and utility of PD. This up-to-date review will summarize current evidence regarding the definition, incidence, causes, and predictors of early PD technique failure. Promising avenues for directing future research efforts will also be discussed. more...

The volume of clinical studies globally in nonalcoholic fatty liver disease has created tremendous competition among sponsors and investigators to identify patients. Patients with nonalcoholic steatohepatitis are often asymptomatic and personally unaware and uneducated about the disease. In addition, many physicians caring for undiagnosed patients are also poorly informed of the disease. This has created a perfect storm of high demand for clinical research participants among a pool of difficult to identify patients with nonalcoholic steatohepatitis. Based on the current data, the current volume of nonalcoholic fatty liver disease studies requires 13,049 patients to fulfill their patient enrollment requirements. more...

There is evidence that transfer of care for older adolescent patients to adult care is associated with a deterioration in health, especially in those with chronic conditions. Because several specific conditions in pediatric and adolescent gynecology continue into adulthood, it is important that patients have a seamless healthcare transition. In this commentary, it is argued that instead of arranging transfer, long-term retention of patients by the same physician or physician team may be the more caring, patient-centered approach. more...

PURPOSE OF REVIEW To assess recent developments in professionally delivered interventions for gambling disorder. RECENT FINDINGS During the past 24 months a number of reviews and individual studies have been published. Collectively they assess the efficacy and effectiveness of a range of interventions and identify methodological and other shortcomings. These studies advance knowledge with respect to pharmacological and psychological treatments including brief interventions delivered face-to-face and in other ways. Increased attention has been given to patient diversity, comorbidity, relapse, and nongambling outcomes. A variety of novel interventions have been developed and assessed. SUMMARY CBT and brief interventions remain well supported and appear to be similarly effective across varied patient groups. A range of promising new and combination treatments have been developed that require further evaluation. Larger, more robust pragmatic trials are required with diverse populations. Increased attention needs to be given to mechanisms of change, therapy mediators, patient retention, comorbidities, long-term treatment outcome, and relapse prevention. more...

Improving access to medications for opioid use disorder (MOUD) is a national priority; however, these efforts commonly focus on the provider. Access to buprenorphine through retail pharmacies and stigma associated with filling prescriptions for MOUD pose additional barriers for patients when embarking on their road to recovery.This study performed a pre-post retrospective chart review to evaluate the potential positive impact on patient retention when providing buprenorphine at office visits instead of at pharmacies. Study staff reviewed electronic medical records to document patient retention in treatment at 6 months as the primary outcome. The study evaluated as secondary outcomes missed office visits, medication adherence, illicit drug use (that drug testing results identified), and drug-related emergency department (ED) utilization. Study staff documented outcomes for patients given their buprenorphine medication at their office visit (n = 154) compared with randomly selected patients prescribed buprenorphine from the same office-based opioid treatment clinic who had to go to retail pharmacies to fill their prescriptions (n = 154).Patients receiving buprenorphine at their office visit demonstrated a 52.2% higher retention rate after 6 months compared to the control group (p = .005). Patients were more likely to attend scheduled office visits (p = .046), less likely to test positive for nonprescribed/illicit drugs (p .001), and less likely to utilize the ED for drug-related reasons (p = .018) when the program alleviated the need to fill buprenorphine prescriptions at retail pharmacies and began to offer the pharmacy services at office visits.Provision of buprenorphine to patients at their treatment visit was associated with higher patient retention rates and better health outcomes compared with patients who filled their buprenorphine at pharmacies prior to the program's integration of medication provision at patient office visits. Understanding how alleviating barriers to medication access impacts retention in care has meaningful implications for opioid use disorder patients and treatment providers. more...

This study examined various organizational, environmental, and professional components of therapeutic communities in Israel and their relationship with patient retention rates. Key elements included the juxtaposition between objective and subjective components of social environments, as reflected in the perceptions of staff (mostly social workers) and patients. The current study's findings suggest that retention rates are predicted to be higher when staff receive more hours of supervision and identify less with their peers, and when their assessments of the organizational climate within facilities is closer to their patients' assessments of this aspect of organizational milieu. These findings are discussed using various organizational and professional perspectives, guided by a field theory framework. more...

Objectives: Benzodiazepine (BZD) use is common in patients who are engaged in methadone as a treatment for opioid use disorder. BZD prescribing is generally discouraged for this patient population due to the increased risk of BZD dependence and BZD use disorder, medication-assisted treatment (MAT) discontinuation, and opioid-overdose death. However, some patients have concurrent mental health disorders, where BZD use may be clinically indicated. This study evaluates the impact of prescribed BZD on MAT outcomes. Methods: Linking urine drug screening data (UDS) and prescribing information from single-payer health records, we conducted a retrospective Kaplan–Meier analysis between patients using prescribed and nonprescribed BZD with methadone treatment retention as the primary outcome. Data are from a network of 52 outpatient clinics in Ontario, Canada, between January 1, 2006 and June 30, 2013. Results: We identified 3692 patients initiating methadone-assisted treatment for the first time; 76% were BZD−/UDS− (no BZD prescription and more...

Objective We conducted a retrospective cohort study to assess the effect of tracking People Living with HIV (PLHIV) after missed clinic visits and factors associated with return to care in rural Uganda. We assessed retention in care among 650 HIV-infected women and men. We used univariable and multivariable generalized linear models to assess demographic and self-reported factors associated with re-engagement in HIV care. Results Of 381 PLHIV who ever missed a scheduled appointment, 68% were female and most (80%) had initiated ART. Most (70%) of those tracked returned to care. Relative to men, women (adjusted risk ratio [ARR] 1.23; 95% confidence interval (CI) 1.05–1.43; p = 0.009) were more likely to return to care after active tracking. PLHIV who missed scheduled visits for other reasons (forgetting, adequate drug supplies, or long distance to clinic) had reduced odds of return to care (ARR 0.41; 95% CI 0.28–0.59; p more...

Introduction When measuring the success of HIV programmes to retain patients in care, few studies distinguish between retention in clinic (individual returns to the same clinic) and retention in care (individual is active in care at initial site or elsewhere). The objectives of this study were to quantify retention in clinic versus retention in care and determine risk factors associated with attrition from care in low‐income settings in Nairobi, Kenya. Methods Between April 2013 and June 2015, adults testing positive for HIV were recruited at two comprehensive care clinics in informal urban settlements. Participants were followed from the time of a positive HIV test for up to 14 months. Participants who did not return to the clinic for their 12‐month appointment between 10 and 14 months after their baseline visit were traced by telephone or community outreach to determine whether they were still receiving HIV care. We used generalized linear regression to determine the association between clinical and socio‐demographic factors and attrition from care at 12 months. Results Of the 1068 individuals screened for study participation, 775 individuals newly presenting to HIV care were included in this study. Between 10 and 14 months, 486 participants (62.7%, 95% confidence intervals [CI], 59.2% to 66.1%) returned to the clinic for their 12‐month appointment (retained in clinic). After telephone tracing and community outreach, an additional 123 of 289 participants were found to be active in care at other HIV clinics (42.6%, 95% CI, 36.8% to 48.5%). Overall, 609 (78.6%, 95% CI, 75.7% to 81.5%) participants were retained in care at any HIV clinic at 12 months. Participants in higher baseline CD4 count categories were more likely to be retained than those whose baseline CD4 count was more...

Retention, or its opposite, dropout, is a common metric of psychotherapy quality, but using it to assess provider performance can be problematic. Differences among providers in numbers of general dropouts, "good" dropouts (patients report positive treatment experiences and outcome), and "bad" dropouts (patients report negative treatment experiences and outcome) were evaluated.Patient records were paired with satisfaction surveys (N=3,054). Binomial mixed-effects models were used to examine differences among providers by dropout type.Thirty-four percent of treatment episodes resulted in dropout. Of these, 14% were bad dropouts and 27% were good dropouts. Providers accounted for approximately 17% of the variance in general dropout and 10% of the variance in both bad dropout and good dropout. The ranking of providers fluctuated by type of dropout.Provider assessments based on patient retention should offer a way to isolate dropout type, given that nonspecific metrics may lead to biased estimates of performance. more...

Background Retention in anti-retroviral therapy (ART) presents a challenge in sub-Saharan Africa. In Mozambique, after roll-out to peripheral facilities, the 12-month retention rate was reported mostly from sites with an electronic patient tracking system (EPTS), representing only 65% of patients. We conducted a nationally representative study, compared 12-month retention at EPTS and non-EPTS sites, and its predictors. Methods Applying a proportionate to population size sampling strategy, we obtained a nationally representative sample of patients who initiated ART between January 2013 and June 2014. We calculated weighted proportions of the patients’ status at 12 months after ART initiation, and 12-month incidence of lost to follow-up (LTFU) and death. We assessed determinants of LTFU and death by calculating adjusted hazard ratios (AHR) through multivariate cox-proportional hazard models. Results Among 19,297 patients sampled, 54.3% were still active, 33.1% LTFU, 2.0% dead, 2.6% transferred-out and 8.0% had unknown status, 12 months after ART initiation. Total attrition rate (LTFU or dead) was 45.5/100PY, higher at facilities without EPTS (51.8/100PY) than with EPTS (37.7/100PY). Clinical stage IV (AHR = 1.7), CD4 count ≤150 (AHR = 1.3) and being pregnant (AHR = 1.6) were significantly associated with LTFU. Clinical stage III or IV (AHR = 2.1 and 3.8), CD4 count ≤150 (AHR = 3.0), not being pregnant (AHR = 3.0), and ART regimens with stavudine (AHR = 4.28) were significantly associated with deaths. Patients enrolled in adherence support groups were 4.6 times less likely to be LTFU, but the number (n = 174) was too small to be significant (p = 0.273). Conclusion Retention in ART was substantially lower at non-EPTS sites. EPTS should be expanded to all ART sites to facilitate comprehensive routine monitoring of retention in care. Retention in Mozambique is low and needs to be improved, especially among pregnant women and patients with advanced disease at ART initiation. The effect of ART adherence support groups needs to be further monitored. more...

Introduction : Significant progress has been made with respect to the initiation of children on antiretroviral therapy (ART) in Southern Africa including Swaziland, however retention of these children in care poses a major challenge. The aim of the study was to assess retention to care in children testing HIV positive taking into account the number of return child welfare care (CWC) visits the child made. Methods : A retrospective cross sectional study and was conducted at 4 facilities in Swaziland. All children who were HIV infected from 0 to 18 months were identified using the child welfare register (CWC). Infant characteristics were obtained from the child welfare register and early infant diagnosis logbooks. Proportion of patients retained in care were calculated at three, six, nine and twelve months. Results : Of the 32 HIV positive children identified tested between December 2014 up to July 2016, sixty eight percent (n = 22) of the children that tested HIV positive were retained at three months, 40.6% at six months, 18.8% at nine months and 12.5% at twelve months. Children that resided in urban areas, more male than female children, children from mothers who were on antiretroviral treatment, children initiated on antiretroviral treatment, mothers on antiretroviral treatment for more than one year and children who received Infant Nevirapine were more likely to be retained. Conclusion : Facilities are performing well in terms of identifying HIV positive children within the first two months of life and linking them into care. However, as time progresses the retention of children in care declines. Innovative strategies need to be developed to enhance patient retention. more...

In several studies of antiretroviral treatment (ART) programs for persons with human immunodeficiency virus infection, investigators have reported that there has been a higher rate of loss to follow-up (LTFU) among patients initiating ART in recent years than among patients who initiated ART during earlier time periods. This finding is frequently interpreted as reflecting deterioration of patient retention in the face of increasing patient loads. However, in this paper we demonstrate by simulation that transient gaps in follow-up could lead to bias when standard survival analysis techniques are applied. We created a simulated cohort of patients with different dates of ART initiation. Rates of ART interruption, ART resumption, and mortality were assumed to remain constant over time, but when we applied a standard definition of LTFU, the simulated probability of being classified LTFU at a particular ART duration was substantially higher in recently enrolled cohorts. This suggests that much of the apparent trend towards increased LTFU may be attributed to bias caused by transient interruptions in care. Alternative statistical techniques need to be used when analyzing predictors of LTFU--for example, using "prospective" definitions of LTFU in place of "retrospective" definitions. Similar considerations may apply when analyzing predictors of LTFU from treatment programs for other chronic diseases. more...

Aims To test recommended implantable cardioverter defibrillator (ICD) follow-up methods by ‘in-person evaluations’ (IPE) vs. ‘remote Home Monitoring’ (HM). Methods and results ICD patients were randomized 2:1 to automatic HM or to Conventional monitoring, with follow-up checks scheduled at 3, 6, 9, 12, and 15 months post-implant. Conventional patients were evaluated with IPE only. Home Monitoring patients were assessed remotely only for 1 year between 3 and 15 month evaluations. Adherence to follow-up was measured. HM and Conventional patients were similar (age 63 years, 72% male, left ventricular ejection fraction 29%, primary prevention 73%, DDD 57%). Conventional management suffered greater patient attrition during the trial (20.1 vs. 14.2% in HM, P = 0.007). Three month follow-up occurred in 84% in both groups. There was 100% adherence (5 of 5 checks) in 47.3% Conventional vs. 59.7% HM (P < 0.001). Between 3 and 15 months, HM exhibited superior (2.2×) adherence to scheduled follow-up [incidence of failed follow up was 146 of 2421 (6.0%) in HM vs. 145 of 1098 (13.2%) in Conventional, P < 0.001] and punctuality. In HM (daily transmission success rate median 91%), transmission loss caused only 22 of 2275 (0.97%) failed HM evaluations between 3 and 15 months; others resulted from clinic oversight. Overall IPE failure rate in Conventional [193 of 1841 (10.5%) exceeded that in HM [97 of 1484 (6.5%), P < 0.001] by 62%, i.e. HM patients remained more loyal to IPE when this was mandated. Conclusion Automatic remote monitoring better preserves patient retention and adherence to scheduled follow-up compared with IPE. Clinical trial registration NCT00336284. more...

Aims and objectives To assess patient retention of initial training on completion of self-administration of a prolonged course of intravenous therapy. Background Outpatient parenteral antibiotic therapy is being used increasingly in the UK, and patients requiring prolonged antibiotic courses may be trained to self-administer therapy. Design Prospective clinical evaluation. Methods Patients self-administering parenteral antibiotic therapy through the Sheffield outpatient parenteral antibiotic therapy service were assessed when nearing completion of therapy for correct technique in five key areas of proficiency using a scoring system. Results Twenty-nine patients and nine carers were reassessed, at a median interval of 35 days after completion of the initial training package. Of these, 35 of 38 were fully competent in all areas. Three patients showed incomplete retention of their initial training. All made errors relating to use of sterile technique. Conclusions Overall retention of training was excellent, and this supports earlier reports that patient-administered outpatient parenteral antibiotic therapy is as safe as nurse-administered therapy. However, this study highlighted a small number of patients or carers who were not fully competent at maintaining sterile technique, and as a result, the protocol for training patients has been altered. Relevance to clinical practice In this study, we assess patients' ability to maintain safe self-administration of therapy over a period of time. Patients are increasingly involved and engaged in their own health care, and this study provides a novel approach to assessing their competence in practical procedures. more...

OBJECTIVE To compare patient retention at 3 stages of pre-antiretroviral (ART) care and 2 stages of post-ART care to identify when greatest attrition occurs. DESIGN An observational cohort study. METHODS We reviewed files of all adult nonpregnant individuals testing HIV-positive January 1-June 30, 2010, at a primary health clinic in Johannesburg, South Africa (N = 842). We classified retention in pre-ART stage 1 (HIV diagnosis to CD4 results notification in ≤3 months), pre-ART stage 2 (initially ineligible for ART with repeat CD4 test ≤1 year of prior CD4), pre-ART stage 3 (initiating ART ≤3 months after first eligible CD4 result), and at 0-6 and 6-12 months post-ART. RESULTS Retention among all patients during pre-ART stage 1 was 69.8% [95% confidence interval (CI): 66.7% to 72.9%]. For patients initially ART ineligible (n = 221), 57.4% (95% CI: 49.5% to 65.0%) returned for a repeat CD4 during pre-ART stage 2. Among those who were ART eligible (n = 589), 73.5% (95% CI: 69.0% to 77.6%) were retained during pre-ART stage 3. Retention increased with time on ART, from 80.2% (95% CI: 75.3% to 84.5%) at 6 months to 95.3% (95% CI: 91.7% to 97.6%) between 6 and 12 months. Cumulative retention from diagnosis to 12 months on ART was 36.9% (95% CI: 33.0% to 41.1%) for those ART eligible and 43.0% (95% CI: 36.4% to 49.8%) from diagnosis to repeat CD4 testing within one year among those ART ineligible. CONCLUSIONS Patient attrition in the first year after HIV diagnosis was greatest before ART initiation: more than 25% at each of 3 pre-ART stages. As countries expand HIV testing and ART programs, success will depend on linkage to care, especially before ART eligibility and initiation. more...

Decreased visit attendance leads to poor health outcomes, decreased viral suppression, and higher mortality rates for persons living with HIV. Retention in care is an important factor in improving health status for people living with HIV but continues to be a challenge in clinical settings. This paper details the development and implementation of the NC-LINK Retention Protocol, a clinic-based protocol to locate and reengage out-of-care patients, as part of overall clinic retention efforts. The protocol was implemented as one of four interventions of the NC-LINK Systems and Linkages Project, a multi-site initiative funded by the HIV/AIDS Bureau and the Special Projects of National Significance. Lists of out-of-care patients who had not received HIV medical care in over nine months and did not have a future appointment were created each month. Patient navigators, case managers, and other staff then followed a standardized protocol to locate and reengage these patients in care. A total of 452 patients were identified for reengagement services. Of those, 194 (43%) returned to care, 108 (24%) had another definitive outcome (incarcerated, deceased, or relocated) and 150 (33%) were referred for additional follow-up to locate and reengage in care. In summary, 67% of patients were located through the efforts of the clinic staff. The results of this intervention indicate that it is possible to successfully integrate a protocol into the existing infrastructure of a clinic and reengage a majority of out-of-care patients into medical care. more...

Introduction : Loss-to-follow-up (LTFU) in the prevention of mother-to-child HIV transmission (PMTCT) programmes can occur at multiple stages of antenatal and follow-up care. This paper presents findings from a national assessment aimed at identifying major bottlenecks in Cote d’Ivoire’s PMTCT cascade, and to distinguish characteristics of high- and low-performing health facilities. Methods : This cross-sectional study, based on a nationally representative sample of 30 health facilities in Cote d’Ivoire used multiple data sources (registries, patient charts, patient booklets, interviews) to determine the magnitude of LTFU in PMTCT services. A composite measure of retention – based on child prophylaxis, maternal treatment and infant testing – was used to identify high- and low-performing sites and determine significant differences using Student’s t -tests. Results : Among 1,741 pregnant women newly recorded as HIV-positive between June 2011 and May 2012, 43% had a CD4 count taken, 77% received appropriate prophylaxis and 70% received prophylaxis intended for their infant. During that time, 1,054 first infant HIV tests were recorded. A conservative rate of adherence to antiretroviral therapy was estimated at 50% ( n= 219 patient charts). Significant differences between high- and low-performing sites included: duration of time elapsed between HIV testing and CD4 results (29.5 versus 56.3 days, p= 0.001); and density (number per 100 first antenatal care visits) of full-time physicians (6.7 versus 1.7, p= 0.04), laboratory technicians (2.3 versus 0.7, p= 0.046), staff trained in PMTCT (10.7 versus 4.7, p= 0.01), and staff performing patient follow-up activities (7.9 versus 2.5, p= 0.02). Key informants highlighted staff presence and training, the availability of medical supplies and equipment (i.e., on-site CD4 machine), and the adequacy of infrastructure (i.e., space and ventilation) as perceived key factors positively and negatively impacting retention in care. Conclusions : Patient LTFU occurred throughout the PMTCT cascade from maternal to infant testing, with retention scores ranging from 0.10 to 0.83. Sites that scored higher had more dedicated and trained frontline health workers, and emphasised patient follow-up through outreach and the reduction of delays in care. Strategies to improve patient retention and decrease transmission should emphasise patient tracking systems that utilise critical human resources to both improve data quality and increase direct patient follow-up. Keywords: PMTCT Cascade; prevention of mother-to-child transmission of HIV; health systems factors; Cote d’Ivoire; health workforce; patient retention. To access the supplementary material to this article please see Supplementary Files in the column to the right (under Article Tools). Published 20 July 2016 Citation: Granato SA et al. Journal of the International AIDS Society 2016, 19(Suppl 4) :20838 http://www.jiasociety.org/index.php/jias/article/view/20838 | http://dx.doi.org/10.7448/IAS.19.5.20838 more...

For patients who are post-hospitalization and on warfarin therapy, one key component is the proper management of warfarin therapy. This descriptive study was conducted using a telephone survey to determine what level of knowledge exists regarding management of warfarin among patients back at home. Analysis of data collection results provides recommendations for evidenced-based practices for the home health clinician, which may improve patient outcomes. Basic knowledge of food and medication interactions can make a significant impact on reduction of adverse events of bleeding or clot formation. An understanding of the therapeutic level of warfarin obtained from lab tests could be of greater value. more...

Social work programs in dental schools and dental clinics have been operated successfully since the 1940s, and have been documented as contributing to patients' access to care and to dental education. However, unlike medical social work, with which it has much in common, social work in dentistry has failed to become a standard feature of dental schools and clinics. Few of the social work initiatives that have been implemented in dental schools have survived after initial grant funding ran out, or the institutional supporters of the program moved on. The authors hope that the CARES program serves as a model for the successful development of other programs at the intersection of social work and dentistry to the benefit of both dental patients and providers. more...

Background One-fifth of the patients on multidrug-resistant tuberculosis treatment at the Drug-Resistant-TB (DR-TB) Site in Gujarat are lost-to-follow-up(LFU). Objective To understand patients’ and providers' perspectives on reasons for LFU and their suggestions to improve retention-in-care. Design Qualitative study conducted between December 2013-March 2014, including in-depth interviews with LFU patients and DOT-providers, and a focus group discussion with DR-TB site supervisors. A thematic-network analysis approach was utilised. Results Three sub-themes emerged: (i) Struggle with prolonged treatment; (ii) Strive against stigma and toward support; (iii) Divergent perceptions and practices. Daily injections, pill burden, DOT, migratory work, social problems, prior TB treatment, and adverse drugs effects were reported as major barriers to treatment adherence and retention-in-care by patients and providers. Some providers felt that despite their best efforts, LFU patients remain. Patient movements between private practitioners and traditional healers further influenced LFU. Conclusion The study points to a need for repeated patient counselling and education, improved co-ordination between various tiers of providers engaged in DR-TB care, collaboration between the public, private and traditional practitioners, and promotion of social and economic support to help patients adhere to MDR-TB treatment and avoid LFU. more...

Research indicates that persons addicted to opiates are likely to relapse following treatment or are at risk of terminating treatment early. The withdrawal experience may be one factor underlying early treatment discharge and several medications, including buprenorphine-naloxone, have been used to reduce withdrawal symptoms during detoxification. This retrospective study sought to determine whether patients who received buprenorphine-naloxone were retained in treatment longer than those who did not receive the medication. Data were collected on 170 patients admitted to the detoxification unit who either received (n = 85) or did not receive (n = 85) the medication. Differences in lengths of stay were found between the groups, thus warranting future research on the usefulness of buprenorphine-naloxone during detoxification and subsequent treatment. The importance of detoxification as an initial phase of treatment in relation to patient retention is discussed. more...

The new guidelines promote initiating ARVs with a CD4þ T-cell threshold of 500 cells/ml or less for adults, adolescents, and older children [1]. These guidelines further recommend ARVs, regardless of CD4þ T-cell count, for patients with active tuberculosis (TB), pregnant and breastfeeding women, and children younger than 5 years of age [1]. This is a call for action to countries to further scale up provision of ARVs in addition to improving patient retention along the continuum of care. more...

Background. Few data are available with which to evaluate the association between depressed subgroups, type of treatment and patient retention during episodes of major depression.Method. This observational study followed 1117 depressed patients over a 12-month period in the primary care setting of six different international sites. The patients were divided into three severity-linked subgroups: moderate to severe depression; moderate depression co-morbid with serious medical conditions; and mild depression.Results. In general, a low dropout rate was found, with significant differences in the rates across the six sites. However, while there was no statistical significance in the association between the three subgroups of depression and overall dropout rates, we did find that older patients were less likely to drop out, more depressed patients were more likely to drop out, and if patients were on antidepressants they were less likely to drop out. Among the three subgroups of depression, patients with moderate depression co-morbid with serious medical conditions received the lowest amount of antidepressants and had the lowest quality of life.Conclusion. Although the overall dropout rate in this study was found very low and did differ between the six sites, an association between the use of antidepressants and patient retention was seen. The group of patients with serious co-morbid medical conditions received fewer antidepressants even when the level of their depressive states was taken into consideration. This group was the least satisfied with treatment and had the lowest self-reported quality of life. more...

Energy demand of remote monitoring in cardiac implantable electronic devices has never been investigated. Biotronik Home Monitoring (HM) is characterized by daily transmissions that may affect longevity.The aim of the study was to retrospectively compare longevity of a specific dual-chamber pacemaker model in patients with HM on and patients with HM off.Hospital files of 201 patients (mean age 87 ± 10 years, 78 men) who had received a Biotronik Cylos DR-T pacemaker between April 2006 and May 2010 for standard indication were reviewed. In 134 patients (67%), HM was activated. The primary end point was device replacement due to battery depletion.The median follow-up period was 56.4 months (interquartile range 41.8-65.2 months). The estimated device longevity was 71.1 months (95% confidence interval [CI] 69.1-72.3 months) in the HM-on group and 60.4 months (CI 55.9-65.1 months) in the HM-off group (P.0001). The frequency of inhospital visits with significant device reprogramming was higher in the HM-on group than in the HM-off group (33.3% vs 25.0%, respectively; P = .03). Lower ventricular pulse amplitude (2.3 ± 0.4 V vs 2.7 ± 0.5 V; P.0001) and pacing percentage (49% ± 38% vs 64% ± 38%; P = .02), both calculated as time-weighted averages, were observed with HM on as compared with HM off. Patient attrition was significantly lower in the HM-on group (9.7%; 95% CI 3.0%-28.7%) than in the HM-off group (45.6%; 95% CI 30.3%-64.3%) (P.0001).In normal practice, energy demand of HM, if present, was overshadowed by programming optimization likely favored by continuous monitoring. Pacemakers controlled remotely with HM showed an 11-month longer longevity. Patient retention was superior. more...

The purpose of this study was to examine the relationship between patient management strategies employed by study personnel, and patient retention and adherence to treatment in the first year of a Phase III clinical trial of interferon beta-1b for treatment of secondary progressive multiple sclerosis (MS). Study staff from each of 35 sites were interviewed regarding patient management practices. Sites which were rated as more empathetic, as instilling a sense of purpose in the patient, and promoting less formal relationships with patients had high rates of adherence to treatment. In addressing specific patient concerns, attention to patients' emotional status and patients' expectations of trial participation were related to better adherence. more...

Objective: This study aimed to determine the success of oral alimentation and patient retention rate 1 to 5 days after passing the Yale Swallow Protocol. Methods: Participants were 200 consecutive acute care inpatients referred for swallow assessment. Inclusion criteria were adequate cognitive abilities to participate safely, completing an oral mechanism examination, and passing the 3-ounce water swallow challenge. Exclusion criteria were altered mental status, failing the 3-ounce challenge, preadmission dysphagia, head-of-bed restrictions < 30°, and a tracheotomy tube. Electronic medical record monitoring post-protocol passing for 1 to 5 consecutive days determined success of oral alimentation and retention rate. Results: All patients who remained medically and neurologically stable drank thin liquids and ate successfully 1 to 5 days after passing the protocol. Mean (SD) volume of liquid ingested per day was 474.2 (435.5) cc. Patient retention declined steadily from day of testing (n = 200) through post-testing day 5 (n = 95). Conclusion: Passing the Yale Swallow Protocol allowed for initial determination of aspiration risk followed by successful oral alimentation for 1 to 5 days in medically and neurologically stable acute care hospitalized patients and without the need for instrumental dysphagia testing. The decline in patient retention was expected because of increasingly rapid transit through the acute care setting, which often renders longer follow-up problematic. more...

Background Since establishment of Zimbabwe's National Antiretroviral Therapy (ART) Programme in 2004, ART provision has expanded from

Aims. To identify predictors of patient retention in methadone maintenance. Design. Prospective study. Setting. Methadone maintenance treatment programme newly established in Geneva, Switzerland. Participants. All patients who initiated treatment between February 1991 and January 1995. Measurements. Baseline patient characteristics, dose of methadone, year of enrollment and retention in treatment. Findings. Overall, 111 patients contributed 164.4 person-years of follow-up. The retention rate was 84% after 12 months. In multivariate analysis, the risk of dropping out was significantly higher for patients who had been using opioids for < 7 years (relative hazard (RH) 3.0, 95% confidence interval (CI) 1.2-7.4), and for patients who had no stable income at baseline (RH 3.3, 95% CI 1.2-9.1). Dropouts were less frequent at the highest doses of methadone (65-110 mg/day, RH 1. 0) than at middle doses (45-60 mg/day, RH 2.0, 95% CI 0. 7-5.5) but, quite unexpectedly, dropouts were least likely at the lowest doses (15-40 mg/day, RH 0.5, 95% CI 0.1-1.8). Dropouts were more likely among patients who enrolled in the first (RH 6.2, 95% CI 2.3-16.7) and second (RH 1.9, 95% CI 0.6-5.6) years of the programme, compared with subsequent years (RH 1.0). Conclusions. Patients who have a long history of drug use and who have a stable income were more likely to stay in methadone maintenance treatment. Independent of patient characteristics, retention improved dramatically in the first years of programme functioning, suggesting that patient retention is a sensitive indicator of programme performance. more...

The retention of patients (n = 399) enrolled in mobile health services (MHS), a Baltimore outpatient mobile methadone treatment program, was compared to patient retention (n = 1588) in six Baltimore fixed-site programs. Mobile program patients were retained for a median of 15.53 months in treatment in comparison to 3.90 for fixed-site patients (n = 664) from the MHS served zip codes (MHSZIPS) and 6.27 for fixed-site patients (n = 924) from zip codes other than those served by MHS (OTHERZIPS), (P < 0.001). Using Cox regression, the characteristics of patients associated with earlier discharge were (1) higher number of arrests, (2) more frequent cocaine use and (3) lower family income. These predictors of shorter retention were generally more prevalent among patients from the MHS served zip codes. Therefore, the longer retention in treatment of MHS patients as compared to OTHERZIPS fixed-site program patients is even more striking. Consistent with these differences in retention, were findings in a prior study suggesting that the mobile program provided greater access to services in reducing patient transportation cost and travel time. Thus, mobile methadone maintenance treatment appears to be a useful means of providing services. more...

Data from the nationwide Treatment Outcome Prospective Study were analyzed to develop strategies for increasing patient retention in methadone programs. The sample comprised 351 daily or weekly heroin users who were admitted to 17 publicly funded methadone programs and completed intake, one month in treatment, and one-year follow-up questionnaires. The analysis suggests three strategies for increasing patient retention: providing more highquality social services, making programs more easily accessible, and individualizing treatment. The analysis also identifies characteristics of patients and programs to which these strategies should be targeted to increase patient retention in methadone programs. more...

The objective of this study was to identify significant factors impacting patient retention and attrition in a university-based breast center.In this pilot study, we surveyed current and former mammography patients at our university hospital and another affiliated site. Three hundred three current mammography patients ("stayers") and 117 patients who no longer receive mammography services at these sites ("leavers") were interviewed by telephone between April and May 2003.Stayers cited "doctor or hospital referral" (20%) and "quality of care" (19%) as reasons for having their mammography examinations at the university-based sites, with 77% "very satisfied" with the service and care they received. Fewer than 1% reported dissatisfaction. Stayers were also very satisfied with travel time from home (36%), convenience of parking (33%), and safety of the neighborhood (27%). Among leavers, 37% cited convenience to home or work as the reason for choosing their current mammography provider. Reasons for leaving the university-based sites included difficulty in scheduling appointments (15%) and current mammography provider mandated by their insurance provider (14%). Leavers expressed high levels of dissatisfaction with facility-related issues: travel time from home (26%), convenience of parking (26%), and safety of the surrounding neighborhood (19%).Although both stayers and leavers reported satisfaction with overall quality of service and care received at the university-based locations, stayers gave higher marks than leavers. more...