The development of effective antiretroviral therapies (ART) transformed Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome ((HIV/AIDS) from a scourge that caused extensive illness and death in the United States into a manageable, chronic health condition. However, to receive the maximum benefit from these advances, people living with HIV/AIDS (PLWHA) must first be identified, and then linked to HIV/AIDS related health services for follow-up care and treatment. Gaining an increased understanding of factors associated HIV/AIDS follow-up appointment keeping is important because care for HIV/AIDS is typically provided during regularly scheduled follow-up appointments, wherein PLWHA receive virologic monitoring. Unfortunately, even when care is accessible and financial considerations have been minimized many PLWHA will have competing needs or face other barriers that prevent their timely return for regularly scheduled follow-up appointments.
The primary objectives of this mixed-method formative evaluation of missed follow-up appointments (no-shows) at one VHA HIV/AIDS clinic were: 1) identify patient-level and clinic level risk factors associated with missed follow-up appointments (i.e. measure quality gaps), and 2) identify VAGLA resources that could be used to improve appointment keeping by PLWHA as well as other vulnerable veteran groups.
In one VHA HIV/AIDS Clinic, this mixed-method formative evaluation examined environmental context by relying upon the organizational diagnosis methodology outlined in step three of the six-step VHA Quality Enhancement Research Initiative (QUERI) implementation and program evaluation process. This study identified no-show patterns and highlighted existing resources that could be used to reduce no-shows in one VHA HIV Clinic. Quantitative methods were used to identify patient-level and clinic level risk factors associated with missed HIV/AIDS clinic follow-up appointments, and qualitative interviews were used to identify VHA resources that could be used to help PLWHA return for follow-up care and treatment.
Our quantitative results revealed that PLWHA aged 31-50 (OR = 0.59, CI = 0.44-0.78) and 51- 65 (OR = 0.75, CI = 0.58-0.98) completed less appointments than patients 66 years or older. African American (OR = 0.63, CI = 0.50-0.79), Hispanic (OR = 0.66, CI = 0.44-0.99), and Asian (OR = 0.73, CI = 0.58-0.91) completed less appointments than Caucasians.
Our qualitative interviews revealed that three main groups of staff that could play a role in reducing missed appointments: front desk staff, providers, and HIV coordinators. At the departmental level, staffing barriers precluded coordinated efforts including different employee union's affiliations and service lines. An additional organizational barrier is that the services homeless clients may need (i.e. substance abuse treatment, mental health, HIV testing) are in separate locations. A "one-stop shopping" program, where the services are all in one place would decrease missed referral appointments and improve communication between the different service lines.
This project identified organizational factors associated with missed HIV/AIDS clinic appointments. The results of this study will be used to inform the development and implementation of future projects to reduce no-shows among PLWHA.
- Henry SR, Cargill V, Justice A, Wright S, Zickmund S, Hagedorn H, Anaya H. Addressing Health Disparities: Treatment Challenges and Collaborative Opportunities to Improve Care for Veterans with HIV/AIDS or Hepatitis. Paper presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
- Henry SR, Hoang T, Goetz MB, Bell-Lewis LS, Asch SM. Disparities in HIV Clinic Appointment Adherence: Factors Associated with Missed HIV Clinic Appointments. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.