Self-reported reasons among HIV-infected patients for missing clinic appointments

Abstract

Summary

Although adherence to clinic visits is important for successful clinical outcome in HIV treatment, little is known about the reasons patients with HIV miss appointments. We prospectively monitored the self-reported reasons for missed clinic appointments among HIV patients at a university hospital in South Korea from June through December 2006. Of the 1562 scheduled clinic visits, 131 (8%) of appointments were missed. Work schedule, forgetfulness and lack of motivation were the primary reasons given for missed appointments. Considering these factors when scheduling appointments may improve adherence to clinic attendance among HIV-infected patients.

Keywords

HIV patient compliance

INTRODUCTION

Adherence to clinic attendance among HIV-infected patients has become increasingly important because of the development in the 1990s of an effective antiviral drug regimen and prophylaxis against opportunistic infection. Previous studies have shown that a missed clinic appointment is a risk factor for virological failure in HIV-infected patients receiving highly active antiretroviral therapy (HAART).^1,2 We also suggested that adherence to clinic visits early after initiation of HAART is an independent predictor for long-term clinical progress in HIV-infected patients.³

Although several studies have explored the reasons non-HIV patients miss appointments,^4–6 none have focused on HIV-infected patients. Because of specific, HIV-related psychosocial issues such as confidentiality, HIV-infected patients may have reasons for missed appointments that differ from those of non-HIV patients.

Understanding the reasons for missed appointments may help increase adherence to clinical schedules. Therefore, we aimed to determine the self-reported reasons for missed appointments among HIV-infected patients.

METHODS

Subjects

We prospectively identified all HIV-infected patients who missed appointments at the HIV clinic at the Seoul National University Hospital from June through December 2006. The hospital is a 1600-bed, university-affiliated teaching hospital and the largest referral centre for HIV/AIDS in the Republic of Korea. A missed appointment was defined as a time that the patient did not keep a scheduled appointment and did not cancel the appointment.

Data collection

A single investigator, who served as a coordinator nurse, obtained through telephone interview the self-reported reasons for missed clinic appointments. For patients who missed more than one appointment during the study period, only the reason for the first missed appointment was included for analysis. The CD4 lymphocyte count and HIV RNA levels used were those obtained closest to the time of the missed appointment.

RESULTS

Of 1562 scheduled clinic appointments, 131 (8%) were missed. Eighty-six patients missed only one appointment, 17 missed two appointments, and three missed three or more appointments during the study period. Of these 106 patients, 37 (35%) patients could not be contacted by telephone, and seven (7%) patients offered only non-specific reasons for the missed appointment (for example, ‘just busy’ or ‘no reason’).

Among the 62 patients who gave specific reasons for missed appointments, 57 (92%) were men and 61 (98%) were Korean. Their median age was 37 years (interquartile range [IQR], 33–42). The median CD4 cell count was 328/mm³ (IQR, 181–445), the median viral load was 3.26 log₁₀ copies/mL (IQR, 1.60–4.26), and 40 (65%) of those patients were receiving HAART. These data did not significantly differ from those of the patients from whom specific reasons could not be obtained.

Table 1 lists the self-reported reasons for missing a clinic appointment and their frequencies. The most frequently cited were conflicts with work schedule (n = 22, 36%), forgetting or confusing the time of the appointment (n = 13, 21%), and lack of motivation to visit the clinic (n = 7, 11%). These same reasons were also the most frequently cited among the 40 patients receiving HAART: work schedule (n = 16, 40%), forgetting or confusing the appointment time (n = 8, 20%), lack of motivation (n = 4, 10%), and a conflict from an unexpected event (n = 4, 10%).

Table 1

The self-reported reasons for missed clinic appointments among HIV-infected patients (n = 62)

Reasons	No. (%)
Work schedule	22 (36)
Forgetting or confusing the time of the appointment	13 (21)
Lack of motivation to visit the clinic	7 (11)
Unexpected event taking precedence over the appointment	5 (8)
Poor medical condition	4 (7)
Fear of going out in public	3 (5)
Travelling or vacation	3 (5)
Economic problem	2 (3)
Distrust of the medical profession	1 (2)
Residence at a great distance from the clinic	1 (2)
Drug intolerance	1 (2)
Total	62 (100)

DISCUSSION

Work schedule, forgetfulness and lack of motivation were the primary reasons for missed clinic appointments among HIV-infected patients. The fact that a busy schedule at work was the greatest obstacle to keeping the clinic appointment is not surprising; most patients in this study were young men with a relatively high CD4 cell count. In addition, confidentiality concerns might have prohibited the patients from informing colleagues at work that they needed to visit the clinic.

Although our hospital has used a short-message service for reminding patients,⁷ forgetfulness about the appointment time was the second most frequent reason for a missed appointment. This finding suggests that additional reminder methods are needed for HIV-infected patients.

Our data show that even among HIV-infected patients receiving HAART, lack of motivation was a major reason for a missed appointment. This result emphasizes the importance of patient education that demonstrates to patients without symptoms why they should regularly visit the clinic.

This study has some limitations. First, there may be information bias. Some patients could have hidden the real reason for their absence and substituted a plausible one. To minimize this bias, the telephone interview was performed by a study nurse trained specifically for HIV-infected patients, and non-specific reasons were excluded from the analysis.

Second, the reasons for missed appointments can vary according to the health insurance system.⁸ For example, because the cost that HIV-infected patients pay at clinic is almost completely refunded by the government in this country, economic reasons were cited relatively rarely.

These results emphasize that to improve adherence to the clinical schedule among HIV-infected patients, it is important to consider work schedule when arranging appointments and to use a reminder system and patient education for reinforcement.

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