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Correcting for mortality among patients lost to follow up on antiretroviral therapy in South Africa: a cohort analysis.

Van Cutsem G, Ford N, Hildebrand K, Goemaere E, Mathee S, Abrahams M, Coetzee D, Boulle A - PLoS ONE (2011)

Bottom Line: Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF.Correction for these misclassified deaths revealed that the risk of true LTF increased over time.Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.

View Article: PubMed Central - PubMed

Affiliation: Médecins Sans Frontières, Cape Town, South Africa. gillesvancutsem@gmail.com

ABSTRACT

Background: Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.

Methods and findings: We included 6411 patients enrolled on ART between March 2001 and June 2007. Patients LTF with available civil identification numbers were matched with the national vital registration system to ascertain vital status. Corrected mortality and true LTF were determined by weighting these patients to represent all patients LTF. We used Kaplan-Meier estimates and Cox regression to describe LTF, mortality among those LTF, and true LTF. Of 627 patients LTF, 85 (28.8%) had died within 3 months after their last clinic visits. Respective estimates of LTF before and after correction for mortality were 6.9% (95% confidence interval [CI] 6.2-7.6) and 4.3% (95% CI 3.5-5.3) at one year on ART, and 23.9% (95% CI 21.0-27.2) and 19.7% (95% CI 16.1-23.7) at 5 years. After correction for mortality, the hazard of LTF was reversed from decreasing to increasing with time on ART. Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF. Mortality of patients LTF at 1, 12 and 24 months after their last visits was respectively 23.1%, 30.9% and 43.8%; 78.0% of deaths occurred during the first 3 months after last visit and 45.0% in patients on ART for 0 to 3 months.

Conclusions: Mortality of patients LTF was high and occurred early after last clinic visit, especially in patients recently started on ART. Correction for these misclassified deaths revealed that the risk of true LTF increased over time. Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.

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Related in: MedlinePlus

Summary diagram of patient outcomes.
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pone-0014684-g001: Summary diagram of patient outcomes.

Mentions: At the end of June 2007, 4967 (77.5%) patients were alive and in care, 512 (8.0%) had died, 305 (4.8%) had been transferred to another facility, and 627 (9.8%) were lost to follow-up (Figure 1). Civil identification numbers were available for 295 (47.0%) of all patients lost to follow-up. Ascertainment of their vital status through the national death registry revealed that 85 (28.8%) had died within three months of LTF, 95 had died before 30 June 2007, and 109 before 25 January 2008. The only difference between patients LTF with and without available identification numbers was in the median CD4 count (respectively, 101 cells/µLµL, IQR 48–163 with, and 82, IQR 34–143 without identity documents, p = 0.007).


Correcting for mortality among patients lost to follow up on antiretroviral therapy in South Africa: a cohort analysis.

Van Cutsem G, Ford N, Hildebrand K, Goemaere E, Mathee S, Abrahams M, Coetzee D, Boulle A - PLoS ONE (2011)

Summary diagram of patient outcomes.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3040750&req=5

pone-0014684-g001: Summary diagram of patient outcomes.
Mentions: At the end of June 2007, 4967 (77.5%) patients were alive and in care, 512 (8.0%) had died, 305 (4.8%) had been transferred to another facility, and 627 (9.8%) were lost to follow-up (Figure 1). Civil identification numbers were available for 295 (47.0%) of all patients lost to follow-up. Ascertainment of their vital status through the national death registry revealed that 85 (28.8%) had died within three months of LTF, 95 had died before 30 June 2007, and 109 before 25 January 2008. The only difference between patients LTF with and without available identification numbers was in the median CD4 count (respectively, 101 cells/µLµL, IQR 48–163 with, and 82, IQR 34–143 without identity documents, p = 0.007).

Bottom Line: Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF.Correction for these misclassified deaths revealed that the risk of true LTF increased over time.Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.

View Article: PubMed Central - PubMed

Affiliation: Médecins Sans Frontières, Cape Town, South Africa. gillesvancutsem@gmail.com

ABSTRACT

Background: Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.

Methods and findings: We included 6411 patients enrolled on ART between March 2001 and June 2007. Patients LTF with available civil identification numbers were matched with the national vital registration system to ascertain vital status. Corrected mortality and true LTF were determined by weighting these patients to represent all patients LTF. We used Kaplan-Meier estimates and Cox regression to describe LTF, mortality among those LTF, and true LTF. Of 627 patients LTF, 85 (28.8%) had died within 3 months after their last clinic visits. Respective estimates of LTF before and after correction for mortality were 6.9% (95% confidence interval [CI] 6.2-7.6) and 4.3% (95% CI 3.5-5.3) at one year on ART, and 23.9% (95% CI 21.0-27.2) and 19.7% (95% CI 16.1-23.7) at 5 years. After correction for mortality, the hazard of LTF was reversed from decreasing to increasing with time on ART. Younger age, higher baseline CD4 count, pregnancy and increasing calendar year were associated with higher true LTF. Mortality of patients LTF at 1, 12 and 24 months after their last visits was respectively 23.1%, 30.9% and 43.8%; 78.0% of deaths occurred during the first 3 months after last visit and 45.0% in patients on ART for 0 to 3 months.

Conclusions: Mortality of patients LTF was high and occurred early after last clinic visit, especially in patients recently started on ART. Correction for these misclassified deaths revealed that the risk of true LTF increased over time. Research targeting groups at higher risk of LTF (youth, pregnant women and patients with higher CD4 counts) is needed.

Show MeSH
Related in: MedlinePlus