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Identifying and Reengaging Patients Lost to Follow-Up in Rural Africa: The “Horizontal” Hospital-Based Approach in Uganda

Faraz Alizadeh, Gideon Mfitumuhoza, Joseph Stephens, Christopher Habimaana, Kwiringira Myles, Michael Baganizi and Gerald Paccione
Global Health: Science and Practice March 2019, 7(1):103-115; https://doi.org/10.9745/GHSP-D-18-00394

Figures & Tables

Figures

Tables

  • TABLE 1.

    Lost to Follow-Up Defined at Kisoro District Hospital, Uganda, by Hospital Unit

    Hospital UnitLTFU DefinitionRationaleFrequency of Chart Review
    Ward dischargeMissed first CCC appointment by 1 monthApproximate time before clinical deterioration and/or depletion of medications.Weekly
    Inpatient TB registryMissed drug refill appointment by 2 or more weeksPatients pick up medication every 2 weeks; public health implications for breaks in treatment are significant.Monthlya
    HIV clinicMissed 2 monthly appointments (either pre- or post-ART initiation)Although patients are scheduled to pick up medications monthly, many come 1 or 2 weeks post-appointment, so a 2-month interval captures the late-comers.Every 2 weeks
    Chronic Care ClinicPatient with at least 2 prior visits (i.e., regular CCC patient) who has not returned for 3–6 months, depending on disease severity (3 months for most severe 25% of patients, 6 months for less severe)Risk severity stratification applied due to large number of CCC patients and limited outreach capacity.Every 2 months
    Nutrition clinicMissed 1 appointmentLow threshold applied due to population of vulnerable children.Monthly

    • Abbreviations: ART, antiretroviral therapy; CCC, Chronic Care Clinic; LTFU, lost to follow-up; TB, tuberculosis.

    • ↵a TB patients identified as LTFU could be off their medications for more than 1 month since staff identify TB patients LTFU once a month.

  • TABLE 2.

    Lapses From Care for Chronic Care Clinic and HIV Clinic Patients,a Kisoro District Hospital, Uganda, May 2015–April 2016

    New PatientsbExisting Patientsc
    CCC patients, N223441
    No. (%) of CCC patients who lapsed from cared95 (43)252 (57)
    No. (%) of lapsed CCC patients who later returned29 (31)141 (56)
    HIV clinic patients, N3611321
    No. (%) of HIV patients who lapsed from care216 (60)401 (30)

    • Abbreviation: CCC, Chronic Care Clinic.

    • ↵a Lapse from care defined as 3 or more months since the last appointment for CCC patients and 2 or more months for HIV clinic patients.

    • ↵b New patients (inception cohort) are those who first enrolled in the clinic between May 2015 and April 2016.

    • ↵c Existing patients (prevalence cohort) are those who made at least 3 clinic visits before May 2015 with at least 1 visit between January and April 2015, or, if they first enrolled in early 2015, returning at least once within 3 months after May 1, 2015.

    • ↵d Median lapse=6 months; longest lapse=19 months.

  • TABLE 3.

    TB, Nutrition, and Ward Discharges LTFU, 2016a

    TBNutritionWard Discharges
    Total number of new enrollees in 2016185245448b
    No. (%) of new enrollees LTFU79 (43)75 (31)182 (41)

    • Abbreviations: LTFU, lost to follow-up; TB, tuberculosis.

    • ↵a LTFU defined differently by hospital unit: TB=missed drug refill by 2 or more weeks; nutrition=missed 1 appointment; ward discharges=missed first CCC appointment by 1 month.

    • ↵b 2,545 were admitted to the internal medicine ward in 2016 but only 448 were given follow-up appointments to the CCC upon discharge.

  • TABLE 4.

    Follow-Up Outcomes Among Patients Lost to Follow-Up, by Hospital Unit, November 2015–October 2016 (N=1,285)

    CCC (n=310)Ward Discharge (n=149)HIV (n=691)TB (n=73)Nutrition (n=62)Total (N= 1,285)
    Patients found, No. (%)234 (75)121(81)360 (52)54 (74)47 (76)816 (64)
    Recording error (not LTFU), No. (%)39 (17)11 (9)57 (16)4 (7)4 (9)115 (14)
    Referred back to KDH clinic, No. (%)142 (61)81 (67)138 (38)36 (67)32 (68)429 (53)
    Referred to another clinic, No. (%)10 (4)2 (1)84 (23)1 (2)1 (2)98 (12)
    Refused to return, No. (%)2 (1)1 (1)8 (2)1 (2)1 (2)13 (2)
    Unable to return (imprisoned, bed-bound), No. (%)2 (1)2 (1)4 (1)0 (0)0 (0)8 (1)
    Confirmed dead39 (17)24 (20)69 (19)12 (22)9 (19)153 (19)
    Patients not found, No. (%)76 (25)28 (19)331 (48)19 (26)15 (24)469 (36)
    Not at home, No. (%)9 (12)3 (11)9 (2)0 (0)1 (7)22 (5)
    Could not find home, No. (%)32 (42)15 (54)214 (65)10 (53)8 (53)279 (59)
    Moved from Kisoro, No. (%)35 (46)10 (36)108 (33)9 (47)6 (40)168 (36)

    • Abbreviations: CCC, Chronic Care Clinic; KDH, Kisoro District Hospital; TB, tuberculosis.

  • TABLE 5.

    Patient Reengagement Outcomes Among Patients With Chronic (Lifelong) Conditions Who Were Located and Referred Back to KDH, November 2015–October 2016 (N=361)

    CCC (n=142)Ward Discharge (n=81)HIV (n=138)
    Did not return to care, No. (%)36 (25)22 (27)64 (46)
    Returned to care, No. (%)106 (75)59 (73)74 (54)
    6-month analysis not possible,a No. (%)18 (17)b19 (32)b11 (15)b
    Alive and eligible for 6-month follow-up, No. (%)88 (83)40 (68)63 (85)
    Still in clinic at 6 months, No. (%)62 (70)21 (52)43 (68)

    • Abbreviations: CCC, Chronic Care Condition; KDH, Kisoro District Hospital; LTFU, lost to follow-up.

    • ↵a Analysis not possible because either the patient file was lost or the patient died before the 6-month mark, was discharged from the clinic, or was transferred to another clinic after returning.

    • ↵b No. of patients who died before the 6-month analysis period: CCC (4), ward discharge (1), HIV (0), total (5).

  • TABLE 6.

    Patient Reengagement Outcomes Among Patients Receiving Curative Treatment Who Were Located and Referred Back to KDH, November 2015–October 2016 (N=68)

    TB (n=36)Nutrition (n=32)
    Did not return to care, No. (%)3 (8)9 (28)
    Returned to care, No. (%)33 (92)23 (72)
    Completed therapy, No. (%)14 (42)16 (70)
    Still on therapy at time of analysis, No. (%)3 (9)3 (13)
    Referred for treatment at a closer health center after returning, No. (%)4 (12)--
    Refused treatment after returning, No. (%)3 (9)--
    Died after returning, No. (%)5 (15)1 (4)
    LTFU again, No. (%)2 (6)3 (13)
    Charts lost and long-term outcome analysis not possible, No. (%)2 (6)0 (0)

    • Abbreviations: KDH, Kisoro District Hospital; LTFU, lost to follow-up; TB, tuberculosis.

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Identifying and Reengaging Patients Lost to Follow-Up in Rural Africa: The “Horizontal” Hospital-Based Approach in Uganda
Faraz Alizadeh, Gideon Mfitumuhoza, Joseph Stephens, Christopher Habimaana, Kwiringira Myles, Michael Baganizi, Gerald Paccione
Global Health: Science and Practice Mar 2019, 7 (1) 103-115; DOI: 10.9745/GHSP-D-18-00394
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