Adjusting Mortality for Loss to Follow-Up: Analysis of Five ART Programmes in Sub-Saharan Africa
Adjusting Mortality for Loss to Follow-Up: Analysis of Five ART Programmes in Sub-Saharan Africa
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DOI：
10.1371/journal.pone.0014149
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发表时间：
2010-11-30
期刊：
影响因子：
3.7
通讯作者：
Sterne, Jonathan A. C.
中科院分区：
文献类型：
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作者：
Brinkhof, Martin W. G.;Spycher, Ben D.;Sterne, Jonathan A. C.
背景：在撒哈拉以南非洲地区，由于许多患者失访，因此很难对抗逆转录病毒治疗（ART）项目进行评估。这些患者的结局通常未知，但追踪患者的研究显示死亡率很高。我们调整方案水平的死亡率在第一年的抗逆转录病毒治疗（ART）的患者死亡率超过失去follow-up.Methods和调查结果：治疗初治患者开始组合ART在科特迪瓦，肯尼亚，马拉维和南非的五个方案是合格的。末次访视在数据库关闭前至少9个月的患者被视为失访。我们通过多重插补，使用追踪失访患者的研究中的死亡率估计值，填补了这些患者缺失的生存时间。使用Weibull模型分析数据，调整年龄、性别、ART方案、CD 4细胞计数、临床分期和治疗方案。共有15 915名艾滋病毒感染者（中位CD 4细胞计数110个细胞/μ L，中位年龄35岁，68%为女性）; 1,001（6.3%）已知死亡，1，285（14.3%）在ART治疗的第一年失访。（95%CI 4.9-6.5%）至10.9%（9.6-12.4%）。比较失访患者与仍在接受治疗的患者，估计死亡风险比范围为6至23。根据这些风险比调整后的估计值范围为10.2%（8.9-11.6%）至16.9%（15.0-19.1%），死亡率的相对增加范围为27%至73%across programmes.Conclusions：天真的生存分析忽略了患者失访的死亡率可能大大低估了总体死亡率，并偏见ART计划的评估。根据失访患者的超额死亡率，可获得调整后的死亡率估计值。
Background: Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up.Methods and Findings: Treatment-naive patients starting combination ART in five programmes in Cote d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/mu L, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes.Conclusions: Naive survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up.