GRADE Guidelines: 29. Rating the certainty in time-to-event outcomes-Study limitations due to censoring of participants with missing data in intervention studies.

OBJECTIVES: To provide Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) guidance for the consideration of study limitations (risk of bias) due to missing participant outcome data for time-to-event outcomes in intervention studies. STUDY DESIGN AND SETTING: We developed this guidance through an iterative process that included membership consultation, feedback, presentation, and iterative discussion at meetings of the GRADE working group. RESULTS: The GRADE working group has published guidance on how to account for missing participant outcome data in binary and continuous outcomes. When analyzing time-to-event outcomes (e.g., overall survival and time-to-treatment failure) data of participants for whom the outcome of interest (e.g., death and relapse) has not been observed are dealt with through censoring. To do so, standard methods require that censored individuals are representative for those remaining in the study. Two types of censoring can be distinguished, end of study censoring and censoring because of missing data, commonly named loss to follow-up censoring. However, both types are not distinguishable with the usual information on censoring available to review authors. Dealing with individuals for whom data are missing during follow-up in the same way as individuals for whom full follow-up is available at the end of the study increases the risk of bias. Considerable differences in the treatment arms in the distribution of censoring over time (early versus late censoring), the overall degree of missing follow-up data, and the reasons why individuals were lost to follow-up may reduce the certainty in the study results. With often only very limited data available, review and guideline authors are required to make transparent and well-considered judgments when judging risk of bias of individual studies and then come to an overall grading decision for the entire body of evidence. CONCLUSION: Concern for risk of bias resulting from censoring of participants for whom follow-up data are missing in the underlying studies of a body of evidence can be expressed in the study limitations (risk of bias) domain of the GRADE approach.

Developing trustworthy recommendations as part of an urgent response (1-2 weeks): a GRADE concept paper.

OBJECTIVES: The aim of this study is to propose an approach for developing trustworthy recommendations as part of urgent responses (1-2 week) in the clinical, public health, and health systems fields. STUDY DESIGN AND SETTING: We conducted a review of the literature, outlined a draft approach, refined the concept through iterative discussions, a workshop by the Grading of Recommendations Assessment, Development and Evaluation Rapid Guidelines project group, and obtained feedback from the larger Grading of Recommendations Assessment, Development and Evaluation working group. RESULTS: A request for developing recommendations within 2 week is the usual trigger for an urgent response. Although the approach builds on the general principles of trustworthy guideline development, we highlight the following steps: (1) assess the level of urgency; (2) assess feasibility; (3) set up the organizational logistics; (4) specify the question(s); (5) collect the information needed; (6) assess the adequacy of identified information; (7) develop the recommendations using one of the 4 potential approaches: adopt existing recommendations, adapt existing recommendations, develop new recommendations using existing adequate systematic review, or develop new recommendations using expert panel input; and (8) consider an updating plan. CONCLUSION: An urgent response for developing recommendations requires building a cohesive, skilled, and highly motivated multidisciplinary team with the necessary clinical, scientific, and methodological expertise; adapting to shifting needs; complying with the principles of transparency; and properly managing conflicts of interest.

Improving Transparency to Build Trust in Real-World Secondary Data Studies for Hypothesis Testing-Why, What, and How: Recommendations and a Road Map from the Real-World Evidence Transparency Initiative.

Real-world data (RWD) and the derivations of these data into real-world evidence (RWE) are rapidly expanding from informing healthcare decisions at the patient and health system level to influencing major health policy decisions, including regulatory approvals and coverage. Recent examples include the approval of palbociclib in combination with endocrine therapy for male breast cancer and the inclusion of RWE in the label of paliperidone palmitate for schizophrenia. This interest has created an urgency to develop processes that promote trust in the evidence-generation process. Key stakeholders and decision-makers include patients and their healthcare providers; learning health systems; health technology assessment bodies and payers; pharmacoepidemiologists and other clinical reseachers, and policy makers interested in bioethical and regulatory issues. A key to optimal uptake of RWE is transparency of the research process to enable decision-makers to evaluate the quality of the methods used and the applicability of the evidence that results from the RWE studies. Registration of RWE studies-particularly for hypothesis evaluating treatment effectiveness (HETE) studies-has been proposed to improve transparency, trust, and research replicability. Although registration would not guarantee better RWE studies would be conducted, it would encourage the prospective disclosure of study plans, timing, and rationale for modifications. A joint task force of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and the International Society for Pharmacoepidemiology (ISPE) recommended that investigators preregister their RWE studies and post their study protocols in a publicly available forum before starting studies to reduce publication bias and improve the transparency of research methods. Recognizing that published recommendations alone are insufficient, especially without accessible registration options and with no incentives, a group of experts gathered on February 25 and 26, 2019, in National Harbor, Maryland, to explore the structural and practical challenges to the successful implementation of the recommendations of the ISPOR/ISPE task force for preregistration. This positioning article describes a plan for making registration of HETE RWE studies routine. The plan includes specifying the rationale for registering HETE RWE studies, the studies that should be registered, where and when these studies should be registered, how and when analytic deviations from protocols should be reported, how and when to publish results, and incentives to encourage registration. Table 1 summarizes the rationale, goals, and potential solutions that increase transparency, in addition to unique concerns about secondary data studies. Definitions of terms used throughout this report are provided in Table 2.

Core Outcomes Set for Trials in People With Coronavirus Disease 2019.

OBJECTIVES: The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019. DESIGN: Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set. SETTING: International. SUBJECTS: Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers). INTERVENTIONS: None. MEASUREMENTS: None. MAIN RESULTS: Six themes were identified. "Responding to the critical and acute health crisis" reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. "Capturing different settings of care" highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. "Encompassing the full trajectory and severity of disease" was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). "Distinguishing overlap, correlation and collinearity" meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). "Recognizing adverse events" refers to the potential harms of new and evolving interventions. "Being cognizant of family and psychosocial wellbeing" reflected the pervasive impacts of coronavirus disease 2019. CONCLUSIONS: Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.

Routine Health Outcome Measurement: Development, Design, and Implementation of the Hand and Wrist Cohort.

Routine measurement of outcome of clinical care is increasingly considered important, but implementation in practice is challenging. This article describes (1) how the authors created and implemented a routine outcome measurement cohort of patients with hand and wrist conditions and (2) how these data are used to improve the quality of care and facilitate scientific research. Starting in 2011, routine outcome measurement was implemented at all practice sites (currently 22) of a specialized treatment center for hand and wrist conditions across The Netherlands. The authors developed five "measurement tracks," including measurements administered at predetermined time points covering all hand and wrist disorders and treatments. An online system automatically distributes measurements among patients, which can be accessed by health care professionals. Using this system, the total number of yearly assigned tracks increased up to over 16,500 in 2018, adding up to 85,000 tracks in 52,000 patients in total. All surgeons, therapists, and other staff have direct access to individual patient data and patients have access to their treatment information using a secure patient portal. The data serve as a basis for studies on, among others, comparative effectiveness, prediction modeling, and clinimetric analyses. In conclusion, the authors present the design and successful implementation of a routine outcome measurement system that was made feasible using a highly automated data collection infrastructure, tightly linked to the patient journey and the workflow of health care professionals. The system serves not only as a tool to improve care but also as a basis for scientific research studies.

Expanding Data Reporting Capacity of Free and Charitable Clinics: A Quality Improvement Project.

BACKGROUND: In 2018, member clinics of the Virginia Association of Free and Charitable Clinics (VAFCC) provided over 235,500 visits to un/underinsured patients. A survey of VAFCC members found that only 67% report on clinical outcome measures and 56% do not collect social determinant of health (SDOH) data. OBJECTIVE: The purpose of this project was to determine if the provision of web-based technical assistance toolkits and peer mentoring improve quality and data reporting capacity of VAFCC member clinics. METHODS: Clinics that self-selected were provided with 16 weeks of customized interventions including SDOH Data Reporting Toolkit, CMS Quality Data Reporting Toolkit, Electronic Health Record Implementation Toolkit, and peer mentoring. RESULTS: Post-implementation, 100% of participating clinics reported that the resources provided benefited their organizations and increased their capacity to report. CONCLUSIONS: The provision of technical assistance, tangible resources, and customized peer mentoring can better equip Free and Charitable Clinics (FCCs) to tell the story of their patients' social barriers and clinical outcomes. IMPLICATIONS FOR NURSING: DNP prepared nurses working with vulnerable populations are positioned to assist FCCs in documenting their relevance in the safety net system. Enhancing the ability of FCCs to collect and report data will allow them to demonstrate the provision of high-quality care, despite limited resources.

Defining Patient Engagement in Research: Results of a Systematic Review and Analysis: Report of the ISPOR Patient-Centered Special Interest Group.

OBJECTIVES: Lack of clarity on the definition of "patient engagement" has been highlighted as a barrier to fully implementing patient engagement in research. This study identified themes within existing definitions related to patient engagement and proposes a consensus definition of "patient engagement in research." METHODS: A systematic review was conducted to identify definitions of patient engagement and related terms in published literature (2006-2018). Definitions were extracted and qualitatively analyzed to identify themes and characteristics. A multistakeholder approach, including academia, industry, and patient representation, was taken at all stages. A proposed definition is offered based on a synthesis of the findings. RESULTS: Of 1821 abstracts identified and screened for eligibility, 317 were selected for full-text review. Of these, 169 articles met inclusion criteria, from which 244 distinct definitions were extracted for analysis. The most frequently defined terms were: "patient-centered" (30.5%), "patient engagement" (15.5%), and "patient participation" (13.4%). The majority of definitions were specific to the healthcare delivery setting (70.5%); 11.9% were specific to research. Among the definitions of "patient engagement," the most common themes were "active process," "patient involvement," and "patient as participant." In the research setting, the top themes were "patient as partner," "patient involvement," and "active process"; these did not appear in the top 3 themes of nonresearch definitions. CONCLUSION: Distinct themes are associated with the term "patient engagement" and with engagement in the "research" setting. Based on an analysis of existing literature and review by patient, industry, and academic stakeholders, we propose a scalable consensus definition of "patient engagement in research."

The Next Frontier of Outcomes Research: Collaborative Quality Initiatives.

Quality improvement efforts at the federal level have instituted both rewards and penalties as incentives to improve health care quality. However, neither of these methods has shown long-lasting improvements. Furthermore, many programs have focused on decreasing mortality or hospital readmissions, measurements that are not applicable to many surgical fields, including plastic surgery. One model that has been shown to be effective is a collaborative quality initiative that uses a pay-for-participation method whereby participants learn from one another and institute changes to improve patient care. Many of these changes are process measures that are easier to implement and quicker to show improvement than structural or outcome measures. Regional collaborative quality initiatives have been developed in other surgical specialties such as bariatric surgery and urology. Currently, the authors are establishing a new collaborative quality initiative for hand surgery: the Michigan Collaborative Hand Initiative for Quality in Surgery. It is a collaboration of nine sites with the goal of identifying areas that are in need of quality improvement in hand surgery and implementing measures to improve on them. The authors believe that collaborative quality initiatives will promote high-quality care and should be incorporated into the field of plastic surgery.

Things Fall Apart: the British Health Crisis 2010-2020.

BACKGROUND: A very large number of studies have reported a stalling of health improvements in the UK since 2010. SOURCES OF DATA: Almost all relevant data are produced by the Office for National Statistics and other national statistical agencies. AREAS OF AGREEMENT: There has been a dramatic slowdown in life expectancy and diverging trends in infant mortality in the UK as a whole and England and Wales, respectively. AREAS OF CONTROVERSY: Many commentators are loath to describe the falls in life expectancy as actual falls or to ascribe blame to the political situation in the UK. GROWING POINTS: Health trends in the UK are worrying and raise important questions about government policies. AREAS TIMELY FOR DEVELOPING RESEARCH: These findings point to a need for greater investment in research on the political determinants of health, on the timely detection and interpretation of evidence of worsening health, and on how political and policy processes respond to such findings.

Development of a core outcome set for pediatric critical care outcomes research.

BACKGROUND: Pediatric Intensive Care Unit (PICU) teams provide care for critically ill children with diverse and often complex medical and surgical conditions. Researchers often lack guidance on an approach to select the best outcomes when evaluating this critically ill population. Studies would be enhanced by incorporating multi-stakeholder preferences to better evaluate clinical care. This manuscript outlines the methodology currently being used to develop a PICU Core Outcome Set (COS). This PICU COS utilizes mixed methods, an inclusive stakeholder approach, and a modified Delphi consensus process that will serve as a resource for PICU research programs. METHODS: A Scoping Review of the PICU literature evaluating outcomes after pediatric critical illness, a qualitative study interviewing PICU survivors and their parents, and other relevant literature will serve to inform a modified, international Delphi consensus process. The Delphi process will derive a set of minimum domains for evaluation of outcomes of critically ill children and their families. Delphi respondents include researchers, multidisciplinary clinicians, families and former patients, research funding agencies, payors, and advocates. Consensus meetings will refine and finalize the domains of the COS, outline a battery instruments for use in future studies, and prepare for extensive dissemination for broad implementation. DISCUSSION: The PICU COS will be a guideline resource for investigators to assure that outcomes most important to all stakeholders are considered in PICU clinical research in addition to those deemed most important to individual scientists. TRIAL REGISTRATION: COMET database (http://www.comet-initiative.org/, Record ID 1131, 01/01/18).

Nurse Case Manager: Measurement of Care Coordination Activities and Quality and Resource Use Outcomes When Caring for the Complex Patient With Hematologic Cancer.

BACKGROUND: The lack of coordination of care for complex patients in the hematology setting has prompted nurse case managers (NCMs) to coordinate that care. OBJECTIVES: This article aimed to identify the frequency of NCM care coordination activities and quality and resource use outcomes in the complex care of patients in the hematology setting. METHODS: NCM aggregate data from complex outpatients with hematologic cancer were retrieved from electronic health records at a comprehensive cancer center in the midwestern United States. Total volume of activities and outcomes were calculated as frequency and percentage. FINDINGS: Care coordination activities included communicating; monitoring, following up, and responding to change; and creating a proactive plan of care. Quality outcomes included improving continuity of care and change in health behavior, and resource use outcomes most documented were patient healthcare cost savings.

Do recovery outcome measures improve clinical practice? A linguistic analysis of the impact of the Hope, Agency and Opportunity measure in community mental health teams.

AIMS: Recovery approaches are identified as the overarching framework for improving mental health services for people with severe and enduring conditions. These approaches prioritise living well with long-term conditions, as evidenced by personal recovery outcomes. There is little research demonstrating how to support busy mental health teams, work in this way. This study assessed the impact of introducing a brief measure of recovery, the Hope, Agency and Opportunity (HAO), on the attitudes and behaviours of staff working in community mental health teams, to test whether routine use of such measures facilitates recovery-based practice. METHODS: Linguistic analysis assumes that language is indicative of wider attitudes and behaviours. Anonymised clinical notes recorded by community mental health team clinicians were analysed for recovery and non-recovery language, over 30 months. This covered periods before, during and after the introduction of the recovery measure. We used a single-case design (N = 1 community mental health team) and hypothesised that clinicians would use recovery-focused language more frequently, and non-recovery-focused language less frequently, following the introduction of the measure, and that these changes would be maintained at 18-month follow-up. RESULTS: Visual inspection of the data indicated that recovery-focused language increased following the introduction of the HAO, though this was not maintained at follow-up. This pattern was not supported by statistical analyses. No clear pattern of change was found for non-recovery-focused language. CONCLUSIONS: The introduction of a brief measure of recovery may have influenced staff attitudes and behaviours temporarily. Any longer term impact is likely to depend on ongoing commitment to the use of the measure, without which staff language, attitudes and behaviours return to previous levels.

Implementation of a pilot electronic stroke outcome reporting system for emergency care providers.

INTRODUCTION: Emergency department (ED) providers and clinicians find that feedback on acute stroke patients is rewarding, valuable to professional development, and helpful for practice improvement. However, feedback is rarely provided, particularly for patients with stroke. Here we describe the implementation of an electronic stroke outcome reporting tool for providing feedback to ED providers. METHODS: We sought to evaluate the implementation of an electronic stroke outcome reporting tool at 3 Nashville hospitals. ED staff and providers voluntarily enrolled to receive de-identified reports of clinical (e.g., survival) and operational (e.g., timeliness) outcomes of patients with acute ischemic stroke and were offered free continuing education (CE) credits for following up on patients. We evaluated the implementation of this system through a descriptive evaluation of the feasibility, use of the system and CE, and perceived usefulness of the reports. RESULTS: We enrolled 232 ED providers, including 107 (46%) nurses and 57 (25%) attending physicians and transmitted 55 stroke outcome reports. Reports took 30-60 min to compile and were viewed by a mean of 2.6 (SD 1.5) registered providers; 97.1% found the reports useful and 36.2% reported likelihood to change practice. Continuing education credits were initiated or claimed by 22 providers. CONCLUSIONS: An electronic stroke outcome reporting tool was used and liked by ED staff and providers but the time to compile the reports is the major challenge to scalability. Future research should address the effectiveness of this reporting tool as a source of provider education and its impact on clinical and operational outcomes.

The impact mechanism of the controlling system in hospitals on quality of care: A study on clinical practice in China.

BACKGROUND: Quality control system is one of the hospital information systems. The adoption of quality control system increases the work efficiency; however, to some extent, it also increases the workload for physicians. OBJECTIVE: The purpose of this study is to investigate the impacts of the quality control system on quality of care (e.g., process and outcome performance). METHODS: Our study collected physicians' behavior information from a large urban hospital in China. We constructed the fixed-effect model to examine the relationship between the quality control system adoption and quality of care. RESULTS: Using the quality control system has a significant (p< 0.001) and negative effect on patients' stay length in the hospital (process performance). Furthermore, using the quality control system has a significant (p< 0.001) and positive effect on the trends of cure rate in the hospital (outcome performance). The coefficient of the dependent variable from the patients' stay length (process performance) is lower than the trends of cure rate (outcome performance). CONCLUSIONS: The controlling system can improve medical quality even though it limits physician behavior to some extent. The controlling system improves both the process performance and outcome performance, and it brings more benefits to outcome performance rather than process performance which means the reflection of the new technology may have more evident on outcome variables.

Surgeon work captured by the National Surgical Quality Improvement Program across specialties.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) database is increasingly used for surgical research. However, it is unclear how well this database represents the breadth of work performed by different specialties. METHODS: Using the 2017 NSQIP participant use file and the 2017 Medicare Physician/Supplier Procedure Summary file, we evaluated (1) what proportion of surgical work is captured by NSQIP, (2) what procedures and disciplines are undersampled, and (3) the overall concordance between the NSQIP sample and a national sample. RESULTS: The NSQIP database reported at least one case for 4,463 out of the 5,272 Current Procedures Terminology codes in the Medicare file, potentially capturing 97.8% of surgical work across all 10 specialties. However, this proportion decreased to 72.1% when only procedures with at least 100 cases in NSQIP were considered. Limiting our analysis to only those procedures with 100 cases had markedly different effects by specialty. In part, this was owing to undersampling of minor procedures, which are more common in disciplines such as otolaryngology and urology. The overall association between the size of the NSQIP sample and the Medicare sample was 0.08. CONCLUSION: Although NSQIP has the potential to capture a diverse surgical caseload, some specialties and procedures are undersampled, limiting the ability for NSQIP to generate valid benchmarks. There was little correlation between the sample sizes in NSQIP and a national sample. Increasing sampling of underrepresented procedures and developing weights to scale NSQIP to a national sample would strengthen the program's ability to inform health outcomes research and provide valid comparisons across procedures and specialties.

The Open Arms Healthcare Center's Integrated HIV Care Services Model.

INTRODUCTION: Mississippi has the seventh highest rate of people newly diagnosed with HIV infection, and the city of Jackson - the capital and largest metropolitan area of Mississippi - has the third highest rate of AIDS diagnoses among all metropolitan areas in the nation. Linking patients to care and proper adherence to antiretroviral therapy is important for achieving viral load suppression and reducing transmission of the virus. However, many HIV-infected patients have social and clinical barriers to achieving viral suppression. To overcome these barriers the Open Arms Healthcare Center has implemented an integrated HIV care services model. PURPOSE AND OBJECTIVES: The purpose of this study was to determine whether an integrated model of HIV care influenced linkage to health care, adherence to antiretroviral therapy, and viral load suppression. INTERVENTION APPROACH: The integrated HIV care services model consisted of 5 care coordination components: 1) case management, 2) HIV health care (primary health care), 3) behavioral health care (mental and substance abuse screening and treatment), 4) adherence counseling (a pharmacist-led intervention), and 5) social support services (transportation, emergency food assistance, housing, and legal assistance). EVALUATION METHODS: We used a cross-sectional research design to examine Open Arms electronic health record data collected from 231 patients from January 2015 through December 2017 to determine if an integrated model of HIV care resulted in increased linkage to health care, higher adherence rates, and improved viral load suppression. RESULTS: Findings showed a 38.0% increase in the viral load suppression rate, a 12.8% increase in antiretroviral therapy adherence rate, and an 11.0% increase in retention rates among Open Arms patients receiving integrated HIV care. IMPLICATIONS FOR PUBLIC HEALTH: A comprehensive, holistic approach helps to effectively identify and connect HIV-positive patients to care and relink patients who may have fallen out of care.

Achieving Appropriate Model Transparency: Challenges and Potential Solutions for Making Value-Based Decisions in the United States.

Transparency in decision modeling remains a topic of rigorous debate among healthcare stakeholders, given tensions between the potential benefits of external access during model development and the need to protect intellectual property and reward research investments. Strategies to increase decision model transparency by allowing direct external access to a model's structure, source code, and data can take on many forms but are bounded between the status quo and free publicly available open-source models. Importantly, some level of transparency already exists in terms of methods and other technical specifications for published models. The purpose of this paper is to delineate pertinent issues surrounding efforts to increase transparency via direct access to models and to offer key considerations for the field of health economics and outcomes research moving forward from a US academic perspective. Given the current environment faced by modelers in academic settings, expected benefits and challenges of allowing direct model access are discussed. The paper also includes suggestions for pathways toward increased transparency as well as an illustrative real-world example used in work with the Institute for Clinical and Economic Review to support assessments of the value of new health interventions. Potential options to increase transparency via direct model access during model development include adequate funding to support the additional effort required and mechanisms to maintain security of the underlying intellectual property. Ultimately, the appropriate level of transparency requires balancing the interests of several groups but, if done right, has the potential to improve models and better integrate them into healthcare priority setting and decision making in the US context.

Implementation and outcomes of a patient tracing programme for HIV in Trinidad and Tobago.

A patient tracing programme was implemented at an HIV clinic in Trinidad and Tobago to address the problem of defaulters from HIV care and non-adherence to antiretroviral treatment (ART). The study objective was to evaluate the implementation and outcomes of this programme conducted between April and September 2017. Using patient tracing contact methods, trained social workers attempted to contact 1058 patients lost to follow up (LTFU) between July 2016 and March 2017. Of the 1058 LTFU, 192 were ineligible: 27 (2.5%) were transferred to another clinic, 64 (6%) deceased, 35 (3.3%) hospitalised, 50 (4.7%) migrated and 16 (1.5%) incarcerated. Of the 866 eligible patients for patient tracing, 277 (32%) remained permanently LTFU and 589 (68%) were successfully contacted, re-engaged in care and received adherence counselling. Of the 589 who returned to care, 507 (86%) restarted ART. The three most common barriers reported among the 589 who were reengaged were 'forgetting their appointments' (20%), 'being too busy/work' (16%), and 'not wanting to be seen attending the HIV clinic' (12%). The study findings demonstrated the tracing programme as feasible for re-engaging those who are LTFU and highlighted barriers that can be addressed to further improve retention in HIV care among people living with HIV.