Ethnic and racial differences in long-term survival from hospitalization for HIV infection

This prospective cohort study compares 200 hospitalized, HIV-infected patients (Hispanic, African American, and white) from May 1992 to October 1998 to assess mortality (versus survival) over 75 months of follow-up. The relative risk of six-year mortality for each ethnic group is compared using Cox proportional hazards models after controlling for sociodemographic and clinical characteristics, access to general medical care, and HIV-specific treatment. The median survival of Hispanics (15.5 months) was significantly (p < 0.05) shorter than that of whites (23.8); survival for African Americans (35.1) did not differ from whites. In multivariate analysis, the adjusted relative risk of six-year mortality for Hispanics compared with whites was 2.14 (95 percent confidence interval = 1.26-3.66). The poor outcomes of Hispanics was not explained by access to general care or by HIV-specific treatment.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection

OBJECTIVE

Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV.

METHOD

The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study.

RESULTS

HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder.

CONCLUSIONS

Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Violence victimization after HIV infection in a US probability sample of adult patients in primary care

OBJECTIVES

This study estimated the proportion of HIV-infected adults who have been assaulted by a partner or someone important to them since their HIV diagnosis and the extent to which they reported HIV-seropositive status as a cause of the violence.

METHODS

Study participants were from a nationally representative probability sample of 2864 HIV-infected adults who were receiving medical care and were enrolled in the HIV Costs and Service Utilization Study. All interviews (91% in person, 9% by telephone) were conducted with computer-assisted personal interviewing instruments. Interviews began in January 1996 and ended 15 months later.

RESULTS

Overall, 20.5% of the women, 11.5% of the men who reported having sex with men, and 7.5% of the heterosexual men reported physical harm since diagnosis, of whom nearly half reported HIV-seropositive status as a cause of violent episodes.

CONCLUSIONS

HIV-related care is an appropriate setting for routine assessment of violence. Programs to cross-train staff in antiviolence agencies and HIV care facilities need to be developed for men and women with HIV infection.

Prevalence and predictors of unmet need for supportive services among HIV-infected persons: impact of case management

BACKGROUND

Previous research has indicated that the needs of persons infected with human immunodeficiency virus (HIV) for supportive services often go unmet. Although case management has been advocated as a method of decreasing unmet needs for supportive services, its effectiveness is poorly understood.

OBJECTIVES

To assess the prevalence of need and unmet need for supportive services and the impact of case managers on unmet need among HIV-infected persons.

RESEARCH DESIGN

National probability sample.

PARTICIPANTS

A total of 2,832 HIV-infected adults receiving care.

MEASURES

Need and unmet need for benefits advocacy, housing, home health, emotional counseling, and substance abuse treatment services.

RESULTS

Sixty-seven percent of the sample had a need for at least one supportive service, and 26.6% had an unmet need for at least one service in the previous 6 months. Contingent unmet need (unmet need among persons who needed the service) was greatest for benefits advocacy (34.6%) and substance abuse treatment (27.6%). Fifty-seven percent of the sample had had contact with their case manager in the previous 6 months. In multiple logistic regression analysis, with adjustment for covariates, having a case manager was associated with decreased unmet need for home healthcare (OR =0.39; 95% CI = 0.25-0.60), emotional counseling (OR = 0.54; 95% CI = 0.38-0.78), and any unmet need (OR = 0.70; 95% CI = 0.54-0.91). An increased number of contacts with a case manager was significantly associated with lower unmet need for home health care, emotional counseling, and any unmet need.

CONCLUSIONS

Need and unmet need for supportive services among HIV-infected persons is high. Case management programs appear to lower unmet need for supportive services.

National probability samples in studies of low-prevalence diseases. Part I: Perspectives and lessons from the HIV cost and services utilization study

OBJECTIVE

To examine the trade-offs inherent in selecting a sample design for a national study of care for an uncommon disease, and the adaptations, opportunities and costs associated with the choice of national probability sampling in a study of HIV/AIDS.

SETTING

A consortium of public and private funders, research organizations, community advocates, and local providers assembled to design and execute the study.

DESIGN

Data collected by providers or collected for administrative purposes are limited by selectivity and concerns about validity. In studies based on convenience sampling, generalizability is uncertain. Multistage probability sampling through households may not produce sufficient cases of diseases that are not highly prevalent. In such cases, an attractive alternative design is multistage probability sampling through sites of care, in which all persons in the reference population have some chance of random selection through their medical providers, and in which included subjects are selected with known probability. DATA COLLECTION AND PRINCIPAL FINDINGS: Multistage national probability sampling through providers supplies uniquely valuable information, but will not represent populations not receiving medical care and may not provide sufficient cases in subpopulations of interest. Factors contributing to the substantial cost of such a design include the need to develop a sampling frame, the problems associated with recruitment of providers and subjects through medical providers, the need for buy-in from persons affected by the disease and their medical practitioners, as well as the need for a high participation rate. Broad representation from the national community of scholars with relevant expertise is desirable. Special problems are associated with organization of the research effort, with instrument development, and with data analysis and dissemination in such a consortium.

CONCLUSIONS

Multistage probability sampling through providers can provide unbiased, nationally representative data on persons receiving regular medical care for uncommon diseases and can improve our ability to accurately study care and its outcomes for diseases such as HIV/AIDS. However, substantial costs and special circumstances are associated with the implementation of such efforts.

National probability samples in studies of low-prevalence diseases. Part II: Designing and implementing the HIV cost and services utilization study sample

OBJECTIVE

The design and implementation of a nationally representative probability sample of persons with a low-prevalence disease, HIV/AIDS.

DATA SOURCES/STUDY SETTING

One of the most significant roadblocks to the generalizability of primary data collected about persons with a low-prevalence disease is the lack of a complete methodology for efficiently generating and enrolling probability samples. The methodology developed by the HCSUS consortium uses a flexible, provider-based approach to multistage sampling that minimizes the quantity of data necessary for implementation.

STUDY DESIGN

To produce a valid national probability sample, we combined a provider-based multistage design with the M.D.-colleague recruitment model often used in non-probability site-specific studies.

DATA COLLECTION

Across the contiguous United States, reported AIDS cases for metropolitan areas and rural counties. In selected areas, caseloads for known providers for HIV patients and a random sample of other providers. For selected providers, anonymous patient visit records.

PRINCIPAL FINDINGS

It was possible to obtain all data necessary to implement a multistage design for sampling individual HIV-infected persons under medical care with known probabilities. Taking account of both patient and provider nonresponse, we succeeded in obtaining in-person or proxy interviews from subjects representing over 70 percent of the eligible target population.

CONCLUSIONS

It is possible to design and implement a national probability sample of persons with a low-prevalence disease, even if it is stigmatized.

The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States

OBJECTIVES

To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data.

DESIGN

Survey of a nationally representative sample of 2,864 adults receiving HIV care.

MAIN INDEPENDENT VARIABLES

Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick.

MAIN OUTCOME MEASURES

Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale.

RESULTS

More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access.

CONCLUSIONS

Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

General neurologist and subspecialist care for multiple sclerosis: patients' perceptions

OBJECTIVE

To compare general neurologists and MS specialists on patients' clinical characteristics and MS care as perceived by patients with MS.

METHODS

We sampled all adult patients with MS having physician visits over a 2-year period from a Midwestern managed-care organization and from the fee-for-service portion of 23 randomly selected California neurologists' practices. In mid-1996, 694 subjects were mailed questionnaires; 532 (77%) responded. Sociodemographic/clinical characteristics, recent utilization of services/treatments, unmet needs, symptom care, and research participation were measured. Of 502 subjects (94%) who indicated their usual physician providing MS care was a neurologist, 217 (43%) reported having a general neurologist and 285 (57%) reported having an MS specialist. Comparisons between these two groups were adjusted for comorbidity and disease severity.

RESULTS

General neurologist and MS specialist patient groups did not differ on any sociodemographic or clinical characteristic except age (p<0.05). Although health care utilization generally was similar, higher proportions of the MS specialist group were aware of or had discussed interferon beta-1b (IFNbeta-1b) with their physician (p<0.05) and were currently taking it (p<0.05); a smaller proportion of the MS specialist group reported stopping it because of side effects (p<0.01). Overall, levels of unmet need and care for recent symptoms were similar, but the MS specialist group reported more confidence in their physician/carefulness in listening (p<0.05). Twice as many MS specialist subjects had participated in nondrug research (p<0.05); drug study participation was similar.

CONCLUSIONS

Patients' perceptions of their care were similar in most ways for those who designated their main MS provider as a general neurologist compared to an MS specialist; however, care differed in potentially important areas. Prospective, longitudinal studies are needed to measure and relate neurologists' training, experience, knowledge, and MS patient volume with both process and outcome measures of quality of MS care.

Variations in the care of HIV-infected adults in the United States: results from the HIV Cost and Services Utilization Study

CONTEXT

Studies of selected populations suggest that not all persons infected with human immunodeficiency virus (HIV) receive adequate care.

OBJECTIVE

To examine variations in the care received by a national sample representative of the adult US population infected with HIV.

DESIGN

Cohort study that consisted of 3 interviews from January 1996 to January 1998 conducted by the HIV Cost and Services Utilization Consortium.

PATIENTS AND SETTING

Multistage probability sample of 2864 respondents (68% of those targeted for sampling), who represent the 231400 persons at least 18 years old, with known HIV infection receiving medical care in the 48 contiguous United States in early 1996 in facilities other than emergency departments, the military, or prisons. The first follow-up consisted of 2466 respondents and the second had 2267 (65% of all surviving sampled subjects).

MAIN OUTCOME MEASURES

Service utilization (<2 ambulatory visits, at least 1 emergency department visit that did not lead to hospitalization, at least 1 hospitalization) and medication utilization (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia).

RESULTS

Inadequate HIV care was commonly reported at the time of interviews conducted from early 1996 to early 1997 but declined to varying degrees by late 1997. Twenty-three percent of patients initially and 15% of patients subsequently had emergency department visits that did not lead to hospitalization, 30% initially and 26% subsequently of those who had CD4 cell counts below 0.20 x 10(9)/L did not receive P carinii pneumonia prophylaxis, and 41% initially and 15% subsequently of those who had CD4 cell counts below 0.50 x 10(9)/L did not receive antiretroviral therapy (protease inhibitor or nonnucleoside reverse transcriptase inhibitor). Inferior patterns of care were seen for many of these measures in blacks and Latinos compared with whites, the uninsured and Medicaid-insured compared with the privately insured, women compared with men, and other risk and/or exposure groups compared with men who had sex with men even after CD4 cell count adjustment. With multivariate adjustment, many differences remained statistically significant. Even by early 1998, fewer blacks, women, and uninsured and Medicaid-insured persons had started taking antiretroviral medication (CD4 cell count adjusted P values <.001 to <.005).

CONCLUSIONS

Access to care improved from 1996 to 1998 but remained suboptimal. Blacks, Latinos, women, the uninsured, and Medicaid-insured all had less desirable patterns of care. Strategies to ensure optimal care for patients with HIV requires identifying the causes of deficiency and addressing these important shortcomings in care.

The United States liver donor population in the 1990s: a descriptive, population-based comparative study

BACKGROUND

Orthotopic liver transplantation in the United States is primarily limited by a shortage of donor organs.

METHODS

To better understand the low rates of organ donation in the United States and identify areas for potential improvement, we analyzed detailed demographic and mortality-specific data from 10,689 adult cadaveric liver donors obtained from the United Network for Organ Sharing from April 1, 1994 to March 31, 1997. Comparative U.S. population demographic and economic data were obtained from the U.S. census.

RESULTS

As compared with the U.S. population, we found there to be significantly fewer nonwhite (P=0.001) and foreign-born donors (P=0.001); 58.9% of liver donors were male (P=0.001). The mean age was 40.6 years; yet during the 3-year period analyzed, there was a significant trend toward increasing age of donors. Median household income was 18% to 32% lower in the donor population than in the general U.S. population. In 91.2% of cases, the donor cause of death was listed as cerebrovascular stroke or head trauma. Numerous significant interracial differences were found in both the donor mechanism and circumstance of death. These included black donors being more likely to have gunshot wound as the listed mechanism of death (P=0.001) and to have homicide as the listed circumstance of death (P=0.001).

CONCLUSIONS

Nonwhites and foreign-born individuals are significantly underrepresented in the U.S. liver donor population. Furthermore, donors seem to be poorer than the general U.S. population. Increasing the liver donor pool, especially among minorities, will require creative and thoughtful public initiatives.

Underuse and overuse of diagnostic testing for coronary artery disease in patients presenting with new-onset chest pain

PURPOSE

To determine the extent of overuse and underuse of diagnostic testing for coronary artery disease and whether the socioeconomic status, health insurance, gender, and race/ethnicity of a patient influences the use of diagnostic tests.

SUBJECTS AND METHODS

We identified patients who presented with new-onset chest pain not due to myocardial infarction at one of five Los Angeles-area hospital emergency departments between October 1994 and April 1996. Explicit criteria for diagnostic testing were developed using the RAND/University of California, Los Angeles, expert panel method. They were applied to data collected by medical record review and patient questionnaire.

RESULTS

Of the 356 patients, 181 met necessity criteria for diagnostic cardiac testing. Of these, 40 (22%) failed to receive necessary tests. Only 7 (3%) of the 215 patients who received some form of cardiac testing had tests that were judged to be inappropriate. Underuse was significantly more common in patients with only a high school education (30% vs 15% for those with some college, P = 0.02) and those without health insurance (34% vs 15% of insured patients, P = 0.01). In a multivariate logistic regression model, only the lack of a post-high school education was a significant predictor of underuse (odds ratio 2.2, 95% confidence interval 1.0 to 4.4).

CONCLUSION

Among patients with new-onset chest pain, underuse of diagnostic testing for coronary artery disease was much more common than overuse. Underuse was primarily associated with lower levels of patient education.

Variation in inpatient resource use in the treatment of HIV: do the privately insured receive more care?

OBJECTIVE

To estimate the impact of insurance status on inpatient resource use after adjusting for health upon admission and site of care.

DESIGN

Detailed patient information linked to billing records from the AIDS Cost and Service Utilization Survey (ACSUS), a longitudinal analysis of inpatient and outpatient care between March 1991 and August 1992.

SETTING

Hospitalizations of human immunodeficiency virus (HIV) patients from 10 US cities with high incidence of AIDS.

PATIENTS

One thousand, nine hundred and forty nine adolescents and adults at various stages of HIV.

MAIN OUTCOME MEASURES

We estimate inpatient charges, payments and length of stay as a function of patient, and provider and reimbursement characteristics for more than 1,500 hospitalizations to HIV patients. We control for patient characteristics and underlying risk factors including disease stage, CD4 percentage, mode of transmission, discharge status, type of admission, and region. We use hospital-fixed effects to control for unmeasured differences across facilities.

RESULTS

Unadjusted means indicate that uninsured patients or patients covered by public insurance have significantly lower charges and payments than privately insured patients with similar medical conditions. We find that those differences are substantially reduced after controlling for the hospital in which care is received. Further, we find little evidence that "underinsured" patients are discharged sooner on average.

CONCLUSIONS

Inpatient resource use is affected by both the hospital in which care is received and the type of patient admitted. Failure to control for unmeasured differences across hospitals is likely to overstate the impact of insurance substantially.

The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium

BACKGROUND AND METHODS

In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas.

RESULTS

During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men who had had sex with men. Forty-six percent had incomes of less than $10,000 per year, 68 percent had public health insurance or no insurance, and 30 percent received care at teaching institutions. The estimated annual direct expenditures for the care of the patients seen during the first two months of 1996 were $5.1 billion; the expenditures for the estimated 335,000 HIV-infected adults seen at least as often as every six months were $6.7 billion, which is about $20,000 per patient per year.

CONCLUSIONS

In this national survey we found that most HIV-infected adults who were receiving medical care had advanced disease. The patient population was disproportionately male, black, and poor. Many Americans with diagnosed or undiagnosed HIV infection are not receiving medical care at least as often as every six months. The total cost of medical care for HIV-infected Americans accounts for less than 1 percent of all direct personal health expenditures in the United States.

A revised measure of symptom-specific health care use

The objective was to determine physicians' ratings of the clinical importance of common adult symptoms and to use these ratings to develop a new measure of symptom-specific use of health care services. We developed a list of common symptoms using the National Ambulatory Medical Care survey. We surveyed a random sample of internists, family physicians, general practitioners and emergency medicine physicians from the American Medical Association's Physician Masterfile and asked them to rate symptoms' seriousness, impact on quality of life and urgency of need for medical attention. The symptoms' prevalences were determined in a general population survey (National Access to Care Survey). Eleven items were classified as "serious" (median seriousness ratings of 7 or higher on scale from 1 to 10); most of these also were judged to have high impact on quality of life. Another 12 items that were not judged "serious" had median quality of life impact scores of 7 or higher and were classified as "morbid". Sixteen items did not meet criteria for either "serious" or "morbid" symptoms and were classified as "intermediate". Six other items had median seriousness and quality of life impact scores of 3 or less and were classified as "benign". A total of 24 of these items (7 "serious", 8 "morbid", 8 "intermediate" and 1 "benign") were selected to form the symptom-response measure. In the national survey, 26.3% reported one or more serious symptom, 30.6% reported one or more morbid symptom and 29.6% reported one or more intermediate symptom. This new instrument expands on earlier "symptom-response" measures by including a larger number and a broader spectrum of symptoms. This measure should be useful to assess differences in patterns of health care use for particularly serious or morbid conditions; such variations may indicate problems with access to medical care.

Is access to medical care associated with receipt of HIV testing and counselling?

Lack of timely HIV testing leads to missed prevention opportunities and poor prevention counselling may be related to further disease spread. We examined the association of self-reported access to medical care with receiving HIV testing and preventive counselling services among a sample of patients with HIV disease prior to hospitalization. We conducted a cross-sectional interview of 217 Los Angeles patients hospitalized with HIV-related illness between 1992 and 1993 and abstracted clinical data from the medical record. Eighty-four per cent of patients received HIV testing prior to hospitalization, but only 33% received preventive counselling services. Only 48% of all patients rated outpatient medical care as somewhat or very easy to obtain. Controlling for severity of illness, better access to outpatient medical care (OR = 1.48; 95% CI = 1.02-2.15), having a regular source of care (OR = 3.40; 95% CI = 1.29-8.97) and non-homosexual mode of HIV transmission (OR = 0.31; 0.12-0.83) were associated with receiving HIV testing services prior to hospitalization. Having a regular source of care (OR = 3.55; 95% CI = 1.37-9.22), being VA (Veterans' Administration) insured (OR = 6.16; 1.46-26.05), older age (OR = 0.95; 95% CI = 0.90-0.99) and having a CD4 count between 101-200 (OR = 0.19; 95% CI = 0.06-0.63) were associated with receiving HIV counselling. Limited self-reported access to medical care is associated with fewer patients receiving HIV testing and counselling. Improving timeliness of HIV testing may require removing the barriers to medical care.

The prospective effect of access to medical care on health-related quality-of-life outcomes in patients with symptomatic HIV disease

OBJECTIVES

This study examined the prospective effect of reported access to medical care on health-related quality-of-life outcomes in patients with symptomatic human immunodeficiency virus (HIV) disease.

METHODS

A cohort study was designed with interviews at baseline, follow-up interviews at 3 months after baseline, mortality follow-up through 6 months after baseline, and medical record reviews for selected baseline clinical data. Participants were HIV-infected patients who were receiving ambulatory and/or hospital care at one county-run municipal and one Veterans Administration hospital in metropolitan Los Angeles and were interviewed about access to medical care (using a reliable 9-item scale assessing affordability, availability, and convenience of medical care). Access to care reported by this sample was compared with that of 2,471 patients with other chronic diseases from the Medical Outcomes Study. The main outcome measures were composite scores for physical and mental health-related quality of life 3 months after baseline, derived from a validated 56-item instrument, scored from 0 to 100, and controlling for baseline health-related quality of life.

RESULTS

Overall reported access to medical care in this sample was significantly poorer than that for patients with other chronic diseases (means scores were 63 and 73, respectively). The sample was categorized into tertiles of initial physical and mental health-related quality of life and into groups with initial high versus low access to care. Among those in the middle tertile of physical health-related quality of life at baseline, those with high access improved in physical health scores by 10.2 points relative to those with low access. Those in the low and middle tertiles of initial mental health improved in mental health to a significantly greater extent for those with high versus low access. There were nonsignificant trends toward similar effects for most other subgroups. The effects of access on health-related quality-of-life outcomes were generally robust in multivariate regression analyses that included CD4, hemoglobin, albumin, insurance status, and sociodemographic characteristics.

CONCLUSIONS

Access to care at baseline predicted better physical and mental health outcomes at 3 months for those in the middle tertile of physical health and for those in the bottom and middle tertiles of mental health at baseline. Increasing access to care for poor public hospital patients with HIV infection may help to improve health-related quality-of-life outcomes among selected persons with advanced disease.

Constitutional symptoms and health-related quality of life in patients with symptomatic HIV disease

PURPOSE

To assess the severity of constitutional symptoms in persons with human immunodeficiency virus (HIV) infection, and their relationship to health-related quality of life (HRQOL).

PATIENTS AND METHODS

Two hundred five HIV-infected patients (93% male, 26% African American, 28% Latino, 39% white, 7% other ethnicity) with diarrhea, fever, or weight loss were studied at a county hospital and a Veterans Administration hospital in southern California. Consenting subjects were administered a battery that included 11 scales measuring various aspects of health-related quality of life and detailed questions about six constitutional symptoms or symptom complexes (myalgias, exhaustion, anorexia/nausea/vomiting, night sweats, fever, and weight loss) as well as about other manifestations of HIV disease.

RESULTS

Constitutional symptoms except weight loss were all strongly related to all measures of quality of life. On 0 (worst) to 100 (best) point scales, mean scores ranged from 34 (for individuals having all five symptoms other than weight loss) to 78 (for those with none) for physical function, 43 to 79 for emotional well-being, and 36 to 73 for social function. Adjustment for helper T-lymphocyte counts, duration of illness, and demographic characteristics did not diminish these associations.

CONCLUSION

The presence, number, and severity of constitutional symptoms in HIV disease is strongly related to health-related quality of life in symptomatic HIV-infected individuals. Identifying and treating these very common symptoms has the potential to improve quality of life in these patients.

Referrals by general internists and internal medicine trainees in an academic medicine practice

Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed.

Reliability and validity of self-report CD4 counts-in persons hospitalized with HIV disease

Studies of health care outcomes and clinical decision making for people with HIV disease depend on CD4 cell count data to accurately assess the stage of disease. The possibility of obtaining reliable and valid data from self-reported CD4 counts is an unexplored source of potentially important, cost-effective information for these purposes. We examined the extent of agreement of self-reported CD4 counts with medical record CD4 among 120 patients (95% male, 69% white, 5% injection drug users) hospitalized with HIV-related illness at seven Los Angeles area hospitals. Average record and report CD4 counts did not differ significantly, and record and report CD4 counts were highly correlated (product moment correlation of 0.84, intraclass correlation of 0.82). Agreement between self-reports and medical records varied by CD4 level: at higher levels of CD4, the differences between self-reports and medical records tended to be larger, with self-reports yielding upwardly biased estimates compared to the medical records. These findings suggest that self-report CD4 data may provide clinically adequate estimates of true CD4 counts. The study needs to be replicated in other populations, notably those with larger numbers of subjects who are female, of minority ethnicity, or injection drug users.

Racial and ethnic disparities in the use of cardiovascular procedures: associations with type of health insurance

OBJECTIVES

This study examined whether disparities in the use of cardiovascular procedures exist among African Americans, Latinos, and Asians relative to White patients, within health insurance categories.

METHODS

Hospital discharge records (n = 104,952) of Los Angeles Country, California, residents with possible coronary artery disease were analyzed.

RESULTS

After adjustment for confounders, lower odds of procedure use were found for African American and Latino patients for most types of insurance. Asians and Pacific Islanders had odds of procedure use similar to those of White patients. Disparities were absent among the privately insured.

CONCLUSIONS

Racial and ethnic disparities in procedure rates were evident in all types of insurance except private insurance.

Regulating pharmaceutical advertising: what will work?

As Dr. Joel Lexchin makes painfully obvious in this issue (see pages 351 to 356), regulatory processes governing pharmaceutical advertising in Canada and elsewhere are seriously compromised. However, the remedial measures Lexchin proposes are not sufficient. Financial sanctions against improper advertising are likely to be regarded by manufacturers as the cost of doing business, and any regulatory body that includes drug industry representatives or individuals receiving financial support from the drug industry cannot be genuinely independent. Moreover, manufacturers are now using promotional strategies that are particularly difficult to regulate. These include providing drugs at lower than the usual cost to ensure their inclusion in managed-care formularies, and using direct-to-consumer advertising to take advantage of the public's lack of sophistication in interpreting scientific evidence. Our best hope of counteracting the power and influence of the drug industry lies in regulation by government agencies, whose interest is the protection of the public.

Geographic variation in the management and outcome of patients with AIDS-related Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia (PCP) is one of the most common reasons for the hospitalization of AIDS patients; however, geographic differences in PCP management have not been evaluated previously. Therefore, we abstracted data on socioeconomic characteristics, prior HIV care, severity of illness, timeliness and intensity of in-hospital care, duration of hospitalization, and survival from 1547 randomly selected medical records of patients hospitalized with AIDS-related PCP between 1987 and 1990 at 82 hospitals in Chicago, Los Angeles, Miami, New York City, and Raleigh-Durham, North Carolina. Multivariate regression models were used to assess factors associated with longer hospital stays and increased inpatient mortality. Our results showed that in-hospital mortality ranged from 15% to 27%, bronchoscopy rates from 53% to 70%, and mean length of stay from 14 days to 23 days. Geographic variations in mortality were accounted for by differences in severity of illness at admission, insurance status, and in-hospital patient management. However, significant regional variations in hospital length of stay persisted, even after adjusting for patient demographics, severity of illness, and use of diagnostic and therapeutic care resources.

Access to community-based medical services and number of hospitalizations among patients with HIV disease: are they related?

To assess whether better access to community-based outpatient medical services was associated with fewer HIV-related hospitalizations, we studied 217 patients hospitalized at seven southern California hospitals. During hospital admission, patients completed an interview that included one item about the reported difficulty or ease of access to community-based medical services prior to their first hospitalization for HIV-related illness. After discharge, medical records were abstracted for data on prior hospitalizations. CD4 counts, and illness severity. About one-half of patients reported that medical services were readily accessible. Medical records revealed that since the time of HIV infection 49% had two or more total hospitalizations (mean = 2. SD = 2). In multiple logistic regression analysis, better reported access to services was significantly associated with not having been hospitalized (vs. having been hospitalized) over the same time period (OR = 0.73, 95% CI = 0.55-0.97), controlling for CD4 count, illness severity, duration of diagnosed HIV infection, having a regular source of care, type of hospital care, insurance coverage, and other patient characteristics. Improving access to community-based medical services for ambulatory HIV-infected patients may help to avert costly hospital care. Prospective studies are needed to assess whether a causal relationship between greater community-based access and reduced hospitalizations exists and, if so, whether community-based services may be cost-effective substitutes for hospital HIV care.