The association of hospital, clinic and provider volume with HIV/AIDS care and mortality: systematic review and meta-analysis

Acceptability of Home-Based HIV Care Offered by Community Health Workers in Tshwane District, South Africa: A Survey

Human immunodeficiency virus (HIV) remains the biggest public health challenge faced by South Africa (SA). To alleviate overcrowding in health facilities, ward-based primary health care outreach teams, consisting of community health workers (CHWs) led by a nurse, were introduced. The aim of this study was to assess the acceptability of community-based HIV services offered by CHWs. A survey was conducted in 10 clinics across Tshwane district, Gauteng, SA, between November 2020 and May 10, 2021. CHWs conducted interviewer-administered standardized questionnaires with 674 adult participants. Overall, 95.5% of participants thought that home-based HIV care is a good initiative and rated screening for illnesses and referral to health facilities highly. Although the vast majority (>94%) were willing to disclose their status to health professionals in clinics, women were more willing to do so. Only 53.6% of participants were willing to disclose their HIV status to a CHW from the same neighborhood and 28.8% would find it problematic if CHWs visited them at home with branded cars. Participants had different preferences, mostly determined by region, how long they had been on antiretroviral treatment, whether they had been informed about CHWs, age, and gender. More work is needed to understand and accommodate regional differences and individual preferences.

Survival Outcomes of Vietnamese People with HIV after Initiating Antiretroviral Treatment: Role of Clinic-Related Factors

Given the rapid development of HIV clinics in Vietnam, this study evaluates the infrastructure surrounding this expansion, identifying clinic-related factors that impact survival outcomes. A retrospective longitudinal study was conducted among people living with HIV (PLWH) who initiated antiretroviral therapy (ART) between 2011 and 2015 among 62 ART clinics in 15 provinces. The mortality rate during the 717674.1 person-years of observation (PYO) was 0.29/100 PYO. Location in rural areas (versus urban) and in Central Vietnam (versus Northern Vietnam) were associated with higher risk of mortality. The risk was lower among clinics that had peer-educators. As Vietnam's HIV/AIDS program continues to expand, this data supports increasing resource allocation for rural clinics, incorporation of ART with the community's existing healthcare infrastructure in its efforts to decentralize, and integration of services to reflect patients' anticipated needs.

Physician network connections to specialists and HIV quality of care

OBJECTIVE

To estimate novel measures of generalist physicians' network connectedness to HIV specialists and their associations with two dimensions of HIV quality of care.

DATA SOURCES

Medicare and Medicaid claims and the American Medical Association Masterfile data on people living with HIV (PLWH) and the physicians providing their HIV care in California between 2007 and 2010.

STUDY DESIGN

I construct regional patient-sharing physician networks from the shared treatment of PLWH and calculate (a) measures of network connectedness to all physician types and (b) specialty-weighted measures to describe connectedness to HIV specialists. Two HIV quality of care outcomes are then evaluated: medication quality (prescribing antiretroviral drugs from at least two drug classes) and monitoring quality (at least two annual HIV virus monitoring scans). Linear probability models estimate the associations between network statistics and the two dimensions of HIV quality of care, and a policy simulation demonstrates the importance of these statistical relationships. These analyses include 16 124 PLWH, 3240 generalists, and 1031 HIV specialists.

DATA COLLECTION/EXTRACTION METHODS

PLWH are identified from claims for patients with any indication of HIV using an existing algorithm from the literature.

PRINCIPAL FINDINGS

Generalists' network connectedness to HIV specialists is positively related with their own HIV medication quality; one additional HIV specialist connection is associated with a 1.46 percentage point (SE 0.42, P < .01) increase in generalist's medication quality. Based on the estimated associations, a simulated policy that increases connectedness between generalists and HIV specialists reduces the annual rate of HIV infections by up to 6%, roughly 290 fewer infections per year. Only network connectedness to all physician types is associated with improved monitoring quality.

CONCLUSIONS

Network connectedness to HIV specialists is positively associated with generalists' HIV medication quality, which suggests that specialists provide clinical support through patient-sharing for complex treatment protocol.

Healthcare facility characteristics associated with achievement and maintenance of HIV viral suppression among persons newly diagnosed with HIV in New York City

Health care facility characteristics have been shown to influence intermediary health outcomes among persons with HIV, but few longitudinal studies of suppression have included these characteristics. We studied the association of these characteristics with the achievement and maintenance of HIV viral suppression among New York City (NYC) residents aged 13 years and older newly diagnosed with HIV between 2006 and 2012. The NYC HIV surveillance registry provided individual and facility data (N = 12,547 persons). Multivariable proportional hazards models estimated the likelihood of individual achievement and maintenance of suppression by type of facility, patient volume, and distance from residence, accounting for facility clustering and for individual-level confounders. Viral suppression was achieved within 12 months by 44% and at a later point by another 29%. Viral suppression occurred at a lower rate in facilities with low HIV patient volume (e.g., 10-24 diagnoses per year vs. ≥75, adjusted hazard ratio [AHR] = 0.87, 95% confidence interval [CI] 0.79-0.95) and in screening/diagnosis sites (vs. hospitals, AHR = 0.86, 95% CI 0.80-0.92). Among persons achieving viral suppression, 18% experienced virologic failure within 12 months and 24% later. Those receiving care at large outpatient facilities or large private practices had a lower rate of virologic failure (e.g., large outpatient facilities vs. large hospitals, AHR = 0.63, 95% CI 0.53-0.75). Achievement and maintenance of viral suppression were associated with facilities with higher HIV-positive caseloads. Some facilities with small caseloads and screening/diagnosis sites may need stronger care or referral systems to help persons with HIV achieve and maintain viral suppression.

Does Systemic Lupus Erythematosus Care Provided in a Lupus Clinic Result in Higher Quality of Care Than That Provided in a General Rheumatology Clinic?

OBJECTIVE

To compare the quality of care received by patients with systemic lupus erythematosus (SLE) in 2 settings within the academic institution (a dedicated lupus clinic and a general rheumatology clinic) using validated SLE quality measures.

METHODS

One hundred fifty consenting, consecutive SLE patients receiving longitudinal care at the Rush University general rheumatology clinic (n = 73) or the subspecialty lupus clinic (n = 77) were recruited. An updated quality measure survey and retrospective medical chart review were used to evaluate each quality measure (n = 20). The overall and individual quality measure performance was calculated and compared between the 2 groups. Data on the number of SLE patients seen by each rheumatologist were collected to assess the relationship between SLE patient volume and quality measures.

RESULTS

Overall quality measure performance was significantly better in SLE patients receiving care at the lupus clinic (85.8% versus 70.2% of patients receiving care at the general rheumatology clinic; P = 0.001). Differences between the 2 groups were observed for sunscreen counseling (98.7% and 83.6%, respectively; P = 0.001), antiphospholipid antibody testing (71.4% and 37%, respectively; P < 0.001), pneumococcal vaccination (84.8% and 48.8%, respectively; P < 0.001), bone mineral density testing (94.2% and 54.5%, respectively; P < 0.001), drug counseling (92.2% and 80.8%, respectively; P = 0.04), use of a steroid-sparing agent (100% and 82%, respectively; P < 0.007), use of an angiotensin-converting enzyme inhibitor (94.4% and 58.3%, respectively; P = 0.03), and cardiovascular disease risk assessment (40.3% and 15.1%, respectively; P = 0.01). There was a moderate correlation between physician volume and quality measure performance (ρ = 0.48, P < 0.001).

CONCLUSION

Compared with the general rheumatology clinic, the dedicated lupus clinic had better quality measure performance in this cross-sectional single-center study. In our health care system, we also observed indicators suggesting that rheumatologists with a higher volume of SLE patients provide higher quality of care.

Long-term HIV/AIDS survivors: Patients living with HIV infection retained in care for over 20 years. What have we learned?

Individuals diagnosed with HIV before 1996 had poor prognoses. Few HIV care centers can track patients continuously from the 1980s to present. We determined the sociodemographic, clinical, and health care utilization characteristics of patients diagnosed and followed for >20 years (i.e. long-term HIV/AIDS survivors) to understand what factors contributed to survival. All HIV-positive patients diagnosed before 1996 were categorized as active, moved/lost, or died as of 1 January 2016. Baseline sociodemographic, clinical characteristics, antiretroviral therapy (ART) usage, retention, HIV care costs, and health status were analyzed. Of 876 patients, 49.5% died, 30.3% moved or left, 20.3% remained active in care for a median of 23.4 years. At diagnosis, continuously-followed patients were younger with a higher CD4 cell count, attended regular clinic visits at higher frequencies, and had received more ART than patients who moved or died. As of 1 January 2016, their median age was 57 years (interquartile range 53-62), 15% were aged >65 years, median CD4 cell count was 591 cells/mm³ (475-863) with 68% >500 cells/mm³. Sixty-two percent remained employed. The total cost of HIV care was $32,251,030 (Cdn$); median cost per patient per year $15,418 ($13,697-$18,392). Individuals diagnosed prior to 1996 benefited from early diagnosis and engagement to care, regular follow-ups, and timely initiation of ART, strongly supporting the modern guidelines of care.

The organizational attributes of HIV care delivery models in Canada: A cross-sectional study

HIV treatment in Canada has rapidly progressed with the advent of new drug therapies and approaches to care. With this evolution, there is increasing interest in Canada in understanding the current delivery of HIV care, specifically where care is delivered, how, and by whom, to inform the design of care models required to meet the evolving needs of the population. We conducted a cross-sectional survey of Canadian care settings identified as delivering HIV care between June 2015 and January 2016. Given known potential differences in delivery approaches, we stratified settings as primary care or specialist settings, and described their structure, geographic location, populations served, health human resources, technological resources, and available clinical services. We received responses from 22 of 43 contacted care settings located in seven Canadian provinces (51.2% response rate). The total number of patients and HIV patients served by the participating settings was 38,060 and 17,678, respectively (mean number of HIV patients in primary care settings = 1,005, mean number of HIV patients in specialist care settings = 562). Settings were urban for 20 of the 22 (90.9%) clinics and 14 (63.6%) were entirely HIV focused. Primary care settings were more likely to offer preventative services (e.g., cervical smear, needle exchange, IUD insertion, chronic disease self-management program) than specialist settings. The study illustrates diversity in Canadian HIV care settings. All settings were team based, but primary care settings offered a broader range of preventative services and comprehensive access to mental health services, including addictions and peer support.

Patient-level outcomes and virologic suppression rates in HIV-infected patients receiving antiretroviral therapy in Rwanda

The Rwanda national HIV program has been successful at scaling up antiretroviral therapy (ART) to achieve universal access. The AIDSRelief Model of Care focuses on four key principles: (1) earlier initiation of ART; (2) use of durable, highly-potent, and sequence-friendly first-line ART regimens; (3) early detection of treatment failure; and (4) provision of community-based care and support to ensure optimal adherence and follow up/engagement in care. We conducted a retrospective cohort study of randomly-selected HIV-infected patients at AIDSRelief-supported sites using a stratified, random sample of 583 adults (>15 years) who initiated ART from 30 June 2008 to 1 February 2010. At ART initiation, the median patient age was 38 years, and 67% were female. The baseline median CD4+ cell count was 309 cells/mm³. Overall virologic suppression was 91%. Married/ever married status (adjusted prevalence odds ratio [aPOR] 3.75, 95% confidence interval [CI] 1.30-10.78) and self-reported adherence ≥95% in the past month (aPOR 2.76, 95% CI 1.00-7.62) were significantly associated with viral suppression in the multivariable model. Excellent virologic outcomes were achieved in Rwandan AIDSRelief sites utilizing the AIDSRelief Model of Care during the scale-up of ART in the country.

Sexually Transmitted Infection Testing of HIV-Positive Medicare and Medicaid Enrollees Falls Short of Guidelines

BACKGROUND

Men who have sex with men with HIV have high sexually transmitted infection (STI) incidence. Thus, the Centers for Disease Control and Prevention (CDC) recommends at least yearly STI screening of HIV-infected individuals.

METHODS

We calculated testing rates for syphilis, chlamydia, and gonorrhea among HIV-positive Californians with Medicare or Medicaid insurance in 2010. Logistic regressions estimated how testing for each bacterial STI relates to demographic and provider factors.

RESULTS

Fewer than two-thirds of HIV-positive Medicare and fewer than three-quarters of Medicaid enrollees received a syphilis test in 2010. Screenings for chlamydia or gonorrhea were less frequent: approximately 30% of Medicare enrollees were tested for chlamydia or gonorrhea in 2010, but higher proportions of Medicaid enrollees were tested (45%-46%). Only 34% of HIV-positive Medicare enrollees who were tested for syphilis were also screened for chlamydia or gonorrhea on the same day. Nearly half of Medicaid enrollees were tested for all 3 STIs on the same day. Patients whose providers had more HIV experience had higher STI testing rates.

CONCLUSIONS

Testing rates for chlamydia and gonorrhea infection are low, despite the increase in these infections among people living with HIV and their close association with HIV transmission. Interventions to increase STI testing include the following: prompts in the medical record to routinely conduct syphilis testing on blood drawn for viral load monitoring, opt-out consent for STI testing, and provider education about the clinical importance of STIs among HIV-positive patients. Last, it is crucial to change financial incentives that discourage nucleic acid amplification testing for rectal chlamydia and gonorrhea infections.

Regional Differences in the Prevalence of Major Opportunistic Infections among Antiretroviral-Naïve Human Immunodeficiency Virus Patients in Japan, Northern Thailand, Northern Vietnam, and the Philippines

To identify regional differences in the distribution of opportunistic infections (OIs) among human immunodeficiency virus (HIV)-infected patients in Asia, the medical records of antiretroviral therapy (ART)-naïve patients who attended the following tertiary hospitals from 2003 to 2011 were reviewed: Nagoya Medical Center (NMC, Nagoya, Japan), Lampang Hospital (LPH, Lampang, northern Thailand), Bach Mai Hospital (BMH, Hanoi, northern Vietnam), and Philippine General Hospital (PGH, Manila, Philippines). Logistic regression analyses were performed to identify associations between country of origin and risk of major OIs. In total, 1,505 patients were included: NMC, N = 365; LPH, N = 442; BMH, N = 384; and PGH, N = 314. The median age was 32 years, and 73.3% of all patients were male. The median CD4 count was 200 cells/μL. Most patients at NMC and PGH were men who have sex with men. Injection drug users were most common at BMH (35.7%). Mycobacterium tuberculosis (TB) was most common at PGH (N = 75) but was rare at NMC (N = 4). Pneumocystis pneumonia (PCP) prevalence was highest at NMC (N = 74) and lowest at BMH (N = 13). Multivariable logistic regression showed increased odds of TB at PGH (adjusted odds ratio [aOR] = 42.2, 95% confidence interval [CI] = 14.6-122.1), BMH (aOR = 12.6, CI = 3.9-40.3), and LPH (aOR = 6.6, CI = 2.1-21.1) but decreased odds of PCP at BMH (aOR = 0.1, CI = 0.04-0.2) and LPH (aOR = 0.2, CI = 0.1-0.4) compared with those at NMC. The cryptococcosis risk was increased at LPH (aOR = 6.2, CI = 0.9-41.0) compared with that at NMC. Cytomegalovirus (CMV) retinitis prevalences were similar in all countries. OI prevalence remained high among ART-naïve patients in our cohort. The risks of TB, PCP, and cryptococcosis, but not CMV retinitis, differed between countries. Improved early HIV detection is warranted.

Quality of Care for HIV/AIDS and for Primary Prevention by HIV Specialists and Nonspecialists

The role of HIV specialists in providing primary care to persons living with HIV/AIDS is evolving, given their increased incidence of comorbidities. Multivariate logit analysis compared compliance with sentinel preventive screening tests and interventions among publicly insured Californians with and without access to HIV specialists in 2010. Quality-of-care indicators [visit frequency, CD4 and viral load (VL) assessments, influenza vaccine, tuberculosis (TB) testing, lipid profile, glucose blood test, and Pap smears for women] were related to patient characteristics and provider HIV caseload. There were 9377 adult Medicare enrollees (71% also had Medicaid coverage) and 2076 enrollees with only Medicaid coverage. Adjusted for patient characteristics, patients seeing providers with greater HIV caseloads (>50 HIV patients) were more likely to meet visit frequency guidelines in both Medicare [98%; confidence interval (CI 97.5-98.2) and Medicaid (97%; CI 96.2-98.0), compared to 60% (CI 57.1-62.3) and 45% (CI 38.3-50.4), respectively, seeing providers without large HIV caseloads (p < 0.001). Patients seeing providers with larger caseloads were significantly more likely to have CD4 (p < 0.001), VL (p < 0.001), and TB testing (p < 0.05). A larger percentage of patients seeing large-volume Medicare providers received influenza vaccinations. Provider caseload was unrelated to lipid or glucose assessments or Pap Smears for women. Patients with access to large-volume providers were more likely to meet clinical guidelines for visits, CD4, VL, tuberculosis testing, and influenza vaccinations, and were not less likely to receive primary preventive care. Substantial insufficiencies remain in both monitoring to assess viral suppression and in preventive care.

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study

OBJECTIVES

To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics.

METHODS

Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS.

RESULTS

Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior.

CONCLUSIONS

Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.

Organization of care for persons with HIV-infection: a systematic review

The objective of this systematic review was to examine the effectiveness of the organization of care: case management, multidisciplinary care, multi-faceted treatment, hours of service, outreach programs and health information systems on medical, immunological, virological, psychosocial and economic outcomes for persons living with HIV/AIDS. We searched PubMed (MEDLINE) and 10 other electronic databases from 1 January 1980 to April, 2012 for both experimental and controlled observational studies. Thirty-three studies met the inclusion criteria. Eleven studies were randomized controlled trials (RCTs), three of which were conducted in low-middle income settings. Patient characteristics, study design, organization measures and outcomes data were abstracted independently by two reviewers from all studies. A risk of bias tool was applied to RCTs and a separate tool was used to assess the quality of observational studies. This review concludes that case management interventions were most consistently associated with improvements in immunological outcomes but case management demonstrates no clear association with other outcome measures. The same mixed results were also identified for multidisciplinary and multi-faceted care interventions. Eight studies with an outreach intervention were identified and demonstrated improvements or non-inferiority with respect to mortality, receipt of antiretroviral medications, immunological outcomes, improvements in healthcare utilization and lower reported healthcare costs when compared to usual care. Of the interventions examined in this review, sustained in-person case management and outreach interventions were most consistently associated with improved medical and economic outcomes, in particular antiretroviral prescribing, immunological outcomes and healthcare utilization. No firm conclusions can be reached about the impact of any one intervention on patient mortality.

Peri- and postoperative management of stage I-III Non Small Cell Lung Cancer: Which quality of care indicators are evidence-based?

Quality of care (QoC) has a central role in our health care system. The aim of this review is to present a set of evidence-based quality indicators for the surgical treatment and postoperative management of lung cancer. A search was performed through PubMed, Embase and the Cochrane library database, including English literature, published between 1980 and 2012. Search terms regarding 'lung neoplasms', 'surgical treatment' and 'quality of care' were used. Potential QoC indicators were divided into structure, process or outcome measures and a final selection was made based upon the level of evidence. High hospital volume and surgery performed by a thoracic surgeon, were identified as important structure indicators. Sleeve resection instead of pneumonectomy and the importance of treatment within a clinical care path setting were identified as evidence-based process indicators. A symptom-based follow-up regime was identified as a new QoC indicator. These indicators can be used for registration, benchmarking and ultimately quality improvement in lung cancer surgery.

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.

Impact of HIV care facility characteristics on the cascade of care in HIV-infected patients in the Netherlands

OBJECTIVE

Successful treatment of people infected with HIV requires that patients are retained in HIV care, use combination antiretroviral therapy (cART) and ultimately reach and sustain viral suppression. Our aim was to identify health facility characteristics associated with these steps in the cascade of HIV care.

DESIGN

Retrospective cohort study.

METHODS

We included data from all adult HIV-1-infected patients who entered care in the Netherlands between 2007 and 2013 (N = 7120). Multivariate logistic regression was used to examine the associations between health facility characteristics and the outcomes 'currently in care', 'initiated cART', and 'viral suppression'.

RESULTS

The proportion of patients 'currently in care' was high in all 26 treatment centres. cART initiation was positively associated with the accreditation of the health facility [OR (odds ratio): 1.62; 95% CI (confidence interval): 1.18-2.23] and the performance of an internal audit in the preceding 3 years (OR: 1.36; 95% CI: 1.02-1.81). The odds of cART initiation were higher in middle-sized (OR: 2.00; 95% CI: 1.25-3.21) and large HIV treatment centres (OR: 1.80; 95% CI: 1.14-2.84) compared with small centres (<300 HIV-infected patients). Viral suppression was negatively associated with the presence of a social worker in the HIV treatment team (OR: 0.62; 95% CI: 0.43-0.91).

CONCLUSIONS

Our results confirm that appointing expert HIV treatment centres facilitates retention in care and that a minimum volume requirement may be desirable. Our findings suggest that quality assessment through accreditation and the measurement of performance benefits the delivery of HIV care.

Service Delivery and Patient Outcomes in Ryan White HIV/AIDS Program-Funded and -Nonfunded Health Care Facilities in the United States

IMPORTANCE

Outpatient human immunodeficiency virus (HIV) health care facilities receive funding from the Ryan White HIV/AIDS Program (RWHAP) to provide medical care and essential support services that help patients remain in care and adhere to treatment. Increased access to Medicaid and private insurance for HIV-infected persons may provide coverage for medical care but not all needed support services and may not supplant the need for RWHAP funding.

OBJECTIVE

To examine differences between RWHAP-funded and non-RWHAP-funded facilities and in patient outcomes between the 2 systems.

DESIGN, SETTING, AND PARTICIPANTS

The study was conducted from June 1, 2009, to May 31, 2012, using data from the 2009 and 2011 cycles of the Medical Monitoring Project, a national probability sample of 8038 HIV-infected adults receiving medical care at 989 outpatient health care facilities providing HIV medical care.

MAIN OUTCOMES AND MEASURES

Data were used to compare patient characteristics, service needs, and access to services at RWHAP-funded vs non-RWHAP-funded facilities. Differences in prescribed antiretroviral treatment and viral suppression were assessed. Data analysis was performed between February 2012 and June 2015.

RESULTS

Overall, 34.4% of facilities received RWHAP funding and 72.8% of patients received care at RWHAP-funded facilities. With results reported as percentage (95% CI), patients attending RWHAP-funded facilities were more likely to be aged 18 to 29 years (8.5% [7.4%-9.5%] vs 5.0% [3.9%-6.2%]), female (29.2% [27.2%-31.2%] vs 20.1% [17.0%-23.1%]), black (47.5% [41.5%-53.5%] vs 25.8% [20.6%-31.0%]) or Hispanic (22.5% [16.4%-28.6%] vs 12.9% [10.6%-15.2%]), have less than a high school education (26.1% [24.0%-28.3%] vs 10.9% [8.7%-13.1%]), income at or below the poverty level (53.6% [50.3%-56.9%] vs 23.9% [19.7%-28.0%]), and lack health care coverage (25.0% [21.9%-28.1%] vs 6.1% [4.1%-8.0%]). The RWHAP-funded facilities were more likely to provide case management (76.1% [69.9%-82.2%] vs 15.4% [10.4%-20.4%]) as well as mental health (64.0% [57.0%-71.0%] vs 18.0% [14.0%-21.9%]), substance abuse (33.6% [27.0%-40.2%] vs 12.0% [8.0%-16.0%]), and other support services; patients attending RWHAP-funded facilities were more likely to receive these services. After adjusting for patient characteristics, the percentage prescribed ART antiretroviral therapy, reported as adjusted prevalence ratio (95% CI), was similar between RWHAP-funded and non-RWHAP-funded facilities (1.01 [0.99-1.03]), but among poor patients, those attending RWHAP-funded facilities were more likely to be virally suppressed (1.09 [1.02-1.16]).

CONCLUSIONS AND RELEVANCE

A total of 72.8% of HIV-positive patients received care at RWHAP-funded facilities. Many had multiple social determinants of poor health and used services at RWHAP-funded facilities associated with improved outcomes. Without facilities supported by the RWHAP, these patients may have had reduced access to services elsewhere. Poor patients were more likely to achieve viral suppression if they received care at a RWHAP-funded facility.

The HIV Workforce in New York State: Does Patient Volume Correlate with Quality?

BACKGROUND

Knowledge of care practices among clinicians who annually treat <20 human immunodeficiency virus (HIV)-positive patients with antiretroviral therapy (ART) is insufficient, despite their number, which is likely to increase given shifting healthcare policies. We analyze the practices, distribution and quality of care provided by low-volume prescribers (LVPs) based on available data sources in New York State.

METHODS

We communicated with 1278 (66%) of the LVPs identified through a statewide claims database to determine the circumstances under which they prescribed ART in federal fiscal year 2009. We reviewed patient records from 84 LVPs who prescribed ART routinely and compared their performance with that of experienced clinicians practicing in established HIV programs.

RESULTS

Of the surveyed LVPs, 368 (29%) provided routine ambulatory care for 2323 persons living with HIV/AIDS, and 910 LVPs cited other reasons for prescribing ART. Although the majority of LVPs (73%) practiced in New York City, patients living upstate were more likely to be cared for by a LVP (odds ratio, 1.7; 95% confidence interval, 1.4-1.9). Scores for basic HIV performance measures, including viral suppression, were significantly higher in established HIV programs than for providers who wrote prescriptions for <20 persons living with HIV/AIDS (P < .01). We estimate that 33% of New York State clinicians who provide ambulatory HIV care are LVPs.

CONCLUSIONS

Our findings suggest that the quality of care associated with providers who prescribe ART for <20 patients is lower than that provided by more experienced providers. Access to experienced providers as defined by patient volume is an important determinant of delivering high-quality care and should guide HIV workforce policy decisions.

A population-based study evaluating family physicians' HIV experience and care of people living with HIV in Ontario

PURPOSE

Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV.

METHODS

We retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period).

RESULTS

The majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients (mean levels of adherence [95% CIs] were 0.34 [0.30-0.39] and 0.40 [0.34-0.45], respectively, vs 0.77 [0.74-0.80]). Patients' receipt of cancer screenings and health care use were unrelated to family physician HIV experience.

CONCLUSIONS

Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings.

A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario

OBJECTIVES

Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided.

DESIGN

Retrospective population-based observational study from 1 April 2009 to 31 March 2012.

PARTICIPANTS

13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care.

OUTCOME MEASURES

Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses.

RESULTS

Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physician-dominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIV-specific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients' HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)).

CONCLUSIONS

How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures.

Health administrative data can be used to define a shared care typology for people with HIV

OBJECTIVES

Building on an existing theoretical shared primary care/specialist care framework to (1) develop a unique typology of care for people living with human immunodeficiency virus (HIV) in Ontario, (2) assess sensitivity of the typology by varying typology definitions, and (3) describe characteristics of typology categories.

STUDY DESIGN AND SETTING

Retrospective population-based observational study from April 1, 2009, to March 31, 2012. A total of 13,480 eligible patients with HIV and receiving publicly funded health care in Ontario. We derived a typology of care by linking patients to usual family physicians and to HIV specialists with five possible patterns of care. Patient and physician characteristics and outpatient visits for HIV-related and non-HIV-related care were used to assess the robustness and characteristics of the typology.

RESULTS

Five possible patterns of care were described as low engagement (8.6%), exclusively primary care (52.7%), family physician-dominated comanagement (10.0%), specialist-dominated comanagement (30.5%), and exclusively specialist care (5.2%). Sensitivity analyses demonstrated robustness of typology assignments. Visit patterns varied in ways that conform to typology assignments.

CONCLUSION

We anticipate this typology can be used to assess the impact of care patterns on the quality of primary care for people living with HIV.

A cross-sectional, population-based study of HIV physicians and outpatient health care use by people with HIV in Ontario

BACKGROUND

People with HIV are living longer and their care has shifted towards the prevention and management of comorbidities. However, little is known about who is providing their care. Our objective was to characterize the provision of HIV care in Ontario by physician specialty.

METHODS

We conducted a retrospective population-based observational study using linked administrative databases in Ontario, Canada, a single payer health care system. All Ontarians with HIV were identified using a validated case ascertainment algorithm. We examined office-based health care visits for this cohort between April 1, 2009 and March 31, 2012. Physician characteristics were compared between specialty groups. We stratified the frequency and distribution of physician care into three categories: (a) care by physician specialty (family physicians, internal medicine specialists, infectious disease specialists, and other specialists), (b) care based on physician caseload (low, medium or high categorized as ≤5, 6-49 or ≥50 HIV patients per physician), and (c) care that is related to HIV versus unrelated to HIV.

RESULTS

Family physicians were older, graduated earlier, were more often female, and were the only group practicing in rural settings. Unlike other specialists, most family physicians (76.8%) had low-volume caseloads. There were 406,411 outpatient visits made by individuals with HIV; one-third were for HIV care. Family physicians provided the majority of care (53.6% of all visits and 53.9% of HIV visits). Internal medicine specialists provided 4.9% of all visits and 9.6% of HIV visits. Infectious disease specialists provided 12.5% of all visits and 32.7% of HIV visits. Other specialties provided 29.0% of visits; most of these (33.0%) were to psychiatrists.

CONCLUSIONS

The distribution of visits to physicians caring for HIV patients reveals different patterns of health care delivery by specialty and HIV caseload. Further research should delineate how specialties share care for this population and how different patterns relate to quality of care.

Tuberculosis treatment managed by providers outside the Public Health Department: lessons for the Affordable Care Act

INTRODUCTION

Tuberculosis (TB) requires at least six months of multidrug treatment and necessitates monitoring for response to treatment. Historically, public health departments (HDs) have cared for most TB patients in the United States. The Affordable Care Act (ACA) provides coverage for uninsured persons and may increase the proportion of TB patients cared for by private medical providers and other providers outside HDs (PMPs). We sought to determine whether there were differences in care provided by HDs and PMPs to inform public health planning under the ACA.

METHODS

We conducted a retrospective, cross-sectional analysis of California TB registry data. We included adult TB patients with culture-positive, pulmonary TB reported in California during 2007-2011. We examined trends, described case characteristics, and created multivariate models measuring two standards of TB care in PMP- and HD-managed patients: documented culture conversion within 60 days, and use of directly observed therapy (DOT).

RESULTS

The proportion of PMP-managed TB patients increased during 2007-2011 (p = 0.002). On univariable analysis (N = 4,606), older age, white, black or Asian/Pacific Islander race, and birth in the United States were significantly associated with PMP care (p<0.05). Younger age, Hispanic ethnicity, homelessness, drug or alcohol use, and cavitary and/or smear-positive TB disease, were associated with HD care. Multivariable analysis showed PMP care was associated with lack of documented culture conversion (adjusted relative risk [aRR] = 1.37, confidence interval [CI] 1.25-1.51) and lack of DOT (aRR = 8.56, CI 6.59-11.1).

CONCLUSION

While HDs cared for TB cases with more social and clinical complexities, patients under PMP care were less likely to receive DOT and have documented culture conversion. This indicates a need for close collaboration between PMPs and HDs to ensure that optimal care is provided to all TB patients and TB transmission is halted. Strategies to enhance collaboration between HDs and PMPs should be included in ACA implementation.

A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario

BACKGROUND

As people diagnosed with HIV and receiving combination antiretroviral therapy are now living longer, they are likely to acquire chronic conditions related to normal ageing and the effects of HIV and its treatment. Comordidities for people with HIV have not previously been described from a representative population perspective.

METHODS

We used linked health administrative data from Ontario, Canada. We applied a validated algorithm to identify people with HIV among all residents aged 18 years or older between April 1, 1992 and March 31, 2009. We randomly selected 5 Ontario adults who were not identified with HIV for each person with HIV for comparison. Previously validated case definitions were used to identify persons with mental health disorders and any of the following physical chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end-stage renal failure. We examined multimorbidity prevalence as the presence of at least two physical chronic conditions, or as combined physical-mental health multimorbidity. Direct age-sex standardized rates were calculated for both cohorts for comparison.

RESULTS

34.4% (95% confidence interval (CI) 33.6% to 35.2%) of people with HIV had at least one other physical condition. Prevalence was especially high for mental health conditions (38.6%), hypertension (14.9%) and asthma (12.7%). After accounting for age and sex differences, people with HIV had significantly higher prevalence of all chronic conditions except myocardial infarction and hypertension, as well as substantially higher multimorbidity (prevalence ratio 1.30, 95% CI 1.18 to 1.44) and combined physical-mental health multimorbidity (1.79, 95% CI 1.65 to 1.94). Prevalence of multimorbidity among people with HIV increased with age. The difference in prevalence of multimorbidity between the two cohorts was more pronounced among women.

CONCLUSION

People living with HIV in Ontario, especially women, had higher prevalence of comorbidity and multimorbidity than the general population. Quantifying this morbidity at the population level can help inform healthcare delivery requirements for this complex population.

Causes of death and risk factors for mortality among HIV-infected patients receiving antiretroviral therapy in Korea

A retrospective study was conducted to determine the mortality, causes and risk factors for death among HIV-infected patients receiving antiretroviral therapy (ART) in Korea. The outcomes were determined by time periods, during the first year of ART and during 1-5 yr after ART initiation, respectively. Patients lost to follow-up were traced to ascertain survival status. Among 327 patients initiating ART during 1998-2006, 68 patients (20.8%) died during 5-yr follow-up periods. Mortality rate per 100 person-years was 8.69 (95% confidence interval, 5.68-12.73) during the first year of ART, which was higher than 4.13 (95% confidence interval, 2.98-5.59) during 1-5 yr after ART. Tuberculosis was the most common cause of death in both periods (30.8% within the first year of ART and 16.7% during 1-5 yr after ART). During the first year of ART, clinical category B and C at ART initiation, and underlying malignancy were significant risk factors for mortality. Between 1 and 5 yr after ART initiation, CD4 cell count ≤ 50 cells/µL at ART initiation, hepatitis B virus co-infection, and visit constancy ≤ 50% were significant risk factors for death. This suggests that different strategies to reduce mortality according to the time period after ART initiation are needed.