HIV Quality Measures and Outcomes: The Next Phase

Factors associated with suicidal ideation among people with HIV engaged in care

BACKGROUND

People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH.

METHOD

We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models.

RESULTS

Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI.

LIMITATIONS

SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor.

CONCLUSIONS

HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed.

The relationship of smoking and unhealthy alcohol use to the HIV care continuum among people with HIV in an integrated health care system

INTRODUCTION

Smoking tobacco and unhealthy alcohol use may negatively influence HIV care continuum outcomes but have not been examined in combination.

METHODS

Participants were people with HIV (PWH) in Kaiser Permanente Northern California. Predictors included smoking status and unhealthy alcohol use (exceeding daily and/or weekly limits) reported by patients during primary care screening (index date). Outcomes were based on not achieving the following steps in the care continuum: linkage to HIV care (≥1 visit within 90 days of newly identified HIV diagnosis), retention (2+ in-person visits, 60+ days apart) and HIV RNA control (<75 copies/mL). Adjusted odds ratios (ORs) were obtained from separate logistic regression models for each outcome associated with smoking and unhealthy alcohol use independently and combined.

RESULTS

The overall sample (N = 8958) had a mean age of 48.0 years; was 91.3 % male; 54.0 % white, 17.6 % Latino, 15.1 % black, and 9.6 % other race/ethnicity. Smoking was associated with higher odds of not being linked to HIV care (OR = 1.60 [95 % CI 1.03-2.48]), not retained (OR = 1.30 [95 % CI 1.13-1.50]), and HIV RNA not in control (OR = 1.91 [95 % CI 1.60-2.27]). Alcohol measures were not independently associated with outcomes. The combination of unhealthy alcohol use and smoking (versus neither) was associated with higher odds of not being linked to care (OR = 2.83 [95 % CI 1.40-5.71]), although the interaction did not reach significance (p = 0.18).

CONCLUSIONS

In this large sample of PWH in an integrated health care system, smoking, both independently and in combination with unhealthy alcohol use, was associated with worse HIV care continuum outcomes.

Beyond the HIV Care Continuum and Viral Suppression: Broadening the Scope of Quality Metrics for Total HIV Patient Care

Assessing quality care for people with HIV (PWH) should not be limited to reporting on HIV Care Continuum benchmarks, particularly viral suppression rates. At Kaiser Permanente Mid-Atlantic States (KPMAS), an integrated health system providing HIV care in the District of Columbia, Maryland, and Virginia, we created a comprehensive measure of HIV quality care, including both preventative measures and clinical outcomes. We included PWH ≥18 years old with ≥6 months KPMAS membership between 2015 and 2018. Process quality metrics (QMs) include: pneumococcal vaccination and influenza vaccination; primary care physician (PCP) and/or HIV/infectious disease (HIV/ID) visits with additional HIV/ID visit; antiretroviral treatment medication fills; and syphilis and gonorrhea/chlamydia screenings. Outcome QMs include HIV RNA <200/mL and other measurements within normal range [blood pressure, body mass index (BMI), hemoglobin, blood sugar, alanine transaminase, low-density lipoproteins, estimated glomerular filtration rate]; no hospitalization/emergency department visit; no new depression diagnosis; remaining or becoming a nonsmoker. Logistic models estimated odds of achieving QMs associated with sex, age, race/ethnicity, insurance type, and HIV risk. A total of 4996 observations were analyzed. 45.6% met all process QMs, while 19.6% met all outcome QMs. Least frequently met process QM was PCP or HIV/ID visit (74.5%); least met outcome QM was BMI (60.2%). Significantly lower odds of achieving all QMs among women {odds ratio (OR) = 0.63 [95% confidence interval (CI): 0.49-0.81]} and those with Medicaid and Medicare [vs. commercial; OR = 0.48 (95% CI: 0.30-0.76) and 0.47 (95% CI: 0.31-0.71)]. Broadening the scope of HIV patient care QMs beyond viral suppression helps identify opportunities for improvement. Successful process metrics do not necessarily coincide with greater outcome metrics.

Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System

Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.

Identifying Spatial Variation Along the HIV Care Continuum: The Role of Distance to Care on Retention and Viral Suppression

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (< 200 copies/mL at last visit) and distance to care were estimated among 3623 DC Cohort participants receiving HIV care in 13 outpatient clinics in Washington, DC in 2015. Logistic regression models and geospatial statistics were computed. RIC was 73%; 97% were on ART, among whom 77% had VS. ZIP code-level clusters of low RIC and high VS were found in Northwest DC, and low VS in Southeast DC. Those traveling ≥ 5 miles had 30% lower RIC (adjusted odds ratio (aOR) 0.71, 95% CI 0.58, 0.86) and lower VS (OR 0.70, 95% CI 0.52, 0.94). Geospatial clustering of RIC and VS was observed, and distance may be a barrier to optimal HIV care outcomes.