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Wood BR, Bauer K, Lechtenberg R, Buskin SE, Bush L, Capizzi J, Crutsinger-Perry B, Erly SJ, Menza TW, Reuer JR, Golden MR, Hughes JP. Direct and Indirect Effects of a Project ECHO Longitudinal Clinical Tele-Mentoring Program on Viral Suppression for Persons With HIV: A Population-Based Analysis. J Acquir Immune Defic Syndr 2022; 90:538-545. [PMID: 35499527 PMCID: PMC9283242 DOI: 10.1097/qai.0000000000003007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/25/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Project Extension for Community Health Outcomes (ECHO) aims to connect community providers to academic specialists, deliver longitudinal clinical mentorship and case consultations, plus encourage dissemination of knowledge and resources. The impact on outcomes for persons with HIV (PWH) is uncertain. SETTING PWH in Washington and Oregon outside of the Seattle and Portland metro areas, January 2011 to March 2018. METHODS Using viral load (VL) surveillance data, we assessed difference in the percentage of PWH who were virally suppressed among PWH whose providers participated versus did not participate in Project ECHO. Analyses included multiple mixed-effects regression models, adjusting for time and for patient, provider, and clinic characteristics. RESULTS Based on 65,623 VL results, Project ECHO participation was associated with an increase in the percentage of patients with VL suppression (13.7 percentage points greater; P < 0.0001), although the effect varied by estimated provider PWH patient volume. The difference was 14.7 percentage points ( P < 0.0001) among patients of providers who order <20 VL's/quarter and 2.3 and -0.6 percentage points among patients of providers who order 20-40 or >40 VL's/quarter, respectively ( P > 0.5). The magnitude of difference in VL suppression was associated with the number of sessions attended. Among patients of lower-volume providers who did not participate, VL suppression was 6.2 percentage points higher if providers worked in a clinic where another provider did participate ( P < 0.0001). CONCLUSION Project ECHO is associated with improvement in VL suppression for PWH whose providers participate or work in the same clinic system as a provider who participates, primarily because of benefits for patients of lower-volume providers.
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Affiliation(s)
- Brian R. Wood
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, USA
- Mountain West AIDS Education and Training Center, Seattle, WA, USA
| | - Karin Bauer
- Mountain West AIDS Education and Training Center, Seattle, WA, USA
| | | | - Susan E. Buskin
- Public Health – Seattle and King County HIV/STD Program, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Lea Bush
- Public Health Division, Oregon Health Authority, Portland, OR, USA
| | - Jeff Capizzi
- Public Health Division, Oregon Health Authority, Portland, OR, USA
| | | | | | - Timothy W. Menza
- Public Health Division, Oregon Health Authority, Portland, OR, USA
| | | | - Matthew R. Golden
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, USA
- Public Health – Seattle and King County HIV/STD Program, Seattle, WA, USA
| | - James P. Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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2
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Morid MA, Lau M, Del Fiol G. Predictive analytics for step-up therapy: Supervised or semi-supervised learning? J Biomed Inform 2021; 119:103842. [PMID: 34146718 DOI: 10.1016/j.jbi.2021.103842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Step-up therapy is a patient management approach that aims to balance the efficacy, costs and risks posed by different lines of medications. While the initiation of first line medications is a straightforward decision, stepping-up a patient to the next treatment line is often more challenging and difficult to predict. By identifying patients who are likely to move to the next line of therapy, prediction models could be used to help healthcare organizations with resource planning and chronic disease management. OBJECTIVE To compared supervised learning versus semi-supervised learning to predict which rheumatoid arthritis patients will move from the first line of therapy (i.e., conventional synthetic disease-modifying antirheumatic drugs) to the next line of therapy (i.e., disease-modifying antirheumatic drugs or targeted synthetic disease-modifying antirheumatic drugs) within one year. MATERIALS AND METHODS Five groups of features were extracted from an administrative claims database: demographics, medications, diagnoses, provider characteristics, and procedures. Then, a variety of supervised and semi-supervised learning methods were implemented to identify the most optimal method of each approach and assess the contribution of each feature group. Finally, error analysis was conducted to understand the behavior of misclassified patients. RESULTS XGBoost yielded the highest F-measure (42%) among the supervised approaches and one-class support vector machine achieved the highest F-measure (65%) among the semi-supervised approaches. The semi-supervised approach had significantly higher F-measure (65% vs. 42%; p < 0.01), precision (51% vs. 33%; p < 0.01), and recall (89% vs. 59%; p < 0.01) than the supervised approach. Excluding demographic, drug, diagnosis, provider, and procedure features reduced theF-measure from 65% to 61%, 57%, 54%, 51% and 49% respectively (p < 0.01). The error analysis showed that a substantial portion of false positive patients will change their line of therapy shortly after the prediction period. CONCLUSION This study showed that supervised learning approaches are not an optimal option for a difficult clinical decision regarding step-up therapy. More specifically, negative class labels in step-up therapy data are not a robust ground truth, because the costs and risks associated with higher line of therapy impact objective decision making of patients and providers. The proposed semi-supervised learning approach can be applied to other step-up therapy applications.
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Affiliation(s)
- Mohammad Amin Morid
- Department of Information Systems and Analytics, Leavey School of Business, Santa Clara University, Santa Clara, CA, United States.
| | - Michael Lau
- Advanced Analytics, Gilead Sciences, San Francisco, CA, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
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3
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Jiang M, Yang G, Fang L, Wan J, Yang Y, Wang Y. Factors associated with healthcare utilization among community-dwelling elderly in Shanghai, China. PLoS One 2018; 13:e0207646. [PMID: 30507929 PMCID: PMC6277110 DOI: 10.1371/journal.pone.0207646] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 11/04/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate the factors associated with the health status of older Chinese people living in the community, in order to inform strategies to expand access to healthcare. METHODS Two-phase stratified cluster sampling was applied; 2000 older people participated in this study. Face-to-face interviews were conducted in Shanghai between June and August, 2011. Descriptive analysis was used to examine the respondents' characteristics. Based on Andersen's healthcare utilization model, a chi-squared test and multiple logistic regression were performed to examine the influences of predisposing, enabling, need, and contextual factors on healthcare utilization. RESULTS We found that 44.5% of the older people in the sample had good self-reported health status, while 12.8% were poor, 14.5% had visited hospitals or clinics as outpatients in the previous two weeks, and 16.5% had been hospitalized in the previous year. Logistic regression analysis revealed that outpatient health services were more likely to be used by women and those whose income was from friends or social relief, who had poor to good self-reported health status, who were experiencing declining health, who engaged in volunteer activities, and who had chronic diseases. Meanwhile, hospitalization was more likely among those in the older age groups, those with pension income, living in outer suburbs, with poor self-reported health status, experiencing difficulty with activities of daily living and outdoor activities, or having a chronic disease. CONCLUSIONS The results showed the impact of economic status, health status, demographic and social characteristics, and other factors on the health service utilization of elderly people living in the community in Shanghai. Need variables were the strongest predictors of health service use, although contextual factors also contributed.
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Affiliation(s)
- Man Jiang
- School of Public Health, Fudan University, Shanghai, China
| | - Guang Yang
- Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Lvying Fang
- School of Public Health, Fudan University, Shanghai, China
| | - Jin Wan
- Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yinghua Yang
- Management Department, Shanghai Municipal Center For Disease Control & Prevention, Shanghai, China
| | - Ying Wang
- School of Public Health/Key Lab of Health Technology Assessment, National Health and Family Planning Commission of the People's Republic of China, Fudan University, Shanghai, China
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4
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Landovitz RJ, Desmond KA, Leibowitz AA. Antiretroviral Therapy: Racial Disparities among Publicly Insured Californians with HIV. J Health Care Poor Underserved 2018; 28:406-429. [PMID: 28239010 DOI: 10.1353/hpu.2017.0031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Only 43% of Americans with HIV are virally suppressed; the rate is lower for African Americans, even among insured populations. This study uses 2010 Medicare and Medicaid data for HIV-positive Californians to examine how antiretroviral treatment (ART) relates to patient and provider characteristics. Logistic regressions isolated the effect of race/ethnicity on receipt of ART. Over 90% of the full sample received any ART. Nearly 80% of ART users received a recommended combination for at least half the year; half had a recommended combination for 90% of the year. Lacking evaluation and management visits, or seeing only providers with low HIV patient volume lowered the odds of receiving ART. Controlling for other factors, African Americans remained less likely to receive ART at all, or to be covered for 90% of the year with a recommended regimen. The observed racial treatment differentials may lead to important health disparities.
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Abstract
No field in medicine has moved as swiftly as HIV/AIDS over the past 35 years. Because of the rapid turnover of key information, this In the Clinic focuses on essential principles of care for newly diagnosed adults with HIV-1 infection and how to prevent infection in persons at risk. To ensure continued usefulness, future directions in therapy and how to access updated information on a continuous basis are emphasized.
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Affiliation(s)
- Judith Feinberg
- From West Virginia University, Morgantown, West Virginia, and the University of Utah, Salt Lake City, Utah
| | - Susana Keeshin
- From West Virginia University, Morgantown, West Virginia, and the University of Utah, Salt Lake City, Utah
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6
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Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, Ohl ME. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open Forum Infect Dis 2017; 4:ofx005. [PMID: 28480278 DOI: 10.1093/ofid/ofx005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/19/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. METHODS We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. RESULTS Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). CONCLUSIONS Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.
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Affiliation(s)
- A Ben Appenheimer
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Barbara Bokhour
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - D Keith McInnes
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Kelly K Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Andrew L Thurman
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Brice F Beck
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Mary Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Steven M Asch
- Division of General Medical Science, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Amanda M Midboe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Thom Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Allen L Gifford
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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7
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Rhodes CM, Chang Y, Regan S, Singer DE, Triant VA. Human Immunodeficiency Virus (HIV) Quality Indicators Are Similar Across HIV Care Delivery Models. Open Forum Infect Dis 2017; 4:ofw240. [PMID: 28480238 DOI: 10.1093/ofid/ofw240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/31/2016] [Accepted: 11/09/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are limited data on human immunodeficiency virus (HIV) quality indicators according to model of HIV care delivery. Comparing HIV quality indicators by HIV care model could help inform best practices because patients achieving higher levels of quality indicators may have a mortality benefit. METHODS Using the Partners HIV Cohort, we categorized 1565 patients into 3 HIV care models: infectious disease provider only (ID), generalist only (generalist), or infectious disease provider and generalist (ID plus generalist). We examined 12 HIV quality indicators used by 5 major medical and quality associations and grouped them into 4 domains: process, screening, immunization, and HIV management. We used generalized estimating equations to account for most common provider and multivariable analyses adjusted for prespecified covariates to compare composite rates of HIV quality indicator completion. RESULTS We found significant differences between HIV care models, with the ID plus generalists group achieving significantly higher quality measures than the ID group in HIV management (94.4% vs 91.7%, P = .03) and higher quality measures than generalists in immunization (87.8% vs 80.6%, P = .03) in multivariable adjusted analyses. All models achieved rates that equaled or surpassed previously reported quality indicator rates. The absolute differences between groups were small and ranged from 2% to 7%. CONCLUSIONS Our results suggest that multiple HIV care models are effective with respect to HIV quality metrics. Factors to consider when determining HIV care model include healthcare setting, feasibility, and physician and patient preference.
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Affiliation(s)
- Corinne M Rhodes
- University of Pennsylvania, Division of General Internal Medicine, Philadelphia, Pennsylvania; Massachusetts General Hospital, Divisions of
| | - Yuchiao Chang
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Susan Regan
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Daniel E Singer
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Virginia A Triant
- General Internal Medicine.,Infectious Diseases, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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8
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Rhodes CM, Chang Y, Regan S, Triant VA. Non-Communicable Disease Preventive Screening by HIV Care Model. PLoS One 2017; 12:e0169246. [PMID: 28060868 PMCID: PMC5218477 DOI: 10.1371/journal.pone.0169246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
Importance The Human Immunodeficiency Virus (HIV) epidemic has evolved, with an increasing non-communicable disease (NCD) burden emerging and need for long-term management, yet there are limited data to help delineate the optimal care model to screen for NCDs for this patient population. Objective The primary aim was to compare rates of NCD preventive screening in persons living with HIV/AIDS (PLWHA) by type of HIV care model, focusing on metabolic/cardiovascular disease (CVD) and cancer screening. We hypothesized that primary care models that included generalists would have higher preventive screening rates. Design Prospective observational cohort study. Setting Partners HealthCare System (PHS) encompassing Brigham & Women’s Hospital, Massachusetts General Hospital, and affiliated community health centers. Participants PLWHA age >18 engaged in active primary care at PHS. Exposure HIV care model categorized as infectious disease (ID) providers only, generalist providers only, or ID plus generalist providers. Main Outcome(s) and Measures(s) Odds of screening for metabolic/CVD outcomes including hypertension (HTN), obesity, hyperlipidemia (HL), and diabetes (DM) and cancer including colorectal cancer (CRC), cervical cancer, and breast cancer. Results In a cohort of 1565 PLWHA, distribution by HIV care model was 875 ID (56%), 90 generalists (6%), and 600 ID plus generalists (38%). Patients in the generalist group had lower odds of viral suppression but similar CD4 counts and ART exposure as compared with ID and ID plus generalist groups. In analyses adjusting for sociodemographic and clinical covariates and clustering within provider, there were no significant differences in metabolic/CVD or cancer screening rates among the three HIV care models. Conclusions There were no notable differences in metabolic/CVD or cancer screening rates by HIV care model after adjusting for sociodemographic and clinical factors. These findings suggest that HIV patients receive similar preventive health care for NCDs independent of HIV care model.
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Affiliation(s)
- Corinne M. Rhodes
- Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Susan Regan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Virginia A. Triant
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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9
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Gallant JE. Editorial Commentary:HIV Infection: Still a Disease for Experts. Clin Infect Dis 2015; 61:1878-9. [DOI: 10.1093/cid/civ724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/11/2015] [Indexed: 12/13/2022] Open
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10
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O'Neill M, Karelas GD, Feller DJ, Knudsen-Strong E, Lajeunesse D, Tsui D, Gordon P, Agins BD. The HIV Workforce in New York State: Does Patient Volume Correlate with Quality? Clin Infect Dis 2015; 61:1871-7. [PMID: 26423383 DOI: 10.1093/cid/civ719] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/19/2015] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Dennis Tsui
- New York State Department of Health AIDS Institute
| | - Peter Gordon
- Department of Medicine, Division of Infectious Diseases, Columbia University, and New York Presbyterian Hospital, New York
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11
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Tsuyuki K, Surratt HL, Levi-Minzi MA, O'Grady CL, Kurtz SP. The Demand for Antiretroviral Drugs in the Illicit Marketplace: Implications for HIV Disease Management Among Vulnerable Populations. AIDS Behav 2015; 19:857-68. [PMID: 25092512 PMCID: PMC4318775 DOI: 10.1007/s10461-014-0856-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The diversion of antiretroviral medications (ARVs) has implications for the integrity and success of HIV care, however little is known about the ARV illicit market. This paper aimed to identify the motivations for buying illicit ARVs and to describe market dynamics. Semi-structured interviews (n = 44) were conducted with substance-involved individuals living with HIV who have a history of purchasing ARVs on the street. Grounded theory was used to code and analyze interviews. Motivations for buying ARVs on the illicit market were: to repurchase ARVs after having diverted them for money or drugs; having limited access or low quality health care; to replace lost or ruined ARVs; and to buy a back-up stock of ARVs. This study identified various structural barriers to HIV treatment and ARV adherence that incentivized ARV diversion. Findings highlight the need to improve patient-provider relationships, ensure continuity of care, and integrate services to engage and retain high-needs populations.
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Affiliation(s)
- Kiyomi Tsuyuki
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, FL, 33137, USA,
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12
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Pappas G, Yujiang J, Seiler N, Malcarney MB, Horton K, Shaikh I, Freehill G, Alexander C, Akhter MN, Hidalgo J. Perspectives on the role of patient-centered medical homes in HIV Care. Am J Public Health 2014; 104:e49-53. [PMID: 24832431 PMCID: PMC4056203 DOI: 10.2105/ajph.2014.302022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2014] [Indexed: 01/22/2023]
Abstract
To strengthen the quality of HIV care and achieve improved clinical outcomes, payers, providers, and policymakers should encourage the use of patient-centered medical homes (PCMHs), building on the Ryan White CARE Act Program established in the 1990s. The rationale for a PCMH with HIV-specific expertise is rooted in clinical complexity, HIV's social context, and ongoing gaps in HIV care. Existing Ryan White HIV/AIDS Program clinicians are prime candidates to serve HIV PCMHs, and HIV-experienced community-based organizations can play an important role. Increasingly, state Medicaid programs are adopting a PCMH care model to improve access and quality to care. Stakeholders should consider several important areas for future action and research with regard to development of the HIV PCMH.
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Affiliation(s)
- Gregory Pappas
- At the time of initial writing and research, Gregory Pappas, Jia Yujiang, Irshad Shaikh, Gunther Freehill, and Mohammad N. Akhter were with the District of Columbia Department of Health, Washington, DC. Naomi Seiler, Mary-Beth Malcarney, Katherine Horton, and Julia Hidalgo were with the Milken Institute School of Public Health, George Washington University, Washington, DC. Carla Alexander was with Institute of Human Virology, University of Maryland School of Medicine, Baltimore
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13
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Socías ME, Sued O, Pryluka D, Patterson P, Fink V, Cesar C, Cahn P. Treatment as prevention: are Argentinean HIV care providers willing to adopt earlier antiretroviral therapy? AIDS Care 2014; 26:1446-51. [PMID: 24773142 DOI: 10.1080/09540121.2014.915286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
HIV guidelines increasingly recommend antiretroviral therapy (ART) initiation at a higher CD4 levels. The extent to which these evolving standards are translated into routine clinical care has not been evaluated in Argentina. During October 2012, we conducted an online survey among Argentinean HIV clinicians to assess their attitudes and practices toward ART initiation and its potential use for HIV prevention. Of the 280 physicians included, 61% would prescribe ART at CD4 ≤ 500 cells/µL for asymptomatic patients. Although, only 11% would recommend ART irrespective of CD4 cell count, 72% would do it for serodiscordant couples, and 75% for sex workers. Most participants agreed that they would consider earlier initiation of ART if transmission risk exists, and that expansion of ART could help decrease HIV incidence. These results suggest that a large proportion of Argentinean HIV care providers are willing to adopt the recently updated Argentinean guidelines recommending earlier ART, especially when high HIV transmission risk exists.
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14
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Carter A, Eun Min J, Chau W, Lima VD, Kestler M, Pick N, Money D, Montaner JSG, Hogg RS, Kaida A. Gender inequities in quality of care among HIV-positive individuals initiating antiretroviral treatment in British Columbia, Canada (2000-2010). PLoS One 2014; 9:e92334. [PMID: 24642949 PMCID: PMC3958538 DOI: 10.1371/journal.pone.0092334] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 02/14/2014] [Indexed: 11/25/2022] Open
Abstract
Objectives We measured gender differences in “Quality of Care” (QOC) during the first year after initiation of antiretroviral therapy and investigated factors associated with poorer QOC among women. Design QOC was estimated using the Programmatic Compliance Score (PCS), a validated metric associated with all-cause mortality, among all patients (≥19 years) who initiated ART in British Columbia, Canada (2000–2010). Methods PCS includes six indicators of non-compliance with treatment initiation guidelines at baseline (not having drug resistance testing before treatment; starting on a non-recommended regimen; starting therapy at CD4<200 cells/mm3) and during first-year follow-up (receiving <3 CD4 tests; receiving <3 viral load tests; not achieving viral suppression within six months). Summary scores range from 0–6; higher scores indicate poorer QOC. Multivariable ordinal logistic regression was used to measure if female gender was an independent predictor of poorer QOC and factors associated with poorer QOC among women. Results QOC was determined for 3,642 patients (20% women). At baseline: 42% of women (34% men) did not have resistance testing before treatment; 17% of women (9% men) started on a non-recommended regimen (all p<0.001). At follow-up: 17% of women (11% men) received <3 CD4; 17% of women (11% men) received <3 VL; 50% of women (41% men) did not achieve viral suppression (all p<0.001). Overall, QOC was better among men (mean PSC = 1.54 (SD = 1.30)) compared with women (mean = 1.89 (SD = 1.37); p<0.001). In the multivariable model, female gender (AOR = 1.16 [95% CI: 0.99–1.35]; p = 0.062) remained associated with poorer QOC after covariate adjustment. Among women, those with injection drug use history, of Aboriginal ancestry, from Vancouver Island, and who initiated ART in earlier years were more likely to have poorer QOC. Conclusions Poorer QOC among women, especially from marginalized communities, demands that barriers undermining women's access to high-quality care be addressed to improve treatment and health for women with HIV.
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Affiliation(s)
- Allison Carter
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - William Chau
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Viviane D. Lima
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Mary Kestler
- Oak Tree Clinic, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Neora Pick
- Oak Tree Clinic, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Deborah Money
- Women's Health Research Institute, BC Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julio S G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert S. Hogg
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Angela Kaida
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- * E-mail:
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Caro-Vega Y, Volkow P, Sierra-Madero J, Colchero MA, Crabtree-Ramírez B, Bautista-Arredondo S. Did Universal Access to ARVT in Mexico Impact Suboptimal Antiretroviral Prescriptions? AIDS Res Treat 2013; 2013:170417. [PMID: 24396592 PMCID: PMC3874343 DOI: 10.1155/2013/170417] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/29/2013] [Accepted: 10/17/2013] [Indexed: 11/17/2022] Open
Abstract
Background. Universal access to antiretroviral therapy (ARVT) started in Mexico in 2001; no evaluation of the features of ARVT prescriptions over time has been conducted. The aim of the study is to document trends in the quality of ARVT-prescription before and after universal access. Methods. We describe ARVT prescriptions before and after 2001 in three health facilities from the following subsystems: the Mexican Social Security (IMSS), the Ministry of Health (SSA), and National Institutes of Health (INS). Combinations of drugs and reasons for change were classified according to current Mexican guidelines and state-of-the-art therapy. Comparisons were made using χ (2) tests. Results. Before 2001, 29% of patients starting ARVT received HAART; after 2001 it increased to 90%. The proportion of adequate prescriptions decreased within the two periods of study in all facilities (P value < 0.01). The INS and SSA were more likely to be prescribed adequately (P value < 0.01) compared to IMSS. The distribution of reasons for change was not significantly different during this time for all facilities (P value > 0.05). Conclusions. Universal ARVT access in Mexico was associated with changes in ARVT-prescription patterns over time. Health providers' performance improved, but not homogeneously. Training of personnel and guidelines updating is essential to improve prescription.
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Affiliation(s)
- Yanink Caro-Vega
- National Institute of Public Health, Health Economics Division, Avendia Universidad No. 655, Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, 62100 Cuernavaca, MOR, Mexico
- National Institute of Medical Sciences and Nutrition, Salvador de Zubirán Unidad del Paciente Ambulatorio (UPA), 5to Piso Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, 14000 Mexico City, DF, Mexico
| | - Patricia Volkow
- Instituto Nacional de Cancerologia, Infectious Diseases Department, Avenida San Fernando No. 22, Col. Sección XVI, Tlalpan, 14080 Mexico City, DF, Mexico
| | - Juan Sierra-Madero
- National Institute of Medical Sciences and Nutrition, Salvador de Zubirán Unidad del Paciente Ambulatorio (UPA), 5to Piso Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, 14000 Mexico City, DF, Mexico
| | - M. Arantxa Colchero
- National Institute of Public Health, Health Economics Division, Avendia Universidad No. 655, Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, 62100 Cuernavaca, MOR, Mexico
| | - Brenda Crabtree-Ramírez
- National Institute of Medical Sciences and Nutrition, Salvador de Zubirán Unidad del Paciente Ambulatorio (UPA), 5to Piso Vasco de Quiroga No. 15, Col. Sección XVI, Tlalpan, 14000 Mexico City, DF, Mexico
| | - Sergio Bautista-Arredondo
- National Institute of Public Health, Health Economics Division, Avendia Universidad No. 655, Colonia Santa María Ahuacatitlán, Cerrada Los Pinos y Caminera, 62100 Cuernavaca, MOR, Mexico
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16
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Horberg MA, Hurley LB, Towner WJ, Allerton MW, Tang BT, Catz SL, Silverberg MJ, Quesenberry CP. Influence of provider experience on antiretroviral adherence and viral suppression. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2012; 4:125-33. [PMID: 22924015 PMCID: PMC3423649 DOI: 10.2147/hiv.s35174] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM Early in the combination antiretroviral therapy (cART) era, provider experience (as measured by panel size) was associated with improved outcomes. We explored that association and other characteristics of provider experience. METHODS We performed a retrospective cohort analysis in Kaiser Permanente California (an integrated health care system in the United States), examining all human immunodeficiency virus seropositive (HIV+) patients initiating a first cART regimen (antiretroviral therapy [ART]-naïve, N = 7071) or initiating a second or later cART regimen (ART-experienced, N = 3730) from 1996-2006. We measured ART adherence through 12 months (pharmacy fill and refill records) and determined HIV viral load levels below limits of quantification at 12 months. Provider experience, updated annually, was measured as (1) HIV panel size (0-10 patients as reference strata), (2) years treating HIV (less than 1 year as reference), and (3) specialty ( noninfectious disease specialty, non-HIV expert as reference). We assessed associations by utilizing mixed modeling analyses (clustered by provider and medical center), controlling for patient age, sex, race/ethnicity, HIV risk behavior, hepatitis C coinfection, ART regimen class, and calendar year. RESULTS Among the ART-experienced, improved adherence was associated with greater years experience (mean increase 3.1% 2-5 years experience; 3.7% 5-10 years; 2.7% 11-20 years; P = 0.07, categorical). In adjusted analyses, viral suppression among ART-naïve was positively associated with panel size (odds ratio 26-50 patients: 1.31, P = 0.03, categorical), but negatively associated with years experience (18% less for greater than 100 patients; P = 0.003). No provider characteristic was significantly associated with improved adherence among ART-naïve or odds of maximal viral suppression among ART-experienced in adjusted analysis. CONCLUSIONS Except for panel size and years experience among ART-naïve, provider characteristics did not significantly influence ART adherence or likelihood of viral suppression.
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Daniels LM, Raasch RH, Corbett AH. Implementation of targeted interventions to decrease antiretroviral-related errors in hospitalized patients. Am J Health Syst Pharm 2012; 69:422-30. [PMID: 22345421 DOI: 10.2146/ajhp110172] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The implementation and effectiveness of targeted interventions aimed at decreasing the frequency of antiretroviral-related errors in hospitalized patients with human immunodeficiency virus (HIV) are described. SUMMARY A prospective investigation conducted at the University of North Carolina Hospitals revealed a high rate of antiretroviral-related errors occurring on admission to the hospital and throughout a patient's hospital stay. The high frequency of errors emphasized the need for targeted interventions aimed at preventing these errors and quickly identifying and resolving errors that do occur. Several interventions aimed at decreasing this error rate were instituted, including the addition of computer alerts for incorrect doses and drug interactions to the pharmacy order-entry system, distribution of an educational pocket-sized card among the staff, addition of commercially available combination antiretroviral products to the hospital formulary, updates of the computerized prescriber-order-entry (CPOE) system to include common dosage defaults, involvement of the infectious diseases consultation service to evaluate prescribed regimens of newly admitted patients with HIV, and daily review of newly initiated anti-retroviral regimens by a clinical pharmacist trained in HIV care. A follow-up analysis was conducted after these interventions were implemented to evaluate their effectiveness. Of the 78 patients identified during the postintervention analysis, 12 (15%) had at least one error in their initial drug regimen versus 49 patients (72%) in the preintervention study (p < 0.001). CONCLUSION Antiretroviral medication error rates decreased after the implementation of targeted interventions that included distributing an educational pocket-sized card, adding alerts to the pharmacy order- entry system, incorporating default dosages into the CPOE system, and adding combination antiretrovirals to the formulary.
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Affiliation(s)
- Lindsay M Daniels
- Department ofPharmacy, University of North Carolina Hospitals, Chapel Hill, NC 27514, USA.
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Improving Access to HIV and AIDS Information Resources for Patients, Caregivers, and Clinicians: Results from the SHINE Project. Online J Public Health Inform 2012; 4:ojphi-04-2. [PMID: 23569627 PMCID: PMC3615804 DOI: 10.5210/ojphi.v4i1.3849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) remains a significant international public health challenge. The Statewide HIV/AIDS Information Network (SHINE) Project was created to improve HIV/AIDS health information use and access for health care professionals, patients, and affected communities in Indiana. OBJECTIVE Our objective was to assess the information-seeking behaviors of health care professionals and consumers who seek information on the testing, treatment, and management of HIV/AIDS and the usability of the SHINE Project's resources in meeting end user needs. The feedback was designed to help SHINE Project members improve and expand the SHINE Project's online resources. METHODS A convenience sample of health care professionals and consumers participated in a usability study. Participants were asked to complete typical HIV/AIDS information-seeking tasks using the SHINE Project website. Feedback was provided in the form of standardized questionnaire and usability "think-aloud" responses. RESULTS Thirteen participants took part in the usability study. Clinicians generally reported the site to be "very good," while consumers generally found it to be "good." Health care professionals commented that they lack access to comprehensive resources for treating patients with HIV/AIDS. They requested new electronic resources that could be integrated in clinical practice and existing information technology infrastructures. Consumers found the SHINE website and its collected information resources overwhelming and difficult to navigate. They requested simpler, multimedia-content rich resources to deliver information on HIV/AIDS testing, treatment, and disease management. CONCLUSIONS Accessibility, usability, and user education remain important challenges that public health and information specialists must address when developing and deploying interventions intended to empower consumers and support coordinated, patient-centric care.
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Westergaard RP, Ambrose BK, Mehta SH, Kirk GD. Provider and clinic-level correlates of deferring antiretroviral therapy for people who inject drugs: a survey of North American HIV providers. J Int AIDS Soc 2012; 15:10. [PMID: 22360788 PMCID: PMC3306203 DOI: 10.1186/1758-2652-15-10] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 02/23/2012] [Indexed: 05/26/2023] Open
Abstract
Background Injection drug users (IDUs) face numerous obstacles to receiving optimal HIV care, and have been shown to underutilize antiretroviral therapy (ART). We sought to estimate the degree to which providers of HIV care defer initiation of ART because of injection drug use and to identify clinic and provider-level factors associated with resistance to prescribing ART to IDUs. Methods We administered an Internet-based survey to 662 regular prescribers of ART in the United States and Canada. Questionnaire items assessed characteristics of providers' personal demographics and training, site of clinical practice and attitudes about drug use. Respondents then rated whether they would likely prescribe or defer ART for hypothetical patients in a series of scenarios involving varying levels of drug use and HIV disease stage. Results Survey responses were received from 43% of providers invited by email and direct mail, and 8.5% of providers invited by direct mail only. Overall, 24.2% of providers reported that they would defer ART for an HIV-infected patient with a CD4+ cell count of 200 cells/mm3 if the patient actively injected drugs, and 52.4% would defer ART if the patient injected daily. Physicians were more likely than non-physician providers to defer ART if a patient injected drugs (adjusted odds ratio 2.6, 95% CI 1.4-4.9). Other predictors of deferring ART for active IDUs were having fewer years of experience in HIV care, regularly caring for fewer than 20 HIV-infected patients, and working at a clinic serving a population with low prevalence of injection drug use. Likelihood of deferring ART was directly proportional to both CD4+ cell count and increased frequency of injecting. Conclusions Many providers of HIV care defer initiation of antiretroviral therapy for patients who inject drugs, even in the setting of advanced immunologic suppression. Providers with more experience of treating HIV, those in high injection drug use prevalence areas and non-physician providers may be more willing to prescribe ART despite on-going injection drug use. Because of limitations, including low response rate and use of a convenience sample, these findings may not be generalizable to all HIV care providers in North America.
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Affiliation(s)
- Ryan P Westergaard
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI, USA.
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20
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Kerr CA, Neeman N, Davis RB, Schulze J, Libman H, Markson L, Aronson M, Bell SK. HIV quality of care assessment at an academic hospital: outcomes and lessons learned. Am J Med Qual 2012; 27:321-8. [PMID: 22326983 DOI: 10.1177/1062860611425714] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.
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Disparities in antiretroviral treatment: a comparison of behaviorally HIV-infected youth and adults in the HIV Research Network. J Acquir Immune Defic Syndr 2011; 58:100-7. [PMID: 21637114 DOI: 10.1097/qai.0b013e31822327df] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Increasing numbers of youth are becoming HIV-infected and need highly active antiretroviral therapy (HAART). We hypothesized that behaviorally HIV-infected youth (BIY) ages 18 to 24 years are less likely than adults (25 years or older) to receive HAART and, once initiated, more likely to discontinue their first HAART regimen. METHODS Longitudinal analysis of treatment-naïve patients (age 18 years or older) meeting criteria for HAART and followed at HIV Research Network sites (2002-2008). Time from meeting criteria to HAART initiation and duration on first regimen were assessed using Cox proportional hazards regression. RESULTS A total of 3127 (268 youth, 2859 adult) treatment-naïve, HIV-infected patients met criteria. BIY were more likely to be black (66.8% vs 51.1%; P < 0.01) and less likely to identify injection drug use HIV risk (1.1% vs 8.8%; P < 0.01) than adults 25 years of age or older. Nearly 69% of BIY started HAART versus 79% of adults (P < 0.001). Adults 25 to 29 years of age (adjusted hazards ratio [AHR], 1.39; 95% confidence interval [CI], 1.12-1.73) and 50 years of age or older (AHR, 1.24; 95% CI, 1.00-1.54), but not 30 to 49 years (AHR, 1.19; 95% CI, 0.99-1.44) were more likely to initiate HAART than BIY. Attending four or more HIV provider visits within 1 year of meeting criteria was associated with HAART initiation (AHR, 1.91; 1.70-2.14). CD4 200 to 350 versus less than 200 cells/mm (AHR, 0.57; 95% CI, 0.52-0.63), and injection drug use (AHR, 0.80; 95% CI, 0.69-0.92) were associated with a lower likelihood of HAART initiation. There were no age-related differences in duration of the first regimen. CONCLUSION BIY are less likely to start HAART when meeting treatment criteria. Addressing factors associated with this disparity is critical to improving care for youth.
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Wright DW, Coveney PV. Resolution of discordant HIV-1 protease resistance rankings using molecular dynamics simulations. J Chem Inf Model 2011; 51:2636-49. [PMID: 21902276 DOI: 10.1021/ci200308r] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The emergence of drug resistance is a major challenge for the effective treatment of HIV. In this article, we explore the application of atomistic molecular dynamics simulations to quantify the level of resistance of a patient-derived HIV-1 protease sequence to the inhibitor lopinavir. A comparative drug ranking methodology was developed to compare drug resistance rankings produced by the Stanford HIVdb, ANRS, and RegaDB clinical decision support systems. The methodology was used to identify a patient sequence for which the three rival online tools produced differing resistance rankings. Mutations at only three positions ( L10I , A71IV, and L90M ) influenced the resistance level assigned to the sequence. We use ensemble molecular dynamics simulations to elucidate the origin of these discrepancies and the mechanism of resistance. By simulating not only the full patient sequences but also systems containing the constituent mutations, we gain insight into why resistance estimates vary and the interactions between the various mutations. In the same way, we also gain valuable knowledge of the mechanistic causes of resistance. In particular, we identify changes in the relative conformation of the two beta sheets that form the protease dimer interface which suggest an explanation of the relative frequency of different amino acids observed in patients at residue 71.
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Affiliation(s)
- David W Wright
- Centre for Computational Science, Department of Chemistry, University College London, London WC1H 0AJ, UK
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Eyawo O, Fernandes K, Brandson E, Palmer A, Chan K, Lima V, Harrigan R, Montaner J, Hogg R. Suboptimal use of HIV drug resistance testing in a universal health-care setting. AIDS Care 2011; 23:42-51. [DOI: 10.1080/09540121.2010.498871] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- O. Eyawo
- a Faculty of Health Sciences, Simon Fraser University , Burnaby , BC , Canada
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - K.A. Fernandes
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - E.K. Brandson
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - A. Palmer
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - K. Chan
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - V.D. Lima
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
| | - R.P. Harrigan
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- c Department of Medicine , University of British Columbia , Vancouver , BC , Canada
| | - J.S. Montaner
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
- c Department of Medicine , University of British Columbia , Vancouver , BC , Canada
| | - R.S. Hogg
- a Faculty of Health Sciences, Simon Fraser University , Burnaby , BC , Canada
- b BC Centre for Excellence in HIV/AIDS , Vancouver , BC , Canada
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Corsino L, Yancy WS, Samsa GP, Dolor RJ, Pollak KI, Lin PH, Svetkey LP. Physician characteristics as predictors of blood pressure control in patients enrolled in the hypertension improvement project (HIP). J Clin Hypertens (Greenwich) 2010; 13:106-11. [PMID: 21272198 DOI: 10.1111/j.1751-7176.2010.00385.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The authors sought to examine the relationship between physician characteristics and patient blood pressure (BP) in participants enrolled in the Hypertension Improvement Project (HIP). In this cross-sectional study using baseline data of HIP participants, the authors used multiple linear regression to examine how patient BP was related to physician characteristics, including experience, practice patterns, and clinic load. Patients had significantly lower systolic BP (SBP) (-0.2 mm Hg for every 1% increase, P=.008) and diastolic BP (DBP) (-0.1 mm Hg for every 1% increase, P=.0007) when seen by physicians with a higher percentage of patients with hypertension. Patients had significantly higher SBP (0.8 mm Hg for every 1% increase, P=.002) when seen by physicians with a higher number of total clinic visits per day. Patients had significantly lower DBP (-4.4 mm Hg decrease, P=.0002) when seen by physicians with inpatient duties. Physician's volume of patients with hypertension was related to better BP control. However, two indicators of a busy practice had conflicting relationships with BP control. Given the increasing time demands on physicians, future research should examine how physicians with a busy practice are able to successfully address BP in their patients.
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Affiliation(s)
- Leonor Corsino
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Au-Yeung CG, Anema A, Chan K, Yip B, Montaner JSG, Hogg RS. Physician's manual reporting underestimates mortality: evidence from a population-based HIV/AIDS treatment program. BMC Public Health 2010; 10:642. [PMID: 20973962 PMCID: PMC2987398 DOI: 10.1186/1471-2458-10-642] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Accepted: 10/25/2010] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In clinical and cohort research, mortality estimates are often derived from manual reports generated by physicians or electronic reports from vital event registries. We examined the rate of underreporting of deaths by manual methods as compared with electronic reports from a vital event registry. METHODS The retrospective analyses included deaths among participants registered in an observational cohort who initiated highly-active antiretroviral therapy (HAART) between August 1, 1996 and June 30, 2006. Deaths were routinely reported manually by physicians and through annual electronic record linkages with a population-based vital event registry. Multivariate logistic regression was carried out to assess independent predictors of death reporting by manual methods. RESULTS Of the 3,116 individuals included in the analyses, 622 (20.0%) died during follow-up. Manual reporting by physicians only identified 377 (60.6%), while electronic linkages captured 598 (96.1%) of all deaths. Multivariate analysis indicated that deaths among individuals with lower CD4 cell count, higher HIV plasma viral load, a history of injection drug use, and under the care of an HIV-experienced physicians were more likely to be reported manually. Furthermore, non-accidental deaths were more likely to be reported manually, and manual reporting of deaths increased over time. CONCLUSIONS Relying only on manual reports to ascertain deaths significantly underestimates the total number of deaths in the population. This can generate important biases when evaluating the impact of therapeutic interventions in the populational setting.
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Affiliation(s)
| | - Aranka Anema
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith Chan
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Benita Yip
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Julio SG Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Ledergerber B, Cavassini M, Battegay M, Bernasconi E, Vernazza P, Hirschel B, Furrer H, Rickenbach M, Weber R. Trends over time of virological and immunological characteristics in the Swiss HIV Cohort Study*. HIV Med 2010; 12:279-88. [DOI: 10.1111/j.1468-1293.2010.00880.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gerbert B, Caspers N, Moe J, Clanon K, Abercrombie P, Herzig K. The mysteries and demands of HIV care: qualitative analyses of HIV specialists’ views on their expertise. AIDS Care 2010; 16:363-76. [PMID: 15203429 DOI: 10.1080/09540120410001665367] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To deepen our understanding of the mysteries and demands associated with HIV care and to inform the debate about HIV specialization, we conducted in-depth interviews with a purposive sample of 20 identified HIV specialists in the San Francisco Bay Area. Participants were from several medical specialties and reported a median of 50% of their time spent in HIV patient care. Through constant comparison, a template of open codes was constructed to identify themes that emerged from the data. Data were analyzed according to the conventions of qualitative research and revealed six interrelated themes: (1) coping with uncertainty and rapid change: being 'comfortable with mystery'; (2) the powerful role of experience; (3) the dual faces of knowledge: 'knowing the patient' and 'knowing the facts'; (4) the dual faces of passion: challenge and calling; (5) stress and burnout; and (6) the relationship between academia and 'the trenches'. The themes underscore the dual dimensions of HIV care: providers must interweave the 'half-baked' science about drug therapies, side effects and drug interactions with the psychosocial and lifestyle factors of the patient. They also provide insight into quantitative findings linking greater HIV experience with better patient outcomes and suggest that providers need skills associated with generalist and specialist training, a phenomenon that argues for a 'special' specialty for HIV care.
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Affiliation(s)
- B Gerbert
- Division of Behavioral Sciences, Department of Preventive and Restorative Dental Sciences University of California, San Francisco, CA 94117, USA.
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Sanne I, Orrell C, Fox M, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R, Rassool M, Gonin R, Stevens W, Truter H, Dehlinger M, van der Horst C, McIntyre J, Wood R. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet 2010; 376:33-40. [PMID: 20557927 PMCID: PMC3145152 DOI: 10.1016/s0140-6736(10)60894-x] [Citation(s) in RCA: 185] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Expanded access to combination antiretroviral therapy (ART) in resource-poor settings is dependent on task shifting from doctors to other health-care providers. We compared outcomes of nurse versus doctor management of ART care for HIV-infected patients. METHODS This randomised non-inferiority trial was undertaken at two South African primary-care clinics. HIV-positive individuals with a CD4 cell count of less than 350 cells per microL or WHO stage 3 or 4 disease were randomly assigned to nurse-monitored or doctor-monitored ART care. Patients were randomly assigned by stratified permuted block randomisation, and neither the patients nor those analysing the data were masked to assignment. The primary objective was a composite endpoint of treatment-limiting events, incorporating mortality, viral failure, treatment-limiting toxic effects, and adherence to visit schedule. Analysis was by intention to treat. Non-inferiority of the nurse versus doctor group for cumulative treatment failure was prespecified as an upper 95% CI for the hazard ratio that was less than 1.40. This study is registered with ClinicalTrials.gov, number NCT00255840. FINDINGS 408 patients were assigned to doctor-monitored ART care and 404 to nurse-monitored ART care; all participants were analysed. 371 (46%) patients reached an endpoint of treatment failure: 192 (48%) in the nurse group and 179 (44%) in the doctor group. The hazard ratio for composite failure was 1.09 (95% CI 0.89-1.33), which was within the limits for non-inferiority. After a median follow-up of 120 weeks (IQR 60-144), deaths (ten vs 11), virological failures (44 vs 39), toxicity failures (68 vs 66), and programme losses (70 vs 63) were similar in nurse and doctor groups, respectively. INTERPRETATION Nurse-monitored ART is non-inferior to doctor-monitored therapy. Findings from this study lend support to task shifting to appropriately trained nurses for monitoring of ART. FUNDING National Institutes of Health; United States Agency for International Development; National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Ian Sanne
- Faculty of Health Sciences, University of the Witwatersrand
| | | | - Matthew Fox
- Center for Global Health and Development, Boston University
| | | | - Prudence Ive
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | | | | | | | | | | | - Wendy Stevens
- Faculty of Health Sciences, University of the Witwatersrand
| | - Handré Truter
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | - James McIntyre
- Faculty of Health Sciences, University of the Witwatersrand
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Sanne I, Orrell C, Fox M, Conradie F, Ive P, Zeinecker J, Cornell M, Heiberg C, Ingram C, Panchia R, Rassool M, Gonin R, Stevens W, Truter H, Dehlinger M, van der Horst C, McIntyre J, Wood R. Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet 2010. [PMID: 20557927 PMCID: PMC3145152 DOI: 10.1016/s0140-6736%2810%2960894-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Expanded access to combination antiretroviral therapy (ART) in resource-poor settings is dependent on task shifting from doctors to other health-care providers. We compared outcomes of nurse versus doctor management of ART care for HIV-infected patients. METHODS This randomised non-inferiority trial was undertaken at two South African primary-care clinics. HIV-positive individuals with a CD4 cell count of less than 350 cells per microL or WHO stage 3 or 4 disease were randomly assigned to nurse-monitored or doctor-monitored ART care. Patients were randomly assigned by stratified permuted block randomisation, and neither the patients nor those analysing the data were masked to assignment. The primary objective was a composite endpoint of treatment-limiting events, incorporating mortality, viral failure, treatment-limiting toxic effects, and adherence to visit schedule. Analysis was by intention to treat. Non-inferiority of the nurse versus doctor group for cumulative treatment failure was prespecified as an upper 95% CI for the hazard ratio that was less than 1.40. This study is registered with ClinicalTrials.gov, number NCT00255840. FINDINGS 408 patients were assigned to doctor-monitored ART care and 404 to nurse-monitored ART care; all participants were analysed. 371 (46%) patients reached an endpoint of treatment failure: 192 (48%) in the nurse group and 179 (44%) in the doctor group. The hazard ratio for composite failure was 1.09 (95% CI 0.89-1.33), which was within the limits for non-inferiority. After a median follow-up of 120 weeks (IQR 60-144), deaths (ten vs 11), virological failures (44 vs 39), toxicity failures (68 vs 66), and programme losses (70 vs 63) were similar in nurse and doctor groups, respectively. INTERPRETATION Nurse-monitored ART is non-inferior to doctor-monitored therapy. Findings from this study lend support to task shifting to appropriately trained nurses for monitoring of ART. FUNDING National Institutes of Health; United States Agency for International Development; National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Ian Sanne
- Faculty of Health Sciences, University of the Witwatersrand
| | | | - Matthew Fox
- Center for Global Health and Development, Boston University
| | | | - Prudence Ive
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | | | | | | | | | | | - Wendy Stevens
- Faculty of Health Sciences, University of the Witwatersrand
| | - Handré Truter
- Faculty of Health Sciences, University of the Witwatersrand
| | | | | | - James McIntyre
- Faculty of Health Sciences, University of the Witwatersrand
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Sloot PMA, Coveney PV, Ertaylan G, Müller V, Boucher CA, Bubak M. HIV decision support: from molecule to man. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2009; 367:2691-2703. [PMID: 19487205 DOI: 10.1098/rsta.2009.0043] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Human immunodeficiency virus (HIV) is recognized to be one of the most destructive pandemics in recorded history. Effective highly active antiretroviral therapy and the availability of genetic screening of patient virus data have led to sustained viral suppression and higher life expectancy in patients who have been infected with HIV. The sheer complexity of the disease stems from the multiscale and highly dynamic nature of the system under study. The complete cascade from genome, proteome, metabolome and physiome to health forms a multidimensional system that crosses many orders of magnitude in temporal and spatial scales. Understanding, quantifying and handling this complexity is one of the biggest challenges of our time, which requires a highly multidisciplinary approach. In order to supply researchers with an interactive framework and to provide the medical professional with appropriate tools and information for making a balanced and reliable clinical decision, we have developed 'ViroLab', a collaborative decision-support system (http://www.virolab.org/). ViroLab contains computational models that cover various spatial and temporal scales from atomic-level interactions in nanoseconds up to sociological interactions on the epidemiological level, spanning years of disease progression. ViroLab allows for personalized drug ranking. It is on trial in six hospitals and various virology and epidemiology laboratories across Europe.
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Affiliation(s)
- P M A Sloot
- Computational Science, University of Amsterdam, 1081 HV Amsterdam, The Netherlands.
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Schneider JA, Zhang Q, Auerbach A, Gonzales D, Kaboli P, Schnipper J, Wetterneck TB, Pitrak DL, Meltzer DO. Do hospitalists or physicians with greater inpatient HIV experience improve HIV care in the era of highly active antiretroviral therapy? Results from a multicenter trial of academic hospitalists. Clin Infect Dis 2008; 46:1085-92. [PMID: 18444829 DOI: 10.1086/529200] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Little is known about the effect of provider type and experience on outcomes, resource use, and processes of care of hospitalized patients with human immunodeficiency virus (HIV) infection. Hospitalists are caring for this population with increasing frequency. METHODS Data from a natural experiment in which patients were assigned to physicians on the basis of call cycle was used to study the effects of provider type-that is, hospitalist versus nonhospitalist-and HIV-specific inpatient experience on resource use, outcomes, and selected measures of processes of care at 6 academic institutions. Administrative data, inpatient interviews, 30-day follow-up interviews, and the National Death Index were used to measure outcomes. RESULTS A total of 1207 patients were included in the analysis. There were few differences in resource use, outcomes, and processes of care by provider type and experience with HIV-infected inpatients. Patients who received hospitalist care demonstrated a trend toward increased length of hospital stay compared with patients who did not receive hospitalist care (6.0 days vs. 5.2 days; P = .13). Inpatient providers with moderate experience with HIV-infected patients were more likely to coordinate care with outpatient providers (odds ratio, 2.40; P = .05) than were those with the least experience with HIV-infected patients, but this pattern did not extend to providers with the highest level of experience. CONCLUSION Provider type and attending physician experience with HIV-infected inpatients had minimal effect on the quality of care of HIV-infected inpatients. Approaches other than provider experience, such as the use of multidisciplinary inpatient teams, may be better targets for future studies of the outcomes, processes of care, and resource use of HIV-infected inpatients.
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Affiliation(s)
- John A Schneider
- Department of Medicine, Tufts-New England Medical Center, Boston, Massachusetts, USA.
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32
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Pastakia SD, Corbett AH, Raasch RH, Napravnik S, Correll TA. Frequency of HIV-related medication errors and associated risk factors in hospitalized patients. Ann Pharmacother 2008; 42:491-7. [PMID: 18349307 DOI: 10.1345/aph.1k547] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Retrospective studies of hospitalized HIV-infected patients have noted a high occurrence of drug-related errors, ranging from 5% to 30%. OBJECTIVE To prospectively evaluate errors in antiretroviral (ARV) prescribing in the inpatient setting of a hospital tertiary care center and the association of risk factors with the occurrence of errors. METHODS HIV-infected patients who received care and continued their ARVs for HIV infection on admission to a large academic teaching hospital between January and April 2006 were included in this study. The care and assessment of these patients was conducted on a daily basis by an infectious diseases/HIV specialized clinical pharmacist. All errors were documented and classified based on a severity scale. RESULTS Among the 68 patients who met the study's eligibility criteria, at least one error in the initial HIV regimen occurred in 72% of patients, and in 56% of patients, the error had the potential to cause moderate-to-severe discomfort or clinical deterioration. Patients on atazanavir-based therapy had a statistically significant increased occurrence of errors throughout their hospitalization (RR = 1.69; 95% CI 1.03 to 2.78; p = 0.02). Receiving nonformulary (combination) HIV medications increased patients' risk of having more than one error occur in their ARV regimen on admission and during hospitalization (RR = 1.95; 95% CI 1.25 to 3.04; p = 0.02). The clinical pharmacist recommendations had 100% acceptance. CONCLUSIONS The alarmingly high frequency of potentially harmful errors uncovered in this study necessitates further investigation using larger sample sizes. Interventions to reduce and prevent these errors must be sought to eliminate the unintended harm associated with hospitalization.
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Affiliation(s)
- Sonak D Pastakia
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, Purdue University, Indianapolis, IN 46202, USA.
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Holmes WC, Pace JL, Frank I. Appropriateness of antiretroviral therapy in clients of an HIV/AIDS case management organization. AIDS Care 2007; 19:273-81. [PMID: 17364410 DOI: 10.1080/09540120600966141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We sought to assess appropriateness of antiretroviral therapy (ART) reported by clients of an HIV/AIDS case management organization and identify variables associated with appropriate ART receipt. A total of 295 such clients were mailed a survey asking them to identify antiretroviral medications they were taking. Of them 220 (75%) returned surveys; 201 (93%) were taking antiretrovirals. Of these, 159 were on appropriate and 36 on inappropriate ART, as determined by guidelines created by the CDC, the International AIDS Society (USA Panel), and the Panel on Clinical Practices for Treatment of HIV Infection. In unadjusted analyses, age, sex, race, sexual orientation, history of injection drug use, history of sexual risk, and HIV knowledge were associated (p< or =0.10) with appropriate ART and entered into one of two logistic regression models. The first model indicated that women (p=0.003) and heterosexuals (p=0.001) were less likely to receive appropriate ART than men and gay/bisexuals (and variables interacted, p=0.001). HIV knowledge--a proxy indicator determined by self-report of a CD4 cell count and viral load--was added to variables retained in first model to create a second model. Only sexual orientation was retained in this second model (p=0.02, in the same direction as in the first model), and those with less versus more HIV knowledge (p=0.04) were found to be less likely to receive appropriate ART (and variables interacted, p=0.04). Findings suggest that heterosexual men are less likely than women who, in turn, are less likely than gay/bisexual men to receive appropriate ART. HIV-related knowledge appears to increase likelihood of receiving appropriate ART and it attenuates the effect of sex.
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Affiliation(s)
- W C Holmes
- University of Pennsylvania School of Medicine, USA.
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Uphold CR, Mkanta WN. Review: use of health care services among persons living with HIV infection: state of the science and future directions. AIDS Patient Care STDS 2005; 19:473-85. [PMID: 16124841 DOI: 10.1089/apc.2005.19.473] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Health care services for persons living with HIV have broadened from short-term, crisis-oriented, and palliative care to include preventive, acute, and long-term services because of advances in HIV treatment and earlier detection. This integrated literature review on utilization of HIV-related health care services provides information on barriers to access, disparities in treatments, and factors contributing to wasteful use of services. Early research focused on describing and quantifying use of in-hospital care. As HIV transformed into a chronic disease, research on utilization expanded into outpatient settings. Predisposing factors such as race, gender, and injection drug use, and enabling factors (i.e., insurance, social support systems, housing) were strong predictors of utilization patterns. Clinical factors, such as immune status, symptoms, and depression, as well as contextual factors (i.e., characteristics of clinicians, urban/rural residence) determined the amounts of services obtained. Additional research is recommended on the utilization of nursing and preventive services and care in rehabilitation settings, home health, and nursing homes. Understanding the patterns and predictors of resource use can facilitate health professionals' efforts in improving the health care delivery system for individuals with HIV infection.
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Affiliation(s)
- Constance R Uphold
- Rehabilitation Outcomes Research Center, University of Florida, Gainesville, Florida 32608-1197, USA.
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Braithwaite RS, Justice AC, Chang CCH, Fusco JS, Raffanti SR, Wong JB, Roberts MS. Estimating the proportion of patients infected with HIV who will die of comorbid diseases. Am J Med 2005; 118:890-8. [PMID: 16084183 DOI: 10.1016/j.amjmed.2004.12.034] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2004] [Revised: 12/16/2004] [Accepted: 12/29/2004] [Indexed: 10/25/2022]
Abstract
PURPOSE Effective antiretroviral therapies have improved the prognosis for patients infected with the human immunodeficiency virus (HIV). We aimed to estimate the likelihood that HIV-infected patients would die of comorbid disease. METHODS A probabilistic simulation of antiretroviral-naïve HIV-infected patients in the United States was calibrated with data from an observational cohort (N = 3545) and validated with data from a separate patient cohort (N = 12574). The simulation explicitly represents the 2 main determinants of treatment failure and subsequent death from HIV-related causes: nonadherence to combination therapy and accumulation of phenotypic resistance to combination therapy. The likelihood of deaths not directly attributable to HIV was estimated from the Collaborations in HIV Outcomes Research-US (CHORUS) cohort. RESULTS For patients with newly diagnosed HIV infections, CD4 counts of 500 cells/mm3, and viral loads of 10000 copies/mL, the median estimated survival was 26.8 years for 30-year-olds, 24.4 years for 40-year-olds and 14.6 years for 50-year-olds. The proportion of deaths not directly attributable to HIV was 36% for 30-year-olds, 53% for 40-year-olds, and 72% for 50-year-olds. For patients with characteristics similar to CHORUS participants, the median estimated survival approached 20.4 years, the mean age at death approached 60.4 years, and 41% died of illnesses not directly attributable to HIV. These estimates of non-HIV mortality were likely conservative. CONCLUSION As HIV-infected patients live longer, our results suggest they will experience increasing mortality from causes not directly attributable to HIV. The projected risk from comorbid disease has clinical and policy implications for future delivery of care to HIV-infected patients.
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Affiliation(s)
- R Scott Braithwaite
- VAMC New Haven and Yale University School of Medicine, New Haven, Conn, USA.
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Bailey JE, Van Brunt DL, Somes GW, Dorko CS, Wan JY. Impact of a statewide Medicaid managed care system on healthcare utilization and outcomes for people living with HIV. Am J Med Sci 2005; 328:305-14. [PMID: 15599325 DOI: 10.1016/s0002-9629(15)33939-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Medicaid managed care (MMC) systems provide insurance for many persons living with HIV and AIDS (PLWH). This study sought to assess the impact of a statewide MMC system (TennCare) on healthcare utilization and outcomes for PLWH. METHODS A retrospective longitudinal analysis of trends in population characteristics was performed. The study population included all Tennessee PLWH identified by State Health Department, enrolled for 1 year or longer in Medicaid (1992-1993) or TennCare (1994-1997). Main outcome measures included health care utilization, incidence of opportunistic infections, and mortality. RESULTS From 1992 to 1997, the following decreased: average number of hospitalizations for HIV (0.72 to 0.37) and AIDS (1.27 to 0.52); emergency visits for HIV (1.70 to 1.12) and AIDS (1.65 to 1.02); outpatient visits for HIV (5.94 to 5.00) and AIDS (8.37 to 7.35), percentage of persons diagnosed with Pneumocystis carinii pneumonia for AIDS (10% to 6%) and percentage of persons diagnosed with community-acquired pneumonia for HIV (14% to 9%) and AIDS (27% to 12%), annual incidence of AIDS in the HIV population (33% to 10%), and annual mortality for HIV (3% to 1%) and AIDS (16% to 3%). The average number of antiretroviral medication prescriptions filled increased for HIV (1.27 to 2.45) and AIDS (1.31 to 3.34). CONCLUSIONS This study documents improvements in utilization patterns, morbidity, and mortality in a statewide MMC system. These findings suggest that MMC patients are benefiting from recent advances in therapy.
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Affiliation(s)
- James E Bailey
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 38105, USA.
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van Leth F, Phanuphak P, Ruxrungtham K, Baraldi E, Miller S, Gazzard B, Cahn P, Lalloo UG, van der Westhuizen IP, Malan DR, Johnson MA, Santos BR, Mulcahy F, Wood R, Levi GC, Reboredo G, Squires K, Cassetti I, Petit D, Raffi F, Katlama C, Murphy RL, Horban A, Dam JP, Hassink E, van Leeuwen R, Robinson P, Wit FW, Lange JMA. Comparison of first-line antiretroviral therapy with regimens including nevirapine, efavirenz, or both drugs, plus stavudine and lamivudine: a randomised open-label trial, the 2NN Study. Lancet 2004; 363:1253-63. [PMID: 15094269 DOI: 10.1016/s0140-6736(04)15997-7] [Citation(s) in RCA: 520] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The 2NN Study was a randomised comparison of the non-nucleoside reverse-transcriptase inhibitors (NNRTI) nevirapine and efavirenz. METHODS In this multicentre, open-label, randomised trial, 1216 antiretroviral-therapy-naive patients were assigned nevirapine 400 mg once daily, nevirapine 200 mg twice daily, efavirenz 600 mg once daily, or nevirapine (400 mg) and efavirenz (800 mg) once daily, plus stavudine and lamivudine, for 48 weeks. The primary endpoint was the proportion of patients with treatment failure (less than 1 log(10) decline in plasma HIV-1 RNA in the first 12 weeks or two consecutive measurements of more than 50 copies per mL from week 24 onwards, disease progression [new Centers for Disease Control and Prevention grade C event or death], or change of allocated treatment). Analyses were by intention to treat. FINDINGS Treatment failure occurred in 96 (43.6%) of 220 patients assigned nevirapine once daily, 169 (43.7%) of 387 assigned nevirapine twice daily, 151 (37.8%) of 400 assigned efavirenz, and 111 (53.1%) of 209 assigned nevirapine plus efavirenz. The difference between nevirapine twice daily and efavirenz was 5.9% (95% CI -0.9 to 12.8). There were no significant differences among the study groups in the proportions with plasma HIV-1 RNA concentrations below 50 copies per mL at week 48 (p=0.193) or the increases in CD4-positive cells (p=0.800). Nevirapine plus efavirenz was associated with the highest frequency of clinical adverse events, and nevirapine once daily with significantly more hepatobiliary laboratory toxicities than efavirenz. Of 25 observed deaths, two were attributed to nevirapine. INTERPRETATION Antiretroviral therapy with nevirapine or efavirenz showed similar efficacy, so triple-drug regimens with either NNRTI are valid for first-line treatment. There are, however, differences in safety profiles. Combination of nevirapine and efavirenz did not improve efficacy but caused more adverse events.
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Affiliation(s)
- F van Leth
- International Antiviral Therapy Evaluation Center, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
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Golin CE, Smith SR, Reif S. Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina. J Gen Intern Med 2004; 19:16-27. [PMID: 14748856 PMCID: PMC1494686 DOI: 10.1111/j.1525-1497.2004.21151.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT National guidelines recommend that practitioners assess and reinforce patient adherence when prescribing antiretroviral (ART) medications, but the extent to which physicians do this routinely is unknown. OBJECTIVE To assess the adherence counseling practices of physicians caring for patients with HIV/AIDS in North Carolina and to determine characteristics associated with providing routine adherence counseling. DESIGN A statewide self-administered survey. SETTING AND PARTICIPANTS All physicians in North Carolina who prescribed a protease inhibitor (PI) during 1999. Among the 589 surveys sent, 369 were returned for a response rate of 63%. The 190 respondents who reported prescribing a PI in the last year comprised the study sample. MAIN OUTCOME MEASURES Physicians reported how often they carried out each of 16 adherence counseling behaviors as well as demographics, practice characteristics, and attitudes. RESULTS On average, physicians reported spending 13 minutes counseling patients when starting a new 3-drug ART regimen. The vast majority performed basic but not more extensive adherence counseling; half reported carrying out 7 or fewer of 16 adherence counseling behaviors "most" or "all of the time." Physicians who reported conducting more adherence counseling were more likely to be infectious disease specialists, care for more HIV-positive patients, have more time allocated for an HIV visit, and to perceive that they had enough time, reimbursement, skill, and office space to counsel. After also controlling for the amount of reimbursement and availability of space for counseling, physicians who were significantly more likely to perform a greater number of adherence counseling practices were those who 1). cared for a greater number of HIV/AIDS patients; 2). had more time allocated for an HIV physical; 3). felt more adequately skilled; and 4). had more positive attitudes toward ART. CONCLUSIONS This first investigation of adherence counseling practices in HIV/AIDS suggests that physicians caring for patients with HIV/AIDS need more training and time allocated to provide antiretroviral adherence counseling services.
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Affiliation(s)
- Carol E Golin
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Reisler RB, Han C, Burman WJ, Tedaldi EM, Neaton JD. Grade 4 events are as important as AIDS events in the era of HAART. J Acquir Immune Defic Syndr 2003; 34:379-86. [PMID: 14615655 DOI: 10.1097/00126334-200312010-00004] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate incidence and predictors of serious or life-threatening events that are not AIDS defining, AIDS events, and death among patients treated with highly active antiretroviral therapy (HAART) in the setting of 5 large multicenter randomized treatment trials conducted in the United States. METHODS Data were analyzed from 2,947 patients enrolled from December 1996 through December 2001. All patients were to receive antiretrovirals throughout follow-up. Data collection was uniform for all main outcome measures: serious or life-threatening (grade 4) events, AIDS, and death. RESULTS During follow-up, 675 patients experienced a grade 4 event (11.4 per 100 person-years); 332 developed an AIDS event (5.6 per 100 person-years); and 272 died (4.6 per 100 person-years). The most common grade 4 events were liver related (148 patients, 2.6 per 100 person-years). Cardiovascular events were associated with the greatest risk of death (hazard ratio = 8.64; 95% CI: 5.1 to 14.5). The first grade 4 event and the first AIDS event were associated with similar risks of death, 5.68 and 6.95, respectively. CONCLUSIONS Grade 4 events are as important as AIDS events in the era of HAART. To adequately evaluate the impact of HAART on morbidity, comorbidities and other key factors must be carefully assessed.
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Affiliation(s)
- Ronald B Reisler
- Institute of Human Virology, University of Maryland, Baltimore, MD 21201, USA.
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40
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O'Connell JM, Braitstein P, Hogg RS, Yip B, Craib KJP, O'Shaughnessy MV, Montaner JSG, Burdge DR. Age, Adherence and Injection Drug use Predict Virological Suppression among Men and Women Enrolled in a Population-Based Antiretroviral Drug Treatment Programme. Antivir Ther 2003; 8:569-76. [PMID: 14760890 DOI: 10.1177/135965350300800601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To characterize 1-year virological response to antiretroviral therapy and its determinants by sex. Methods This is a population-based analysis of anti-retroviral therapy naive HIV-positive adult men and women. Factors associated with sex and with plasma HIV RNA viral load suppression to below 500 copies/ml were examined using non-parametric tests and logistic regression analyses. Results A total of 739 subjects (92 women and 647 men) were eligible. Female participants were younger (34 vs 37 years; P<0.001), less likely to have AIDS (6.5 vs 14.4%; P=0.039), more frequently injection drug users (44.6 vs 25.2%; P=0.001) and were less likely to be adherent to therapy (34.8 vs 62.9%; P<0.001) than male participants. There was no difference in baseline median CD4 count ( P=0.424) or HIV RNA levels ( P=0.140), physician experience ( P=0.057), or with respect to antiretroviral regimens containing protease inhibitors or non-nucleoside reverse transcriptase inhibitors ( P=0.911). With treatment, 46.7% (43/92) of women and 64.8% (419/647) of men ( P=0.001) suppressed HIV RNA viral load to below 500 copies/ml at 1 year. In a multivariate analysis, the association of sex with HIV RNA response to antiretroviral therapy fell from statistical significance (odds ratio 1.18; 95% CI: 0.72–1.95) after adjusting for adherence, injection drug use and age. Conclusion Our data indicate that in this population-based setting, sex differences in 1-year virological response to antiretroviral therapy are explained by age, adherence and injection drug use.
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Affiliation(s)
- Jacqueline M O'Connell
- BC Centre for Excellence in HIV/AIDS, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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41
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Giordano TP, White AC, Sajja P, Graviss EA, Arduino RC, Adu-Oppong A, Lahart CJ, Visnegarwala F. Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic. J Acquir Immune Defic Syndr 2003; 32:399-405. [PMID: 12640198 DOI: 10.1097/00126334-200304010-00009] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ethnic minority, female, and drug-using patients may be less likely to receive highly active antiretroviral therapy (HAART), despite its proven benefits. We reviewed the medical records of a consecutive population of 354 patients entering care in 1998 at the Thomas Street Clinic, an academically affiliated, public, HIV-specialty clinic in Houston, to determine the factors associated with not receiving HAART as recorded in pharmacy records. Ninety-two patients (26.0%) did not receive HAART during at least 6 months of follow-up. Patients who did not receive HAART were more likely to be women and to have missed more than two physician appointments and were less likely to have a CD4 count <200 cells/microL or a viral load > or = 10 copies/mL. In multivariate logistic analysis, missed appointments (OR = 5.85, p<.0001), female sex (OR = 2.53, =.001), and CD4 count > or = 200 cells/microL (OR = 2.50, p=.001) were independent predictors of not receiving HAART. More than half the patients who never received HAART never returned to the clinic after their first appointment. Among patients new to care, women and those with poor appointment adherence were less likely to receive HAART. Efforts to improve clinic retention and further study of the barriers to HAART use in women are needed.
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Affiliation(s)
- Thomas P Giordano
- Sections of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas 77009, USA
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42
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Landon BE, Wilson IB, Cohn SE, Fichtenbaum CJ, Wong MD, Wenger NS, Bozzette SA, Shapiro MF, Cleary PD. Physician specialization and antiretroviral therapy for HIV. J Gen Intern Med 2003; 18:233-41. [PMID: 12709089 PMCID: PMC1494839 DOI: 10.1046/j.1525-1497.2003.20705.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has important implications for the types of physicians that can best care for patients with HIV infection. OBJECTIVE To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART). DESIGN Observational cohort study of patients under care for HIV infection and their physicians. PATIENTS AND SETTING This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians. MEASUREMENTS Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor. RESULTS Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio [OR], 0.32; 95% confidence interval [95% CI], 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations. CONCLUSIONS Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that expert generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.
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Affiliation(s)
- Bruce E Landon
- Received from the Division of General Medicine, Beth Israel Deaconess Medical Center (BEL) and the Department of Health Care Policy (BEL, PDC), Harvard Medical School, Boston, Mass 02115, USA.
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43
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Kitahata MM, Dillingham PW, Chaiyakunapruk N, Buskin SE, Jones JL, Harrington RD, Hooton TM, Holmes KK. Electronic human immunodeficiency virus (HIV) clinical reminder system improves adherence to practice guidelines among the University of Washington HIV Study Cohort. Clin Infect Dis 2003; 36:803-11. [PMID: 12627367 DOI: 10.1086/368085] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2002] [Accepted: 12/09/2002] [Indexed: 11/03/2022] Open
Abstract
We conducted a prospective study of an electronic clinical reminder system in an academic medical center-based human immunodeficiency virus (HIV) specialty clinic. Published performance indicators were used to examine adherence to HIV practice guidelines before and after its implementation for 1204 patients. More than 90% of patients received CD4 cell count and HIV type 1 (HIV-1) RNA level monitoring every 3-6 months during both time periods, and approximately 80% of patients with a CD4 cell count nadir of <350 cells/mm(3) received highly active antiretroviral therapy. Patients were significantly more likely to receive prophylaxis against Mycobacterium avium complex (hazard ratio, 3.84; 95% confidence interval [CI], 1.58-9.31; P=.003), to undergo annual cervical carcinoma screening (OR, 2.09; 95% CI, 1.04-4.16; P=.04), and to undergo serological screening for Toxoplasma gondii (odds ratio [OR], 1.86; 95% CI, 1.05-3.27; P=.03) and syphilis infection (OR, 3.71; 95% CI, 2.37-5.81; P<.0001). HIV clinical reminders delivered at the time that HIV care is provided were associated with more timely initiation of recommended practices.
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Affiliation(s)
- Mari M Kitahata
- Department of Medicine, University of Washington, Harborview Medical Center, Box 359931, 325 9th Ave., Seattle, WA 98104, USA.
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Kitahata MM, Van Rompaey SE, Dillingham PW, Koepsell TD, Deyo RA, Dodge W, Wagner EH. Primary care delivery is associated with greater physician experience and improved survival among persons with AIDS. J Gen Intern Med 2003; 18:95-103. [PMID: 12542583 PMCID: PMC1494825 DOI: 10.1046/j.1525-1497.2003.11049.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE It has been shown that greater physician experience in the care of persons with AIDS prolongs survival, but how more experienced primary care physicians achieve better outcomes is not known. DESIGN/SETTING/PATIENTS Retrospective cohort study of HIV-infected patients enrolled in a large staff-model health maintenance organization from 1990 through 1999. MEASUREMENTS Adjusted odds of medical service delivery and adjusted hazard ratio of death by physician experience level (least, moderate, most) and service utilization. MAIN RESULTS Primary care delivery by physicians with greater AIDS experience was associated with improved survival. After controlling for disease severity, patients cared for by the most experienced physicians were twice as likely to receive a primary care visit in a given month compared with patients of the least and moderately experienced physicians (P <.01). Patients of the least experienced physicians received the lowest level of outpatient pharmacy and laboratory services (P <.001) and were half as likely to have a specialty care visit compared with patients of the most and moderately experienced physicians (P <.05). Patients who received infrequent primary care visits by the least experienced physicians were 15.3 times more likely to die than patients of the most experienced physicians (P =.02). There was a significant increase in primary care services delivered to the population of HIV-infected patients receiving care in 1999, when highly active antiretroviral therapy (HAART) was in general use, compared with the time period prior to the introduction of HAART. CONCLUSIONS Primary care delivery by physicians with greater HIV experience contributes to improved patient outcomes.
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Affiliation(s)
- Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, Wash, USA.
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Kitahata MM, Tegger MK, Wagner EH, Holmes KK. Comprehensive health care for people infected with HIV in developing countries. BMJ 2002; 325:954-7. [PMID: 12399350 PMCID: PMC1124448 DOI: 10.1136/bmj.325.7370.954] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Mari M Kitahata
- Center for AIDS and STD, University of Washington, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA.
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Abstract
This article reviews AIDS surveillance data and the rural health literature to summarize what is known about the rural AIDS epidemic, characteristics of rural environments that affect HIV service delivery, and approaches that rural areas are using to address the health and support service needs of HIV-positive residents. During 1999, nonmetropolitan (non-MSA) adult/adolescent AIDS rates were highest in the South (11 per 100,000) and Northeast (9 per 100,000). The South had the highest non-MSA proportion of adult/adolescent AIDS cases (12%), followed by the North Central region (9%), the West (4%), and the Northeast (3%). Variations in rural HIV/AIDS epidemiologic patterns and the demographic, socio-economic, and cultural characteristics of rural environments are likely to require different levels of resource investment and different methods of organizing and delivering HIV services. Currently, many HIV-positive rural residents are traveling to metropolitan areas for medical care because of concerns about confidentiality or a lack of confidence in the HIV management capabilities of local physicians. Rural communities are attempting to address these problems by developing the HIV care capacity of existing clinics, building local networks of physicians with HIV management experience, and cultivating "shared care" arrangements with urban-based specialists.
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Mathews WC, Cole J, Ballard C, Colwell B, Haubrich R, Barber E, Lew T. Early adoption of HIV-1 resistance testing in the San Diego County Ryan White CARE Act Program: predictors and outcome. AIDS Patient Care STDS 2002; 16:337-48. [PMID: 12214573 DOI: 10.1089/108729102320231171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This research identifies predictors and outcomes of early use of human immunodeficiency virus type 1 (HIV-1) resistance testing in the San Diego County Ryan White CARE Act program. Between January and November 2000, 98 patients receiving care in 7 clinics participated in the resistance testing program. Provider characteristics predictive of participation included number of patients and percent of practice devoted to HIV care and number of HIV-related continuing medical education hours over the preceding 12 months. Providers rarely requested expert panel review of test results, and expert review was not predictive of better viral load responses. Regimens specified before knowledge of resistance results had more active drugs than those prescribed after knowledge of test results. Phenotypic susceptibility was predictive of virologic response, as was degree of prior nucleoside analogue exposure. There was little relationship between phenotypic susceptibility and a clinician's decision to prescribe a drug. Early adopters of this technology were more experienced HIV providers than their colleagues and utilized susceptibility information using reasoning processes in which resistance was a contributory but not necessarily dominating factor.
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Hospital and outpatient health services utilization among HIV-infected patients in care in 1999. J Acquir Immune Defic Syndr 2002; 30:21-6. [PMID: 12048359 DOI: 10.1097/00126334-200205010-00003] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The evolving epidemiology and therapeutic management of HIV disease has important implications for health care resource utilization in HIV-infected patients, and health care resource use data are also needed to support policy and financial decision making. METHODS Demographic, clinical, and resource utilization data were collected from 9 U.S. HIV primary and specialty care sites in calendar year 1999. Rates of resource use were calculated for hospital admission, length of hospital stay, and outpatient clinic/office visits. RESULTS The sample included 5255 patients from HIV primary care sites in 3 eastern, 3 midwestern, and 3 western areas of the United States. Hospital admissions accounted for an annual mean of 297 days per 100 persons/y in 1999. Hospital days ranged from a low of 165 per 100 persons/mo for a CD4 > 500 cells/mm(3) to 840 per 100 persons/mo for a CD4 < 50 cells/mm(3) (p <.01). Mean annual outpatient clinic/office visits were 10.7 per person in 1999. A declining CD4 level and an increasing HIV-1 RNA level were both associated with higher hospital and outpatient utilization. HAART use was associated with fewer hospital days, and a higher outpatient visit rate. Injecting drug use risk was associated with an increase in hospital days. African American race was associated with a higher number of hospital days, but a lower outpatient visit rate. Female gender was associated with higher outpatient utilization. Mean monthly inpatient and outpatient expenditures in 1999 were $423 and $168, respectively. CONCLUSION As HIV care continues to evolve, data from our network of HIV providers will be useful in quantifying changes in HIV health services utilization to guide policy makers, as well as HIV care payers and providers.
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McKinney MM, Marconi KM. Delivering HIV services to vulnerable populations: a review of CARE Act-funded research. Public Health Rep 2002; 117:99-113. [PMID: 12356994 PMCID: PMC1497418 DOI: 10.1093/phr/117.2.99] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This article summarizes key findings from evaluation and research studies that have received financial support from the HIV/AIDS Bureau of the Health Resources and Services Administration or from Ryan White Comprehensive AIDS Resources Emergency (CARE) Act grantees. These studies suggest that the CARE Act has improved but not equalized service accessibility, quality, and outcomes for different populations living with HIV disease. Evaluations of access to highly active antiretroviral therapy (HAART) found that uninsured patients, women, people of color, and injection drug users waited much longer than others to receive the new therapies. These disparities were not uniform across study sites, suggesting that clinic characteristics and geographic location have a major influence on prescribing patterns. Once patients gained access to HAART, health insurance status made little difference in clinical outcomes.
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Cohn SE, Berk ML, Berry SH, Duan N, Frankel MR, Klein JD, McKinney MM, Rastegar A, Smith S, Shapiro MF, Bozzette SA. The care of HIV-infected adults in rural areas of the United States. J Acquir Immune Defic Syndr 2001; 28:385-92. [PMID: 11707677 DOI: 10.1097/00126334-200112010-00013] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. METHODS Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States. RESULTS We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006). CONCLUSIONS Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.
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Affiliation(s)
- S E Cohn
- University of Rochester, Rochester, New York, USA.
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