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Wilson IB, Cole MB, Lee Y, Shireman TI, Justice AC, Rahman M. The relationship of age and comorbid conditions to hospital and nursing home days in Medicaid recipients with HIV. AIDS 2024; 38:993-1001. [PMID: 38411618 PMCID: PMC11062810 DOI: 10.1097/qad.0000000000003870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/30/2024] [Accepted: 02/12/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To determine how aging impacts healthcare utilization in persons with HIV (PWH) compared with persons without HIV (PWoH). DESIGN Matched case-control study. METHODS We studied Medicaid recipients in the United States, aged 18-64 years, from 2001 to 2012. We matched each of 270 074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth. RESULTS We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for female and male individuals, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for female individuals and 0.4 extra days for male individuals. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55 years, this represents an 81% increase in the nursing home DPM for male individuals, and a 110% increase for female individuals, compared PWoH. CONCLUSION Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared with PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.
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Affiliation(s)
- Ira B. Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Megan B. Cole
- Department of Health Law, Policy, & Management, Boston University School of Public Health, Boston, MA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Theresa I. Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Amy C. Justice
- Schools of Medicine and Public Health, Yale University; Veterans Affairs Connecticut Healthcare System, New Haven, CT, USA
| | - Momotazur Rahman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
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Frey E, Johnston CD, Siegler EL. Treatment Regimens and Care Models for Older Patients Living with HIV: Are We Doing Enough? HIV AIDS (Auckl) 2023; 15:191-208. [PMID: 37153650 PMCID: PMC10155713 DOI: 10.2147/hiv.s311613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023] Open
Abstract
With improved access to antiretroviral therapy throughout the world, people are aging with HIV, and a large portion of the global population of people with HIV (PWH) is now age 50 or older. Older PWH experience more comorbidities, aging-related syndromes, mental health challenges, and difficulties accessing fundamental needs than the population of older adults without HIV. As a result, ensuring that older PWH are receiving comprehensive healthcare can often be overwhelming for both PWH and the providers. Although there is a growing literature addressing the needs of this population, gaps remain in care delivery and research. In this paper, we suggest seven key components to any healthcare program designed to address the needs of older people with HIV: management of HIV, comorbidity screening and treatment, primary care coordination and planning, attention to aging related-syndromes, optimization of functional status, support of behavioral health, and improved access to basic needs and services. We review many of the difficulties and controversies related to the implementation of these components, which include the absence of screening guidelines for this population and the challenges of care integration, and we suggest key next steps.
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Affiliation(s)
- Emily Frey
- Department of Medicine, Weill Cornell/New York Presbyterian Hospital, New York, NY, USA
- Correspondence: Emily Frey, Department of Medicine, Weill Cornell Medicine, 505 East 70th Street, New York, NY, 10021, USA, Tel +1 212 746 4749, Fax +1 212 746 4609, Email
| | - Carrie D Johnston
- Division of Infectious Diseases, Weill Cornell Medicine, New York, NY, USA
| | - Eugenia L Siegler
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, New York, NY, USA
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Olivieri-Mui B, Shi S, McCarthy EP, Montano M, Wilson I, Oh G, Manjourides J, Kim DH. Categorizing Comorbid Risk for People Living With HIV: A Latent Profile Analysis. J Acquir Immune Defic Syndr 2022; 90:449-455. [PMID: 35413021 PMCID: PMC9248847 DOI: 10.1097/qai.0000000000002999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Categorizing clinical risk amidst heterogeneous multimorbidity in older people living with HIV/AIDS (PLWH) may help prioritize and optimize health care engagements. METHODS PLWH and their prevalent conditions in 8 health domains diagnosed before January 1, 2015 were identified using 2014-2016 Medicare claims and the Chronic Conditions Data Warehouse. Latent profile analysis identified 4 distinct clinical subgroups based on the likelihood of conditions occurring together [G1: healthy, G2: substance use (SU), G3: pulmonary (PULM), G4: cardiovascular conditions (CV)]. Restricted mean survival time regression estimated the association of each subgroup with the 365 day mean event-free days until death, first hospitalization, and nursing home admission. Zero-inflated Poisson regression estimated hospitalization frequency in 2-year follow-up. RESULTS Of 11,196 older PLWH, 71% were male, and the average age was 61 (SD 9.2) years. Compared with healthy group, SU group had a mean of 30 [95% confidence interval: (19.0 to 40.5)], PULM group had a mean of 28 (22.1 to 34.5), and CV group had a mean of 22 (15.0 to 22.0) fewer hospitalization-free days over 1 year. Compared with healthy group (2.8 deaths/100 person-years), CV group (8.4) had a mean of 4 (3.8 to 6.8) and PULM group (7.9) had a mean of 3 (0.7 to 5.5) fewer days alive; SU group (6.0) was not different. There was no difference in restricted mean survival time for nursing home admission. Compared with healthy group, SU group had 1.42-fold [95% confidence interval: (1.32 to 1.54)], PULM group had 1.71-fold (1.61 to 1.81), and CV group had 1.28-fold (1.20 to 1.37) higher rates of hospitalization. CONCLUSION Identifying clinically distinct subgroups with latent profile analysis may be useful to identify targets for interventions and health care optimization in older PLWH.
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Affiliation(s)
- Brianne Olivieri-Mui
- The Roux Inst and Department of Health Sciences, Northeastern University
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School
| | - Sandra Shi
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School
| | - Ellen P. McCarthy
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School
| | - Monty Montano
- Brigham and Women’s Hospital, Harvard Medical School
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health
| | - Gahee Oh
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School
| | - Justin Manjourides
- The Roux Inst and Department of Health Sciences, Northeastern University
| | - Dae Hyun Kim
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School
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Zhang T, Shireman TI, Meyers DJ, Zullo A, Lee Y, Wilson IB. Use of antiretroviral therapy in nursing home residents with HIV. J Am Geriatr Soc 2022; 70:1800-1806. [PMID: 35332518 PMCID: PMC10103632 DOI: 10.1111/jgs.17763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antiretroviral therapies (ARTs) are essential HIV care. As people living with HIV age and their presence in nursing homes (NHs) increases, it is critical to evaluate the quality of HIV care. We determine the rate of ART use and examine individual- and facility-level characteristics associated with no ART use in a nationally representative long-stay NH residents with HIV. METHODS This retrospective cohort study included all long-stay Medicare fee-for-service NH residents (2013-2016) with HIV who had a valid Minimum Data Set assessment. Residents were followed from long-stay qualification until death, Part D disenrollment, transfer from long-term care to another healthcare setting, or December 31, 2016. We identified individual and facility characteristics that were associated with non-use of ART using generalized estimating equation logistic regression. RESULTS Exactly 4171 eligible HIV+ residents from 2459 NHs were included in our study. Only 36% (1507 of 4171) received any ART regimen during an average of 11.6 months of observation. Older age, females, white race, receipt of Medicare skilled nursing benefits, and some major cardiometabolic comorbidities and mental health conditions were associated with non-ART use. Rates of non-ART use did not vary significantly by residents' end-of-life status (p = 0.21). Residents in facilities with a higher HIV concentration [adjusted odds ratio (adjOR) 3.42; 95% confidence interval (CI) 2.13-5.48] and an AIDS unit (adjOR 2.51; 95% CI 1.92-3.30) had higher odds of using an ART. CONCLUSIONS AND IMPLICATIONS The rate of ART use by HIV+ long-stay NH residents was low. Facilities' experience with HIV played an important role in ART receipt. Interventions to improve rates of ART use in NHs are urgently needed to ensure optimal health outcomes.
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Affiliation(s)
- Tingting Zhang
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Theresa I Shireman
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - David J Meyers
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew Zullo
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Yoojin Lee
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Ira B Wilson
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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Olivieri-Mui B, McGuire J, Griffith J, Cahill S, Briesacher B. Exploring the Association Between the Quality of HIV Care in Nursing Homes and Hospitalization. J Healthc Qual 2021; 43:174-182. [PMID: 32658007 PMCID: PMC7790902 DOI: 10.1097/jhq.0000000000000277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Persons living with HIV/AIDS (PLWH) are living long enough to need age-related and HIV-related nursing home (NH) care. Nursing home quality of care has been associated with risk for hospitalization, but it is unknown if quality of HIV care in NHs affects hospitalization in this population. We assessed HIV care quality with four national measures adapted for the NH setting. We applied the measures to 2011-2013 Medicare claims linked to Minimum Data Set assessments of resident health, prescription dispensing data, and national reports of NH characteristics. Cox proportional hazards models calculated the risk of all-cause and HIV/AIDS-related hospitalization by HIV care compliance. We identified 1,246 PLWH in 201 NHs with 382 all-cause and 63 HIV/AIDS-related hospitalizations. Nursing home HIV care compliance varied from 24.9% to 64.7%. After regression adjustment, we could detect no difference in all-cause or HIV/AIDS-related hospitalizations by NH HIV care compliance. We postulate that the lack of association may be due to inappropriate HIV care quality measures that do not accurately represent NHs ability to care for PLWH. There is urgent need to create valid NH HIV care quality measures.
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Olivieri-Mui BL, Koethe B, Briesacher B. Economic Barriers to Antiretroviral Therapy in Nursing Homes. J Am Geriatr Soc 2020; 68:777-782. [PMID: 31829445 PMCID: PMC7578773 DOI: 10.1111/jgs.16288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/18/2019] [Accepted: 11/20/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Our aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). Medicare Part A pays NHs a bundled skilled nursing rate that includes prescription drugs for up to 100 days, after which individuals are responsible for the costs. DESIGN A cross-sectional study. SETTING NHs. PARTICIPANTS A total of 694 newly admitted long-stay (>100 d) NH residents with HIV. MEASUREMENTS We used Minimum Dataset v.3.0, pharmacy dispensing data, NH provider surveys, and Medicare claims from 2011 to 2013. We assessed receipt of any HIV antiretrovirals or recommended combinations (ART), as defined by national care guidelines, and the source of payment. We identified predictors of antiretroviral use with risk-adjusted generalized estimating equation logistic models. RESULTS All study persons living with HIV/AIDS in NHs had prescription drug coverage through Medicare's Part D program, and ART was 100% covered. However, only 63.9% received recommended ART, and 15.2% never received any antiretrovirals during their NH stay. The strongest predictor of not receiving antiretrovirals was the first 100 days of a long NH stay (odds ratio [OR] = .44; 95% confidence interval [CI] = .24-.80). The strongest predictor of receiving recommended ART was health acuity (OR = 1.51; 95% CI = 1.20-1.88). CONCLUSION People living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers. J Am Geriatr Soc 68:777-782, 2020.
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Affiliation(s)
- Brianne L Olivieri-Mui
- The Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Benjamin Koethe
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
| | - Becky Briesacher
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
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Olivieri-Mui B, McGuire J, Griffith J, Cahill S, Briesacher B. Assessing the Quality of Human Immunodeficiency Virus Care in Nursing Homes. J Am Geriatr Soc 2020; 68:1226-1234. [PMID: 32052860 DOI: 10.1111/jgs.16359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Quality of human immunodeficiency virus (HIV) care in nursing homes (NHs) has never been measured. DESIGN A cross-sectional study. SETTING NHs. PARTICIPANTS A total of 203 NHs and 1375 persons living with HIV. MEASUREMENTS Medicare claims from 2011 to 2013 were linked to assessments of resident health, prescription dispensing data, and national reports of NH characteristics. Five nationally validated HIV care quality measures (prescription of antiretroviral therapy; CD4/viral load monitoring; frequency of medical visits; gaps in medical visits; and Pneumocystis pneumonia prophylaxis) were adapted and applied to NHs. Logistic regression predicted compliance by organizational factors. Random intercept logistic regression predicted if persons living with HIV received care by person and organizational factors. RESULTS Compliance ranged from 43.3% (SD = 31.1%) for CD4/viral load monitoring to 92.4% (SD = 13.6%) for gaps in medical visits. More substantiated complaints against an NH decreased the likelihood of high compliance with CD4/viral load monitoring (odds ratio [OR] = 0.846; 95% confidence interval [CI] = 0.726-0.986), while NH-reported incidents increased the likelihood of high compliance with pneumocystis pneumonia prophylaxis (OR = 1.173; 95% CI = 1.044-1.317). Differences between NHs explained 21.2% or less of variability in receipt of care. CONCLUSIONS Since 2013, the population with HIV and NH HIV care quality has inevitably evolved; however, this study provides previously unknown baseline metrics on NH HIV care quality and highlights significant challenges when measuring HIV care in NHs. J Am Geriatr Soc 68:1226-1234, 2020.
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Affiliation(s)
- Brianne Olivieri-Mui
- The Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Jean McGuire
- Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | - John Griffith
- Department of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Sean Cahill
- Department of Health Sciences, Northeastern University, Boston, Massachusetts.,The Fenway Institute, Fenway Health, Boston, Massachusetts
| | - Becky Briesacher
- Department of Pharmacy and Health Systems Sciences, Northeastern University, Boston, Massachusetts
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Justice AC, Akgün KM. What Does Aging with HIV Mean for Nursing Homes? J Am Geriatr Soc 2019; 67:1327-1329. [PMID: 31063666 PMCID: PMC6612581 DOI: 10.1111/jgs.15950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/27/2019] [Indexed: 12/17/2022]
Abstract
This editorial comments on the article by Miller et al.
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Affiliation(s)
- Amy C. Justice
- Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Kathleen M. Akgün
- Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Access to HIV Medication in the Community Versus a Nursing Home for the Medicare Eligible HIV population. Dela J Public Health 2019; 5:74-79. [PMID: 34467032 PMCID: PMC8396749 DOI: 10.32481/djph.2019.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Access to appropriate antiretroviral therapy (ART) is key to people living with HIV/AIDS (PLWH) living a near normal life time, which has resulted in increasing numbers of PLWH requiring nursing home care for age-related reasons. However, one study found that 21% of Medicare eligible PLWH in US nursing homes between 2011 and 2013 were not dispensed ART through the nursing home pharmacy. Cost-sharing assistance programs exist to facilitate access to medications for low-income community dwelling older adults, but these programs do not necessarily extend to people admitted to a nursing home, which may cause interruptions in access to ART for PLWH in this setting. Policies may need to be updated to reduce drug-related financial burden to PLWH and nursing homes in order to maintain continued access to ART in the nursing home setting.
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