Readmissions in HIV-Infected Inpatients: A Large Cohort Analysis

Human immunodeficiency virus infection is associated with greater risk of pneumonia and readmission after cardiac surgery

Objective

Human immunodeficiency virus infection (HIV+) is associated with a 2-fold increased risk of cardiovascular disease. Increasingly, patients who are HIV + are being evaluated to undergo cardiac surgery. Current risk-adjusted scoring systems, including the Society of Thoracic Surgeons Predicted Risk of Mortality score, fail to stratify HIV + risk. Unfortunately, there exists a paucity of cardiac surgery outcomes data in modern patients who are HIV+.

Methods

We conducted a retrospective review of PearlDiver, an all-payer claims administrative database. In total, 14,714,743 patients were captured between 2010 and 2020. Of these, 59,695 (0.4%) of patients had a history of HIV+, and 1759 (2.95%) of these patients underwent cardiac surgery. Patients who were HIV+ were younger, more often male, and had greater comorbidity, history of hypertension, chronic obstructive pulmonary disease, chronic liver disease, chronic kidney disease, chronic lung disease, and heart failure.

Results

Postoperatively, patients who were HIV + had significantly greater rates of pneumonia (relative risk, 1.70; P = .0003) and 30-day all-cause readmission (relative risk, 1.28, P < .0001). After linear regression analysis, these results remained significant. Data also show that a lesser proportion of patients with HIV + underwent coronary artery bypass grafting, aortic valve replacement, and any cardiac surgery compared with controls.

Conclusions

Patients who are HIV + undergoing cardiac surgery are at greater risk of pneumonia and readmission. Moreover, we discovered lower rates of cardiac surgery in patients who are HIV+, which may reflect limited access to surgery when indicated. Today's risk-adjusted scoring systems in cardiac surgery need to better account for the modern patient who is HIV+.

Hospital Readmissions Among Persons With Human Immunodeficiency Virus in the United States and Canada, 2005-2018: A Collaboration of Cohort Studies

BACKGROUND

Hospital readmission trends for persons with human immunodeficiency virus (PWH) in North America in the context of policy changes, improved antiretroviral therapy (ART), and aging are not well-known. We examined readmissions during 2005-2018 among adult PWH in NA-ACCORD.

METHODS

Linear risk regression estimated calendar trends in 30-day readmissions, adjusted for demographics, CD4 count, AIDS history, virologic suppression (<400 copies/mL), and cohort.

RESULTS

We examined 20 189 hospitalizations among 8823 PWH (73% cisgender men, 38% White, 38% Black). PWH hospitalized in 2018 versus 2005 had higher median age (54 vs 44 years), CD4 count (469 vs 274 cells/μL), and virologic suppression (83% vs 49%). Unadjusted 30-day readmissions decreased from 20.1% (95% confidence interval [CI], 17.9%-22.3%) in 2005 to 16.3% (95% CI, 14.1%-18.5%) in 2018. Absolute annual trends were -0.34% (95% CI, -.48% to -.19%) in unadjusted and -0.19% (95% CI, -.35% to -.02%) in adjusted analyses. By index hospitalization reason, there were significant adjusted decreases only for cardiovascular and psychiatric hospitalizations. Readmission reason was most frequently in the same diagnostic category as the index hospitalization.

CONCLUSIONS

Readmissions decreased over 2005-2018 but remained higher than the general population's. Significant decreases after adjusting for CD4 count and virologic suppression suggest that factors alongside improved ART contributed to lower readmissions. Efforts are needed to further prevent readmissions in PWH.

Risk factors associated with 30-day hospital readmissions among persons living with HIV in Nantong, China

OBJECTIVE

To estimate 30-day hospital readmission rates among persons living with HIV (PLWH) at the Nantong Infectious Disease Hospital in China and analyse the related risk factors.

METHODS

A single-centre retrospective cohort study was conducted. There were 894 PLWH records obtained from the electronic medical record (EMR) system at the Nantong Infectious Disease Hospital in China, from October 2013 to February 2018. The 30-day readmission rates were calculated, and the risk factors were analysed by generalised estimating equations (GEEs).

RESULTS

A total of 1153 hospitalizations from 894 patients were recorded between October 2013 and February 2018. The median time of 30-day readmissions was 13 days (interquartile range (IQR), 6-23). The reasons for all causes, acquired immunodeficiency syndrome (AIDS)-defining illnesses (ADIs), and non-AIDS-defining infections (non-ADIs) were 9.08, 13.52, and 7.91%, respectively. The results from the GEE analysis demonstrated that the risk factors associated with 30-days readmissions were as follows: no antiretroviral therapy (ART) prior to hospitalisations (odds ratio (OR) = 1.90, 95% confidence interval (CI): 1.21-3.00), low CD4 counts (OR = 2.17, 95% CI: 1.33-3.54), and multiple comorbidities (OR = 6.45, 95% CI: 1.62-25.73).

CONCLUSION

Early detection of HIV infection and early initiation of ART treatment are the keys to controlling 30-day readmissions.

A Multicomponent Intervention to Reduce Readmissions Among People With HIV

BACKGROUND

Hospital readmissions are common, costly, and potentially preventable, including among people with HIV (PWH). We present the results of an evaluation of a multicomponent intervention aimed at reducing 30-day readmissions among PWH.

METHODS

Demographic, socioeconomic, and clinical variables were collected from the electronic health records of PWH or those with cellulitis (control group) hospitalized at an urban safety-net hospital before and after (from September 2012 to December 2016) the implementation of a multidisciplinary HIV transitional care team. After October 2014, hospitalized PWH could receive a medical HIV consultation ± a transitional care nurse intervention. The primary outcome was readmission to any hospital within 30 days of discharge. Multivariate logistic regression and propensity score analyses were conducted to compare readmissions before and after intervention implementation in PWH and people with cellulitis.

RESULTS

Overall, among PWH, 329 of the 2049 (16.1%) readmissions occurred before and 329 of the 2023 (16.3%) occurred after the transitional care team intervention. After including clinical and social predictors, the adjusted odds ratio of 30-day readmissions for postintervention for PWH was 0.81 (95% confidence interval: 0.66 to 0.99, P= 0.04), whereas little reduction was identified for those with cellulitis (adjusted odds ratio 0.91 (95% confidence interval: 0.81 to 1.02, P= 0.10). A dose-response effect was not observed for receipt of different HIV intervention components.

CONCLUSIONS

A multicomponent intervention reduced the adjusted risk of 30-day readmissions in PWH, although no dose-response effect was detected. Additional efforts are needed to reduce overall hospitalizations and readmissions among PWH including increasing HIV prevention, early diagnosis and engagement in care, and expanding the availability and spectrum of transitional care services.

Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis

Background

The identification and appropriate management of people with advanced HIV disease is a key component in the HIV response. People with HIV who are hospitalised are at a higher risk of death, a risk that might persist after discharge. The aims of this study were to estimate the frequency of negative post-discharge outcomes, and to determine risk factors for such outcomes in people with HIV.

Methods

Using a broad search strategy combining terms for hospital discharge and HIV infection, we searched MEDLINE via PubMed and Embase from Jan 1, 2003 to Nov 30, 2021 to identify studies reporting outcomes among people with HIV following discharge from hospital. We estimated pooled proportions of readmissions and deaths after hospital discharge using random-effects models. We also did subgroup analyses by setting, region, duration of follow-up, and advanced HIV status at admission, and sensitivity analyses to assess heterogeneity.

Findings

We obtained data from 29 cohorts, which reported outcomes of people living with HIV after hospital discharge in 92 781 patients. The pooled proportion of patients readmitted to hospital after discharge was 18·8% (95% CI 15·3–22·3) and 14·1% (10·8–17·3) died post-discharge. In sensitivity analyses, no differences were identified in the proportion of patients who were readmitted or died when comparing studies published before 2016 with those published after 2016. Post-discharge mortality was higher in studies from Africa (23·1% [16·5–29·7]) compared with the USA (7·5% [4·4–10·6]). For studies that reported both post-discharge mortality and readmission, the pooled proportion of patients who had this composite adverse outcome was 31·7% (23·9–39·5). Heterogeneity was moderate, and largely explained by patient status and linkage to care. Reported risk factors for readmission included low CD4 cell count at admission, longer length of stay, discharge against medical advice, and not linking to care following discharge; inpatient treatment with antiretroviral therapy (ART) during hospitalisation was protective of post-discharge mortality.

Interpretation

More than a quarter of patients with HIV had an adverse outcome after hospital discharge with no evidence of improvement in the past 15 years. This systematic review highlights the importance of ensuring post-discharge referral and appropriate management, including ART, to reduce mortality and readmission to hospital among this group of high-risk patients.

Funding

Bill & Melinda Gates Foundation.

Translations

For the French and Spanish translations of the abstract see Supplementary Materials section.

CD4+ cell count and outcomes among HIV-infected compared with uninfected medical ICU survivors in a national cohort

BACKGROUND

People with HIV (PWH) with access to antiretroviral therapy (ART) experience excess morbidity and mortality compared with uninfected patients, particularly those with persistent viremia and without CD4+ cell recovery. We compared outcomes for medical intensive care unit (MICU) survivors with unsuppressed (>500 copies/ml) and suppressed (≤500 copies/ml) HIV-1 RNA and HIV-uninfected survivors, adjusting for CD4+ cell count.

SETTING

We studied 4537 PWH [unsuppressed = 38%; suppressed = 62%; 72% Veterans Affairs-based (VA) and 10 531 (64% VA) uninfected Veterans who survived MICU admission after entering the Veterans Aging Cohort Study (VACS) between fiscal years 2001 and 2015.

METHODS

Primary outcomes were all-cause 30-day and 6-month readmission and mortality, adjusted for demographics, CD4+ cell category (≥350 (reference); 200-349; 50-199; <50), comorbidity and prior healthcare utilization using proportional hazards models. We also adjusted for severity of illness using discharge VACS Index (VI) 2.0 among VA-based survivors.

RESULTS

In adjusted models, CD4+ categories <350 cells/μl were associated with increased risk for both outcomes up to 6 months, and risk increased with lower CD4+ categories (e.g. 6-month mortality CD4+ 200-349 hazard ratio [HR] = 1.35 [1.12-1.63]; CD4+ <50 HR = 2.14 [1.72-2.66]); unsuppressed status was not associated with outcomes. After adjusting for VI in models stratified by HIV, VI quintiles were strongly associated with both outcomes at both time points.

CONCLUSION

PWH who survive MICU admissions are at increased risk for worse outcomes compared with uninfected, especially those without CD4+ cell recovery. Severity of illness at discharge is the strongest predictor for outcomes regardless of HIV status. Strategies including intensive case management for HIV-specific and general organ dysfunction may improve outcomes for MICU survivors.

Toxoplasmosis Encephalitis: A Cross-Sectional Analysis at a U.S. Safety-Net Hospital in the Late cART Era

Despite decreasing incidence of toxoplasmosis encephalitis(TE) among people living with HIV(PLWH) in the late antiretroviral era, U.S. safety-net hospitals still see significant numbers of admissions for TE. Little is known about this population, their healthcare utilization and long-term outcomes. We conducted an 8-year retrospective review of PLWH with TE at a safety-net hospital. Demographics, clinical characteristics, treatments, readmissions, and outcomes were collected. We used chi-squared test to evaluate 6-month all-cause readmission and demographic/clinical characteristics. Of 38 patients identified, 79% and 40% had a new diagnosis of TE and HIV respectively. 59% had 6-month all-cause readmission. Social factors were associated with readmission (uninsured (p = 0.036), Spanish as primary language (p = 0.017), non-adherence (p = 0.030)) and not markers of clinical severity (ICU admission, steroid-use, concomitant infections, therapeutic adverse events). Despite high readmission rates, at follow-up, 60% had a complete response, 30% had a partial response. Improving TE outcomes requires focus on culturally competent, coordinated care.

Hospitalization Rates and Outcomes Among Persons Living With Human Immunodeficiency Virus in the Southeastern United States, 1996-2016

BACKGROUND

Antiretroviral therapy (ART) advances, aging, and comorbidities impact hospitalizations in human immunodeficiency virus (HIV)-positive populations. We examined temporal trends and patient characteristics associated with hospitalization rates and outcomes.

METHODS

Among patients in the University of North Carolina Center for AIDS Research HIV Clinical Cohort receiving care during 1996-2016, we estimated annual hospitalization rates, time to inpatient mortality or live discharge, and 30-day readmission risk using bivariable Poisson, Fine-Gray, and log-binomial regression models.

RESULTS

The 4323 included patients (29% women, 60% African American) contributed 30 007 person-years. Overall, the hospitalization rate per 100 person-years was 34.3 (95% confidence interval [CI], 32.4-36.4) with a mean annual change of -3% (95% CI, -4% to -2%). Patients who were black (vs white), older, had HIV RNA >400 copies/mL, or had CD4 count <200 cells/μL had higher hospitalization rates (all P < .05). Thirty-day readmission risk was 18.9% (95% CI, 17.7%-20.2%), stable over time (P > .05 for both 2010-2016 and 2003-2009 vs 1996-2002), and higher among black patients, those with detectable HIV RNA, and those with lower CD4 cell counts (all P < .05). Higher inpatient mortality was associated with older age and lower CD4 cell count (both P < .05).

CONCLUSIONS

Hospitalization rates decreased from 1996 to 2016, but high readmissions persisted. Older patients, those of minority race/ethnicity, and those with uncontrolled HIV experienced higher rates and worse hospitalization outcomes. These findings underscore the importance of early ART and care engagement, particularly at hospital discharge.

Severe mental illness and health service utilisation for nonpsychiatric medical disorders: A systematic review and meta-analysis

BACKGROUND

Psychiatric comorbidity is known to impact upon use of nonpsychiatric health services. The aim of this systematic review and meta-analysis was to assess the specific impact of severe mental illness (SMI) on the use of inpatient, emergency, and primary care services for nonpsychiatric medical disorders.

METHODS AND FINDINGS

PubMed, Web of Science, PsychINFO, EMBASE, and The Cochrane Library were searched for relevant studies up to October 2018. An updated search was carried out up to the end of February 2020. Studies were included if they assessed the impact of SMI on nonpsychiatric inpatient, emergency, and primary care service use in adults. Study designs eligible for review included observational cohort and case-control studies and randomised controlled trials. Random-effects meta-analyses of the effect of SMI on inpatient admissions, length of hospital stay, 30-day hospital readmission rates, and emergency department use were performed. This review protocol is registered in PROSPERO (CRD42019119516). Seventy-four studies were eligible for review. All were observational cohort or case-control studies carried out in high-income countries. Sample sizes ranged from 27 to 10,777,210. Study quality was assessed using the Newcastle-Ottawa Scale for observational studies. The majority of studies (n = 45) were deemed to be of good quality. Narrative analysis showed that SMI led to increases in use of inpatient, emergency, and primary care services. Meta-analyses revealed that patients with SMI were more likely to be admitted as nonpsychiatric inpatients (pooled odds ratio [OR] = 1.84, 95% confidence interval [CI] 1.21-2.80, p = 0.005, I2 = 100%), had hospital stays that were increased by 0.59 days (pooled standardised mean difference = 0.59 days, 95% CI 0.36-0.83, p < 0.001, I2 = 100%), were more likely to be readmitted to hospital within 30 days (pooled OR = 1.37, 95% CI 1.28-1.47, p < 0.001, I2 = 83%), and were more likely to attend the emergency department (pooled OR = 1.97, 95% CI 1.41-2.76, p < 0.001, I2 = 99%) compared to patients without SMI. Study limitations include considerable heterogeneity across studies, meaning that results of meta-analyses should be interpreted with caution, and the fact that it was not always possible to determine whether service use outcomes definitively excluded mental health treatment.

CONCLUSIONS

In this study, we found that SMI impacts significantly upon the use of nonpsychiatric health services. Illustrating and quantifying this helps to build a case for and guide the delivery of system-wide integration of mental and physical health services.

Patient and Provider Perspectives on 30-Day Readmissions, Preventability, and Strategies for Improving Transitions of Care for Patients with HIV at a Safety Net Hospital

Thirty-day hospital readmissions, a key quality metric, are common among people living with HIV. We assessed perceived causes of 30-day readmissions, factors associated with preventability, and strategies to reduce preventable readmissions and improve continuity of care for HIV-positive individuals. Patient, provider, and staff perspectives toward 30-day readmissions were evaluated in semistructured interviews (n = 86) conducted in triads (HIV-positive patient, medical provider, and case manager) recruited from an inpatient safety net hospital. Iterative analysis included both deductive and inductive themes. Key findings include the following: (1) The 30-day metric should be adjusted for safety net institutions and patients with AIDS; (2) Participants disagreed about preventability, especially regarding patient-level factors; (3) Various stakeholders proposed readmission reduction strategies that spanned the inpatient to outpatient care continuum. Based on these diverse perspectives, we outline multiple interventions, from teach-back patient education to postdischarge home visits, which could substantially decrease hospital readmissions in this underserved population.

Risk of Readmission Among HIV Patients in Public Portuguese Hospitals: Longitudinal Multilevel Population-Based Study

Background: Thirty-day hospital readmission is receiving growing attention as an indicator of the quality of hospital care. Understanding factors associated with 30-day hospital readmission among HIV patients in Portugal is essential given the high burden cost of HIV hospitalizations in Portugal, a country suffering from financial constrains for almost 10 years. Objectives: We aimed to estimate the 30-day hospital readmission rates among HIV patients in Portugal and to identify its determinants using population-based data for Portuguese public hospitals. Study Design: A multilevel longitudinal population-based study. Methods: Between January 2009 and December 2014, a total of 37,134 registered discharges in the Portuguese National Health Service (NHS) facilities with HIV/AIDS as a main or secondary cause of admission were analyzed. Logistic regression was used to compare 30-day hospital readmission categories by computing odds ratio (OR) and corresponding 95% confidence intervals (95% CIs). A normal random effects model was used to determine unmeasured factors specific to each hospital. Results: A total of 4914 (13.2%, 95% CI: 12.9%-13.6%) hospitalizations had a subsequent 30-day readmission. Hospitalizations that included exit against medical opinion (OR = 1.18, 95% CI: 1.01-1.39), scheduled admissions (OR = 1.71, 95% CI: 1.58-1.85), and tuberculosis infection (OR = 1.20, 95% CI: 1.05-1.38) exhibited a higher risk of hospitalizations with subsequent 30-day readmission. In contrast, hospitalizations that included females (OR = 0.87, 95% CI: 0.81-0.94), a transfer to another facility (OR = 0.78, 95% CI: 0.67-0.91), and having a responsible financial institution (OR = 0.63, 95% CI: 0.55-0.72) exhibited a lower risk of hospitalizations with subsequent 30-day readmission. Hospitalizations associated with higher number of diagnosis, older ages, or hospitalizations during the economic crisis showed an increasing trend of 30-day readmission, whereas an opposite trend was observed for hospitalizations with higher number of procedures. Significant differences exist between hospital quality, adjusting for other factors. Conclusion: This study analyzes the indicators of 30-day hospital readmission among HIV patients in Portugal and provides useful information for enlightening policymakers and health care providers for developing health policies that can reduce costs associated with HIV hospitalizations.

Clinical and Sociobehavioral Prediction Model of 30-Day Hospital Readmissions Among People With HIV and Substance Use Disorder: Beyond Electronic Health Record Data

BACKGROUND

Under the Affordable Care Act, hospitals receive reduced reimbursements for excessive 30-day readmissions. However, the Centers for Medicare and Medicaid Services does not consider social and behavioral variables in expected readmission rate calculations, which may unfairly penalize systems caring for socially disadvantaged patients, including patients with HIV.

SETTING

Randomized controlled trial of patient navigation with or without financial incentives in HIV-positive substance users recruited from the inpatient setting at 11 US hospitals.

METHODS

External validation of an existing 30-day readmission prediction model, using variables available in the electronic health record (EHR-only model), in a new multicenter cohort of HIV-positive substance users was assessed by C-statistic and Hosmer-Lemeshow testing. A second model evaluated sociobehavioral factors in improving the prediction model (EHR-plus model) using multivariable regression and C-statistic with cross-validation.

RESULTS

The mean age of the cohort was 44.1 years, and participants were predominantly males (67.4%), non-white (88.0%), and poor (62.8%, <$20,000/year). Overall, 17.5% individuals had a hospital readmission within 30 days of initial hospital discharge. The EHR-only model resulted in a C-statistic of 0.65 (95% confidence interval: 0.60 to 0.70). Inclusion of additional sociobehavioral variables, food insecurity and readiness for substance use treatment, in the EHR-plus model resulted in a C-statistic of 0.74 (0.71 after cross-validation, 95% confidence interval: 0.64 to 0.77).

CONCLUSIONS

Incorporation of detailed social and behavioral variables substantially improved the performance of a 30-day readmission prediction model for hospitalized HIV-positive substance users. Our findings highlight the importance of social determinants in readmission risk and the need to ask about, adjust for, and address them.

Impact of Patient-Provider Attachment on Hospital Readmissions Among People Living With HIV: A Population-Based Study

BACKGROUND

Hospital readmission 30 days after discharge is associated with adverse health outcomes, and people living with HIV (PLWH) experience elevated rates of hospital readmission. Although continuity of care with a health care provider is associated with lower rates of 30-day readmission among the general population, little is known about this relationship among PLWH. The objective of this study is to examine whether engaging with the same provider, defined as patient-provider attachment, is associated with 30-day readmission for this population.

SETTING

Data were derived from the Seek and Treat for Optimal Prevention of HIV in British Columbia cohort.

METHODS

Using generalized estimating equation with a logit link function, we examined the association between patient-provider attachment and 30-day hospital readmission. We determined whether readmission was due to all cause or to a similar cause as the index admission.

RESULTS

Seven thousand thirteen PLWH were hospitalized during the study period. Nine hundred twenty-one (13.1%) were readmitted to hospital for all cause and 564 (8.0%) for the similar cause as the index admission. Patient-provider attachment was negatively associated with 30-day readmission for all causes (adjusted odds ratio = 0.85, confidence interval = 0.83 to 0.86). A second multivariable model indicated that patient-provider attachment was also negatively associated with 30-day readmission for a similar cause (adjusted odds ratio = 0.86, confidence interval = 0.84 to 0.88).

CONCLUSIONS

Our results indicate that a higher proportion of patient-provider attachment was negatively associated with 30-day hospital readmission among PLWH. Our study findings support the adoption of interventions that seek to build patient-provider relationships to optimize outcomes for PLWH and enhance health care sustainability.

Multimorbidity, not human immunodeficiency virus (HIV) markers predicts unplanned admission among people with HIV in regional New South Wales

BACKGROUND

Multimorbidity and unplanned admissions are common among people with human immunodeficiency virus (PWH).

AIMS

To determine factors predictive of unplanned admission among PWH in regional New South Wales and compare care coordination between people with and without unplanned admissions.

METHODS

A prospective cohort study of PWH attending a regional human immunodeficiency virus (HIV) service was conducted. Baseline HIV-specific results and multimorbidity markers including Cumulative Illness Rating Scale (CIRS) were assessed as predictors of time to first unplanned admission using Cox regression analysis. Care coordination markers were compared between people with and without unplanned admission, using χ² statistic for proportions and t-test for means.

RESULTS

A cohort of 181 PWH was followed for a maximum of 5 years. During a total of 739 person-years of follow up, 39 (20.6%) patients reached the endpoint of unplanned admission. In multivariate analysis, the baseline CIRS score was predictive of unplanned admission (P < 0.001). Age, HIV-specific markers and missed visits were not predictive of unplanned admission. For patients with an unplanned admission, discharge summaries were documented for 22/39 (56.4%). Of 180 PWH with a visit after baseline, 131 (72.8%) had a letter to a general practitioner and 79 (43.7%) had two or more prescribers. Having two or more prescribers was more common in people with an unplanned admission than in those without (64.1% vs 38.0%, P = 0.004).

CONCLUSION

Unplanned admission among PWH is predicted by multimorbidity. Care for PWH should include coordinated management of other health conditions in order to reduce their severity and prevent unplanned admissions.

The impact of HIV diagnosis on length of hospital stay in New York City, NY, USA

While hospitalizations among people living with human immunodeficiency virus (PLWH) have been elevated in the past compared to their uninfected counterparts, the introduction of antiretroviral therapy (ART) has resulted in great strides in controlling symptomatic infection. However, research largely overlooks important differences among HIV-infected individuals, primarily PLWH who are symptomatic versus those who are asymptomatic. We conducted a retrospective study assessing the length of hospital stay among 717,237 admissions from three hospitals in the New York City area. Using zero-truncated negative binomial regression we documented trends in length of hospital stay among individuals who are HIV positive (with symptoms versus those without symptoms) compared to HIV-negative patients over nine consecutive years, from 2006 to 2014. Approximately 0.85% of the admissions were infected with asymptomatic HIV (n = 6,131), while 1.43% of admissions were infected with symptomatic HIV (n = 10,271). The length of stay (LOS) among symptomatic HIV-infected admissions was 32.0% (95% CI: 29.7%-34.2%) longer than LOS in the general admissions. The mean LOS dropped about 1.5% (95% CI: 1.5%-1.6%) per year in the study sample. The LOS in inpatients with asymptomatic HIV had the same LOS as the general inpatient population. Our findings highlight the need for comprehensive strategies to reduce length of hospitalization among HIV-infected individuals.

Thirty-day Readmission Rates in an HIV-infected Cohort From Rio de Janeiro, Brazil

BACKGROUND

The 30-day readmission rate is an indicator of the quality of hospital care and transition to the outpatient setting. Recent studies suggest HIV infection might increase the risk of readmission although estimates of 30-day readmission rates are unavailable among HIV-infected individuals living in middle/low-income settings. Additionally, factors that may increase readmission risk in HIV-infected populations are poorly understood.

METHODS

Thirty-day readmission rates were estimated for HIV-infected adults from the Instituto Nacional de Infectologia Evandro Chagas/Fiocruz cohort in Rio de Janeiro, Brazil, from January 2007 to December 2013. Cox regression models were used to evaluate factors associated with the risk of 30-day readmission.

RESULTS

Between January 2007 and December 2013, 3991 patients were followed and 1861 hospitalizations were observed. The estimated 30-day readmission rate was 14% (95% confidence interval: 12.3 to 15.9). Attending a medical visit within 30 days after discharge (adjusted hazard ratio [aHR] = 0.73, P = 0.048) and being hospitalized in more recent calendar years (aHR = 0.89, P = 0.002) reduced the risk of 30-day readmission. In contrast, low CD4 counts (51-200 cells/mm³: aHR = 1.70, P = 0.024 and ≤ 50 cells/mm³: aHR = 2.05, P = 0.003), time since HIV infection diagnosis ≥10 years (aHR = 1.58, P = 0.058), and leaving hospital against medical advice (aHR = 2.67, P = 0.004) increased the risk of 30-day readmission.

CONCLUSIONS

Patients with advanced HIV/AIDS are most at risk of readmission and should be targeted with prevention strategies to reduce this risk. Efforts to reduce discharge against medical advice and to promote early postdischarge medical visit would likely reduce 30-day readmission rates in our population.

Relationship between HIV serostatus, CD4 count and rehospitalisation: Potential implications for health systems strengthening in South Africa

BACKGROUND

Despite three decades of scientific response to HIV/AIDS, the generalised HIV epidemic continues to persist in South Africa. There is growing acknowledgement that health system strengthening will be critical in tackling HIV/AIDS. Patient rehospitalisation is an important quality benchmark of health service delivery, but there is currently limited data on rehospitalisation of patients with HIV/AIDS in South Africa, a setting with a high burden of HIV disease.

OBJECTIVES

To determine the relationship between combined HIV serostatus and CD4 count, and rehospitalisation in South Africa.

METHODS

This study was a retrospective analysis of data from 11,362 non-surgical adult patients who attended the Hlabisa Hospital in South Africa. Data related to patient age, gender, HIV serostatus, CD4 count (for HIV-positive patients) and comorbidity were analysed through univariate (Fisher's Exact or χ2 tests) and multivariate (Cox regression) statistical methods to determine associations with rehospitalisation within 1 month (acute rehospitalisation) or 12 months (long term rehospitalisation).

RESULTS

An HIV-positive serostatus with CD4 count < 350 cells/mm3 or an HIV-positive serostatus with an unknown CD4 count were independently associated with a higher risk of acute (p = 0.010 and p = 0.003) and long term rehospitalisation (p < 0.001 for both categories) when compared with an HIV-negative serostatus group.

CONCLUSIONS

HIV-positive individuals with immune deficiency, or lacking a CD4 count measurement are at risk of rehospitalisation. Strengthening primary healthcare service delivery of these key affected inpatient populations should be a priority.