HIV-related medical service use by rural/urban residents: a multistate perspective.

OBJECTIVE: Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites. METHODS: Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000-100,000), and urban (>100,000). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS-defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage, and virologic suppression were compared among patients, using χ(2) tests for categorical variables, t-tests for means, and logistic regression for HAART utilization. RESULTS: HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage, or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have four or more annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis. CONCLUSION: Although demographic and health care utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and injection drug users.

Contemporary costs of HIV healthcare in the HAART era.

BACKGROUND: The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management. METHODS: We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/µl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care. RESULTS: Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/µl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/µl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/µl or less, for whom inpatient costs were highest. CONCLUSION: HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

Associations between outpatient and inpatient service use among persons with HIV infection: a positive or negative relationship?

OBJECTIVE: To examine the prospective association between frequency of outpatient visits and subsequent inpatient admissions. DATA SOURCES: Medical record data on 13,942 patients with HIV infection seen in 10 HIV speciality care sites across the United States. STUDY DESIGN: This observational study followed a cohort of HIV-infected patients who were in care in the first half of 2001. Numbers of inpatient admissions and outpatient visits were calculated for each patient for each 3-month period, from 2001 through 2004. ANALYSIS: Negative binomial and logistic regression analyses using random-effects models examined the effects of inpatient admissions and outpatient visits in the previous period on inpatient and outpatient service utilization, controlling for background characteristics and HIV disease stage. RESULTS: For 3-month periods, between 5 and 9 percent of patients had an inpatient admission. The linear association between number of outpatient visits and any inpatient admission in the subsequent period was positive (adjusted odds ratio=1.05; 95 percent confidence interval [CI]=1.04, 1.06). However, patients with zero prior outpatient visits had significantly greater admission rates than those with one prior visit. Hospitalization rates were also higher among those with a prior hospitalization and those with more advanced HIV disease. CONCLUSIONS: These results suggest a J-shaped relationship between outpatient use and inpatient use among persons with HIV disease. Those in worse health have greater utilization of both inpatient and outpatient care. However, having no outpatient visits may also increase the likelihood of subsequent hospitalization. Although outpatient care cannot be justified as a cost-saving mechanism, maintaining regular clinical monitoring of patients is important.

Background--the origins of the care system assessment demonstration project.

The Care System Assessment Demonstration Project was designed to assist community planning bodies in determining barriers to care for people living with HIV (PLWH) in selected underserved minority populations and generating recommendations for care system enhancement that would lower those barriers. This paper describes the selection of three sites to participate in the project and sketches the two primary tools used in implementing the project: Rapid Assessment, Response and Evaluation (RARE) techniques initially developed to assess community HIV prevention needs, and a system assessment model created to help communities conduct systematic evaluations of their HIV care systems. The paper also provides an overview of the remaining chapters of the supplement, detailing how the project was implemented at the national level and the three participating sites and evaluating both the project's process and its local impact.

CARE Act planning for unmet need.

The Ryan White CARE Act, a safety net program first enacted in 1990, provides health and support services to people living with HIV (PLWH) in the U.S. through several Titles. Recipients of CARE Act funds--particularly metropolitan areas and States under Titles I and II, respectively--prioritize and allocate funds to cover unmet service needs. In the 2000 reauthorization of the CARE Act, Title I and II grantees were directed to determine unmet needs for services. This paper describes a process by which the HIV/AIDS Bureau of the Health Resources and Services Administration of the U.S. Department of Health and Human Services has assisted grantees in developing tools to make quantitative estimates of the unmet need for HIV primary care services. The process enables grantees to identify underserved populations and implement strategies to bring them into regular primary care. The Care System Assessment Demonstration Project supplements these tools.

The care system assessment model and its operationalization.

The care system assessment model is intended to help community planning bodies for HIV services conduct systematic evaluations of existing care systems, with an eye toward changing them to make services more accessible to people living with HIV (PLWH) from underserved minority communities. The model has four structural and three cultural/behavioral dimensions. The structural dimensions are system comprehensiveness, capacity, integration, and accessibility; the cultural/behavioral dimensions are service acceptability, technical competencies (of both providers and potential system users), and client health-seeking behaviors. This chapter describes the model's dimensions and ways to operationalize them through document reviews and other methods.

Adapting RARE to assess barriers to service receipt among people out of care.

This paper describes the components of Rapid Assessment, Response and Evaluation (RARE), developed for HIV prevention planning; the adaptation of its methods to services planning; the venues in which the use of RARE was recommended for the present Care System Assessment Demonstration Project; constraints on what projects using RARE and the system assessment model may expect to accomplish; the focus of RARE questions for the project, concerning the characteristics of PLWH not in regular primary care, the care system as PLWH not in care perceive and experience it, and characteristics of the physical and social environments in which they live; how information from RARE can contribute to the enhancement of care systems; and the types of questions that sites could ask to gather RARE information for services planning.

Catalyzing system changes to make HIV care more accessible.

Although a comprehensive evaluation of the Care System Assessment Project is still several years off, the project quickly catalyzed changes in each of the communities in which it was piloted. All the sites found the system assessment model useful in identifying gaps in services. The project also clarified ways to engage underserved minorities in both care and planning for HIV care, and it helped to create community consensus in shaping initiatives to bring these populations into care. At all three sites, immigrant and refugee populations had to change beliefs that tended to delay their entry into care, and HIV-related stigma remained a significant barrier to entering care. However, all three communities also faced financial constraints that were likely to impede their ability to implement needed changes quickly. All of the sites identified needs for expanded public information campaigns and support services.

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.

BACKGROUND: Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. OBJECTIVE: The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV. DESIGN: Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. SETTING: This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. PATIENTS: In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. MAIN OUTCOME MEASURES: Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. RESULTS: Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002. CONCLUSION: Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

Using data to make decisions: planning HIV/AIDS care under the Ryan White CARE Act.

This article describes the challenges of using data to plan and fund HIV/AIDS care services for underserved populations under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. It also outlines methods that have been developed by the Health Resources and Services Administration of the U.S. Department of Health and Human Services to assist community planning groups in using data to decide how to target limited federal resources under the CARE Act. Use of CARE Act dollars is guided largely by an array of legislatively identified priority areas, such as targeting of low income HIV-infected individuals who are not in care for their HIV disease. CARE Act program guidance covers the use of epidemiologic HIV and AIDS case data, quantification of unmet need for HIV care, guidance on making objective decisions on priorities for funding within a community planning process, and other instructions on the use of data in making decisions.

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001.

BACKGROUND: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization. METHODS: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART. RESULTS: In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART. CONCLUSIONS: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Trends and responsiveness in national resource allocation for needed HIV services: a five year (1996-2000) analysis.

A recent study conducted by the Institute of Medicine concluded that there are approximately 1,200 to 1,400 avoidable deaths per year in the U.S. among people living with HIV (PLWH) who do not have health insurance (Institute of Medicine, 2002). The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was passed by the U.S. Congress in 1990 to provide funding for community-based HIV care services for uninsured and underinsured PLWH--the only Federal program to provide such funding. There is substantial local autonomy in the allocation of CARE Act funds, with planning processes that take place in both States and metropolitan areas. The purpose of this study is to examine trends in the allocation of such funds from 1996 through 2000, the first five years during which effective antiretroviral medications were available for HIV. The study also considers whether these trends were responsive to the evolving modalities of care and the service needs of a changing population of PLWH.

Ryan White CARE Act service use by Asian/Pacific Islanders and other clients in three California metropolitan areas (1997-1998).

The HIV epidemic disproportionately affects historically underserved members of racial/ethnic minorities. This paper compares HIV service use patterns for 653 Asians and Pacific Islanders (APIs) with those of other racial and ethnic minority clients (N = 28,201) at three selected Ryan White Comprehensive AIDS Resource Emergency (CARE) Act grantee sites in California. Study results show a relatively high proportion of APIs with advanced HIV disease. APIs use hospital-based HIV clinics at relatively high rates, and they use HIV case management, housing assistance, day/respite care, food/nutrition, substance abuse treatment, and health education services in relatively low numbers. Research suggests that social, cultural, and economic factors may influence health seeking behaviors and providers' practices. While there are relatively few APIs living with HIV in the US, the rate of API population growth from immigration underscores the need for service providers to take into account cultural and social factors to improve access to treatment.

Association of medical insurance and other factors with receipt of antiretroviral therapy.

OBJECTIVES: This study was designed to assess sociodemographic and medical insurer factors associated with receipt of highly active antiretroviral therapy (HAART). METHODS: Patients included (n = 959) were enrolled in the Johns Hopkins HIV Clinic after April 1, 1996, received > or = 90 days of care, and had a CD4 count > or = 500 cells/mm3 or HIV-1 RNA > 20 000 copies/mL. We assessed the associations of sociodemographic factors and medical insurance with receipt of HAART, stratified by 2 time periods (April 1996 through March 1997 versus April 1997 through March 1999). RESULTS: HAART was more likely to be used in patients who were > 39 years, White, had CD4 counts < 350 cells/mm3, had fewer missed clinic visits, and did not have intravenous drug use as their risk factor for HIV transmission. In period 1 (April 1996 through March 1997), HAART was more likely to be used in patients who were commercially insured than in other payer groups; differences between payers narrowed in period 2 (April 1997 through March 1999), however, as did differences by race. CONCLUSIONS: Differences in use of HAART on the basis of payer have narrowed since 1996. This encouraging finding may demonstrate the importance of programs that lower economic barriers to medical care.

Health-Based Payment for HIV/AIDS in Medicaid Managed Care Programs.

In recent years, State Medicaid programs have begun adopting health-based payment systems to help ensure quality care for people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), and to ensure equity for the managed care organizations (MCOs) in which these people are enrolled. In this article, the authors discuss reasons why such payment systems are needed and describe AIDS-specific capitation rates that have been adopted in several State Medicaid waiver programs. The authors also examine comprehensive risk-adjustment systems both within Medicaid and outside the program. Several research questions needing further work are discussed.