Thirty-day hospital readmissions for adults with and without HIV infection.

OBJECTIVES: Risk-adjusted 30-day hospital readmission rate is a commonly used benchmark for hospital quality of care and for Medicare reimbursement. Persons living with HIV (PLWH) may have high readmission rates. This study compared 30-day readmission rates by HIV status in a multi-state sample with planned subgroup comparisons by insurance and diagnostic categories. METHODS: Data for all acute care, nonmilitary hospitalizations in nine states in 2011 were obtained from the Healthcare Costs and Utilization Project. The primary outcome was readmission for any cause within 30 days of hospital discharge. Factors associated with readmission were evaluated using multivariate logistic regression. RESULTS: A total of 5 484 245 persons, including 33 556 (0.6%) PLWH, had a total of 6 441 695 index hospitalizations, including 45 382 (0.7%) among PLWH. Unadjusted readmission rates for hospitalizations of HIV-uninfected persons and PLWH were 11.2% [95% confidence interval (CI) 11.2, 11.2%] and 19.7% (95% CI 19.3, 20.0%), respectively. After adjustment for age, gender, race, insurance, and diagnostic category, HIV infection was associated with 1.50 (95% CI 1.46, 1.54) times higher odds of readmission. Predicted, adjusted readmission rates were higher for PLWH within every insurance category, including Medicaid [12.9% (95% CI 12.8, 13.0%) and 19.1% (95% CI 18.4, 19.7%) for HIV-uninfected persons and PLWH, respectively] and Medicare [13.2% (95% CI 13.1, 13.3%) and 18.0% (95% CI 17.4, 18.7%), respectively], and within every diagnostic category. CONCLUSIONS: HIV infection is associated with significantly increased readmission risk independent of demographics, insurance, and diagnostic category. The 19.7% 30-day readmission rate may serve as a preliminary benchmark for assessing quality of care of PLWH. Policy-makers may consider adjusting for HIV infection when calculating a hospital's expected readmission rate.

Incidence of and risk factors for bacteraemia in HIV-infected adults in the era of highly active antiretroviral therapy.

BACKGROUND: HIV-infected patients have an increased risk for bacteraemia compared with HIV-negative patients. Few data exist on the incidence of and risk factors for bacteraemia across time in the current era of highly active antiretroviral therapy (HAART). METHODS: We assessed the incidence of bacteraemia among patients followed between 2000 and 2008 at 10 HIV Research Network sites. This large multisite, multistate clinical cohort study collected demographic, clinical and therapeutic data longitudinally. International Statistical Classification of Diseases and Related Health Problems (ICD)-9 codes were examined to identify all cases of in-patient bacteraemia. Logistic regression analysis was used to assess risk factors for bacteraemia and trends over time in the odds of bacteraemia. RESULTS: A total of 39 318 patients were followed for 146 289 person-years (PY). During the study period, there were 2025 episodes of bacteraemia (incidence 13.8 events/1000 PY). The most common bacteraemia diagnosis was 'bacteraemia, not otherwise specified (NOS)' (51%) followed by Staphylococcus aureus (16%) and Streptococcus species (6.5%). In multivariate analysis, the likelihood of bacteraemia was found to have increased in 2005-2008, compared with 2000. Other factors associated with higher odds of bacteraemia included a history of injection drug use (IDU), age ≥ 50 years, Black race and greater immunosuppression. CONCLUSIONS: The likelihood of bacteraemia has risen slightly in recent years. Patients who are Black or have a history of IDU are at higher risk. Further research is needed to identify reasons for this increase and to evaluate programmes designed to reduce the bacteraemia risk.

Emergency department utilization among HIV-infected patients in a multisite multistate study.

OBJECTIVE: The aim of this study was to examine Emergency Department (ED) utilization and clinical and sociodemographic correlates of ED use among HIV-infected patients. METHODS: During 2003, 951 patients participated in face-to-face interviews at 14 HIV clinics in the HIV Research Network. Respondents reported the number of ED visits in the preceding 6 months. Using logistic regression, we identified factors associated with visiting the ED in the last 6 months and admission to the hospital from the ED. RESULTS: Thirty-two per cent of respondents reported at least one ED visit in the last 6 months. In multivariate analysis, any ED use was associated with Medicaid insurance, high levels of pain (the third or fourth quartile), more than seven primary care visits in the last 6 months, current or former illicit drug use, social alcohol use and female gender. Of those who used ED services, 39% reported at least one admission to the hospital. Patients with pain in the highest quartile reported increased admission rates from the ED as did those who made six or seven primary care visits, or more than seven primary care visits vs. three or fewer. CONCLUSIONS: The likelihood of visiting the ED has not diminished since the advent of highly active antiretroviral therapy (HAART). More ED visits are to treat illnesses not related to HIV or injuries than to treat direct sequelae of HIV infection. With the growing prevalence of people living with HIV infection, the numbers of HIV-infected patients visiting the ED may increase, and ED providers need to understand potential complications produced by HIV disease.

Use of mental health and substance abuse treatment services among adults with HIV in the United States.

BACKGROUND: The need for mental health and substance abuse services is great among those with human immunodeficiency virus (HIV), but little information is available on services used by this population or on individual factors associated with access to care. METHODS: Data are from the HIV Cost and Services Utilization Study, a national probability survey of 2864 HIV-infected adults receiving medical care in the United States in 1996. We estimated 6-month use of services for mental health and substance abuse problems and examined socioeconomic, HIV illness, and regional factors associated with use. RESULTS: We estimated that 61.4% of 231 400 adults under care for HIV used mental health or substance abuse services: 1.8% had hospitalizations, 3.4% received residential substance abuse treatment, 26.0% made individual mental health specialty visits, 15.2% had group mental health treatment, 40.3% discussed emotional problems with medical providers, 29.6% took psychotherapeutic medications, 5.6% received outpatient substance abuse treatment, and 12.4% participated in substance abuse self-help groups. Socioeconomic factors commonly associated with poorer access to health services predicted lower likelihood of using mental health outpatient care, but greater likelihood of receiving substance abuse treatment services. Those with less severe HIV illness were less likely to access services. Persons living in the Northeast were more likely to receive services. CONCLUSIONS: The magnitude of mental health and substance abuse care provided to those with known HIV infection is substantial, and challenges to providers should be recognized. Inequalities in access to care are evident, but differ among general medical, specialty mental health, and substance abuse treatment sectors.

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States.

BACKGROUND: There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders. SUBJECTS AND METHODS: We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses. RESULTS: Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder. CONCLUSIONS: Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Impact of psychiatric conditions on health-related quality of life in persons with HIV infection.

OBJECTIVE: Little is known about the impact of comorbid psychiatric symptoms in persons with HIV. This study estimates the burden on health-related quality of life associated with comorbid psychiatric conditions in a nationally representative sample of persons with HIV. METHOD: The authors conducted a multistage sampling of urban and rural areas to produce a national probability sample of persons with HIV receiving medical care in the contiguous United States (N=2,864). Subjects were screened for psychiatric conditions with the short form of the Composite International Diagnostic Interview. Heavy drinking was assessed on the basis of quantity and frequency of drinking. Health-related quality of life was rated with a 28-item instrument adapted from similar measures used in the Medical Outcomes Study. RESULTS: HIV subjects with a probable mood disorder diagnosis had significantly lower scores on health-related quality of life measures than did those without such symptoms. Diminished health-related quality of life was not associated with heavy drinking, and in drug users it was accounted for by presence of a comorbid mood disorder. CONCLUSIONS: Optimization of health-related quality of life is particularly important now that HIV is a chronic disease with the prospect of long-term survival. Comorbid psychiatric conditions may serve as markers for impaired functioning and well-being in persons with HIV. Inclusion of sufficient numbers of appropriately trained mental health professionals to identify and treat such conditions may reduce unnecessary utilization of other health services and improve health-related quality of life in persons with HIV infection.

Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV Cost and Services Utilization Study.

PURPOSE: To measure health-related quality of life among adult patients with human immunodeficiency virus (HIV) disease; to compare the health-related quality of life of adults with HIV with that of the general population and with patients with other chronic conditions; and to determine the associations of demographic variables and disease severity with health-related quality of life. SUBJECTS AND METHODS: We studied 2,864 HIV-infected adults participating in the HIV Cost and Services Utilization Study, a probability sample of adults with HIV receiving health care in the contiguous United States (excluding military hospitals, prisons, or emergency rooms). A battery of 28 items covering eight domains of health (physical functioning, emotional well-being, role functioning, pain, general health perceptions, social functioning, energy, disability days) was administered. The eight domains were combined into physical and mental health summary scores. SF-36 physical functioning and emotional well-being scales were compared with the US general population and patients with other chronic diseases on a 0 to 100 scale. RESULTS: Physical functioning was about the same for adults with asymptomatic HIV disease as for the US population [mean (+/- SD) of 92+/-16 versus 90+/-17) but was much worse for those with symptomatic HIV disease (76+/-28) or who met criteria for the acquired immunodeficiency syndrome (AIDS; 58+/-31). Patients with AIDS had worse physical functioning than those with other chronic diseases (epilepsy, gastroesophageal reflux disease, clinically localized prostate cancer, clinical depression, diabetes) for which comparable data were available. Emotional well-being was comparable among patients with various stages of HIV disease (asymptomatic, 62+/-9; symptomatic, 59+/-11; AIDS, 59+/-11), but was significantly worse than the general population and patients with other chronic diseases except depression. In multivariate analyses, HIV-related symptoms were strongly associated with physical and mental health, whereas race, sex, health insurance status, disease stage, and CD4 count were at most weakly associated with physical and mental health. CONCLUSIONS: There is substantial morbidity associated with HIV disease in adults. The variability in health-related quality of life according to disease progression is relevant for health policy and allocation of resources, and merits the attention of clinicians who treat patients with HIV disease.

Pediatric human immunodeficiency virus infection. Recent evidence on the utilization and costs of health services.

OBJECTIVE: To measure the utilization and costs of pediatric human immunodeficiency virus (HIV)-related health care services. DESIGN: Cohort survey. SETTING: Eight outpatient departments serving large numbers of HIV-infected children in five standard metropolitan areas with high prevalence of HIV-infected children. PATIENTS: One hundred forty-one HIV-seropositive children older than 15 months of age or children whose clinical conditions meet the definition of acquired immunodeficiency syndrome (AIDS) at any age who visited the selected providers during the second quarter of 1991. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Quarterly interview survey (via adult proxies) of health care services utilization during each preceding 3-month period, repeated six times between March 1991 and August 1992. Charge data were abstracted from inpatient, outpatient, home health care, and pharmacy bills. RESULTS: Children with AIDS averaged 1.4 hospitalizations, 16 inpatient days, two emergency department visits, 18 ambulatory care visits, 15 professional home health care visits, and one dental visit per year, generating an estimated $37,928 in annual charges. The HIV-infected children used fewer services, with annual charges of $9382. CONCLUSIONS: We found lower utilization than reported in prior research on pediatric HIV and similar unit costs after inflation adjustment. Increasing experience in clinical management and expanded ambulatory care may have contributed to reductions in inpatient services utilization and total costs since the mid-1980s.

Coping and depressive symptoms among people with AIDS.

This study examined coping behaviors of people with AIDS, using a large sample (N = 736) that was both geographically and sociodemographically diverse. In-person interviews were conducted with people receiving AIDS-related medical or social services; follow-up interviews were conducted approximately 11 months later. Factor analyses of 16 coping behaviors revealed three factors: Positive Coping, Seeking Social Support, and Avoidance Coping. Respondents with a history of injected drug use, as compared with gay or bisexual men, had higher scores for Avoidance Coping and lower scores for Positive Coping. Each coping scale was significantly related to depressive symptoms in cross-sectional analyses. In longitudinal analyses that controlled for prior depressive symptoms, Positive Coping was significantly related to decreases in symptoms.

Utilization of home care among people with HIV infection.

OBJECTIVE: To examine factors affecting the utilization of formal and informal home care services by people with HIV infection. DATA SOURCES AND STUDY SETTING: Study participants are adults with HIV infection receiving services at major providers of medical care in ten U.S. cities. Six interviews were conducted over an 18-month period (March 1991 to September 1992). DATA COLLECTION METHODS: Data on home care utilization, personal background characteristics, insurance status, and functional status are based on self-report. Disease stage is based on medical record data. STUDY DESIGN: This is an observational study using a panel survey design. Cross-tabular and longitudinal regression analyses (N = 1,727) were conducted to determine the effects of sociodemographic factors, functional status, disease stage, and insurance status on the receipt of home care from nurses, paraprofessionals, other professional providers, household residents, nonresident family and friends, and volunteers. PRINCIPAL FINDINGS: Over a 12-month period, 16 percent of respondents received home nursing visits; 11 percent received paraprofessional care (e.g., nurse's aides, helpers); 4 percent received help from volunteers; 11 percent from non-resident family or friends, and 21 percent from household members. Among the subgroup with AIDS (n = 837), corresponding percentages were 29, 20, 7, 17, and 29 percent for each provider type. In multivariate analyses, illness stage and functional status had strong effects on odds of utilization. Blacks and Hispanics were less likely than whites to have nursing care, but racial/ethnic group did not affect receipt of informal care. CONCLUSIONS: Home care utilization is concentrated among people with AIDS, compared to those at less advanced disease stages. In addition to functional limitations, fatigue is associated with the use of home care. Nursing and non-nursing home care have somewhat different correlates. Medicaid may provide better coverage of personal care services than private insurance.

AIDS case management: the client's perspective.

The Robert Wood Johnson Foundation's AIDS Health Services Program uses case management to provide community-based care for people with AIDS. This article reports data concerning implementation of case management, based on interviews with program clients in nine communities. Some clients receive case management from a community-based organization (CBO), while others have clinic-based case managers. Clinic clients are more likely to be disadvantaged. Over 25 percent of respondents report having no case manager at either site, and 10 percent report having two case managers. Those who need social services are more likely to have a case manager. Between 18 and 25 percent have had no contact with their case manager in a month, but over 50 percent have had multiple contacts. Frequency of contact is positively related to having needs for social services. Evaluations of case managers are favorable, but there is some dissatisfaction with ease of access. Having a case manager is positively related to having service needs met. Results suggest that (1) efforts to coordinate care through case management must deal with the existence of clinics and CBOs as distinct treatment sites with differing clientele, and (2) explicit policies concerning eligibility for case management and frequency of monitoring must be developed.

Correlates of medical service utilization among people with HIV infection.

OBJECTIVE: To examine factors affecting the use of inpatient, outpatient, and emergency room services by people with HIV infection. DATA SOURCES AND STUDY SETTING: Study participants are adults with HIV infection receiving services at major providers of medical care in ten U.S. cities. Six interviews were conducted over an 18-month period (March 1991 to September 1992). DATA COLLECTION METHODS: Data on service utilization, personal background characteristics, insurance status, and functional status are based on self-report. Disease stage is based on medical record data. STUDY DESIGN: This is an observational study using a panel survey design. Linear and Poisson regression analyses were conducted to determine the effects of need, enabling, and predisposing factors on the dependent variables of ambulatory visits, emergency room visits, inpatient admissions, and average length of inpatient stay. Analyses use 1,449 respondents who completed the second and third interviews. Independent variables were measured as of the second interview, while dependent variables were measured in the third and fourth interview periods. PRINCIPAL FINDINGS: Service utilization was higher among respondents with AIDS than among those at earlier stages of HIV infection. Functional limitations, experienced pain, and negative mood each were associated with increased service use, over and above disease stage. Black respondents reported more hospital admissions and longer lengths of inpatient stays than white respondents. Lack of insurance was related to reduced service use. The effects of disease stage and functional limitations were reduced among people with public, compared to private, insurance. CONCLUSIONS: While disease stage affects use of medical care, the experience of adverse HIV-related conditions, such as pain or functional limitations, has an additional effect on service use. Persistent racial differences in utilization remain to be explained. Lack of insurance impedes use directly and also modifies the effects of disease stage and functioning.

AIDS treatment costs during the last months of life: evidence from the ACSUS.

OBJECTIVE: The volume and cost of services consumed by persons with AIDS (PWAs) during their last months of life are examined in this study. DATA SOURCES: This study utilizes data from the AIDS Costs and Service Utilization Survey (ACSUS). The ACSUS is the most comprehensive survey of medical services that are consumed by persons with HIV. STUDY DESIGN: This study is restricted to persons with AIDS who survived the fifth time period (an approximately three-month period in the early spring and summer of 1992). The types and costs of services consumed during the fifth time period by PWAs who did survive (609) and who did not survive (79) the sixth time period are compared. DATA COLLECTION: The ACSUS consists of six interviews over an 18-month period from Spring 1991 to Fall 1992. PRINCIPAL FINDINGS: Decedents were hospitalized more than four times as many days and experienced more than four times the number of home health visits as survivors. Both the average length of stay (19.3 days for decedents and 10.3 for survivors) and the frequency of hospitalization during the fifth time period (.70 for decedents and .28 for survivors) were higher for decedents than survivors. The levels of outpatient care (including emergency room care) and of prescription drug use were similar for decedents and survivors. CONCLUSIONS: This study shows that the cost of treating decedents is more than three times the cost of treating survivors.

Combining activities of daily living with instrumental activities of daily living to measure functional disability.

Measures of functional disability typically contain items that reflect limitations in performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs). Combining IADL and ADL items together in the same scale would provide enhanced range and sensitivity of measurement. This article presents psychometric justification for a combined ADL/IADL scale. Data come from 2,977 disabled respondents in the 1989 National Long-Term Care Survey. Respondents indicated whether they received human help on 7 ADL items; they also indicated whether they were unable to perform each of 9 IADL items due to health reasons. Factor analyses using tetrachoric correlations demonstrated that 15 of the 16 items reflected one major dimension. Item response theory (IRT) methods were used to calibrate the items; a one-parameter IRT model fit the data. Item calibrations showed that ADL and IADL items were not hierarchically related. Analyses showed that a simple sum of item responses could be used to derive a measure of functional disability. Implications of using a 15-item ADL/IADL scale for eligibility determination and for comparing groups are discussed.

Transitions in insurance and employment among people with HIV infection.

This article examines the extent to which people with HIV infection change their insurance and employment status over time and investigates the correlates of such changes. Data come from the AIDS Cost and Services Utilization Survey, which followed 1,949 HIV-infected adults over an 18-month period that began March 1, 1991. In the first interview, overall, 33% of respondents had private insurance; 40% had public coverage (i.e., Medicaid, Medicare, CHAMPUS); and 27% had no insurance. Among the subgroup with AIDS, corresponding figures were 32%, 54%, and 14%. Overall, 65% were unemployed; among those with AIDS, 82% were unemployed. Over the 18-month period, 23% of respondents reported a change in insurance status and 27% reported a change in employment status. Among those who began the study with private insurance, only 15% reported losing this coverage. Transitions from no insurance to public coverage occurred most frequently. Compared to those who began the study with AIDS, those who progressed to AIDS during the study period were more likely to experience a change in insurance (18% vs. 32%). Consistent with prior studies, public insurance plays a major role in financing care for people with HIV infection. Transitions from public coverage to no insurance may disrupt access to care.

Location, race, and hospital care for AIDS patients: an analysis of 10 states.

This study is the first statewide comparison of hospital utilization and inpatient mortality rates for people with acquired immune deficiency syndrome (AIDS). Data from 120,772 hospital discharge abstracts for all AIDS-related admissions in 10 states (California, Colorado, Florida, Iowa, Kansas, Maryland, New Jersey, New York, Pennsylvania, and South Carolina) in 1996 were combined with data on the number and the racial and ethnic characteristics of all people living with AIDS (PLWAs) in each state. These data were used to derive population-based estimates of the use of hospital services per PLWA and of inpatient mortality rates in each state. Multivariate analyses examined sources of variation in inpatient length of stay and inpatient mortality. The primary finding of this study is that hospital utilization rates and inpatient mortality rates for people with AIDS vary substantially across states and among racial and ethnic groups within states even after adjusting for severity of illness. Blacks and Hispanics had longer hospital stays and were more likely to die in the hospital than whites. State-level policies, such as home and community-based waiver programs and enhanced HIV reimbursement rates, significantly affected hospital use.

Insurance status among people with AIDS: relationships with sociodemographic characteristics and service use.

This paper presents data on health insurance coverage among people with AIDS. The data came from interviews with 937 people with AIDS recruited from outpatient HIV clinics and community-based AIDS service organizations in nine communities across the United States. At the time of the interview, 30% had private insurance, 29% had no insurance, and 41% were covered by some form of public health insurance. Respondents who were nonwhite, injected-drug users, unemployed, and had incomes of less than $500 per month were more likely than their respective counterparts to have no insurance or to have publicly funded insurance. There were marked regional variations in insurance status, with the South having the highest proportion of of uninsured and the lowest proportion receiving Medicaid. Ninety-five percent of the uninsured and the publicly insured, compared to 47% of those with private insurance, used clinics as their source of medical care. People without insurance were less likely than those with private insurance to have been admitted overnight to a hospital, and their lengths of stay were shorter.

Sampling and accessing people with AIDS. Implications for program evaluation.

This article describes issues that arose in attempting to conduct a survey of people with acquired immune deficiency syndrome (AIDS) as part of an evaluation of a program to deliver health and social services to this population. Demands to maintain the confidentiality of people with human immunodeficiency virus (HIV) infection posed a large impediment to randomly sampling and accessing program recipients. Efforts to contact people with AIDS through the mediation of health service providers encountered problems of nonimplementation and slow accrual. Comparisons of the obtained sample with a more comprehensive data base of program clients suggest that clients who were more accessible and compliant were overrepresented in the sample. People with AIDS themselves, however, were willing to be interviewed, as demonstrated by refusal rates less than 11%. Future studies of people with AIDS must overcome direct service providers' lack of time to contact and recruit respondents; it may be wise to allocate funds to support recruitment activities conducted by an administrative staff person in the service delivery agency.