Assessing Antiretroviral Use During Gaps in HIV Primary Care Using Multisite Medicaid Claims and Clinical Data.

BACKGROUND: Some individuals who appear poorly retained by clinic visit-based retention measures are using antiretroviral therapy (ART) and maintaining viral suppression. We examined whether individuals with a gap in HIV primary care (≥180 days between HIV outpatient clinic visits) obtained ART during that gap after 180 days. SETTING: HIV Research Network data from 5 sites and Medicaid Analytic Extract eligibility and pharmacy data were combined. METHODS: Factors associated with having both an HIV primary care gap and a new (ie, nonrefill) ART prescription during a gap were evaluated with multinomial logistic regression. RESULTS: Of 6892 HIV Research Network patients, 6196 (90%) were linked to Medicaid data, and 4275 had any Medicaid ART prescription. Over half (54%) had occasional gaps in HIV primary care. Women, older people, and those with suppressed viral load were less likely to have a gap. Among those with occasional gaps (n = 2282), 51% received a new ART prescription in a gap. Viral load suppression before gap was associated with receiving a new ART prescription in a gap (odds ratio = 1.91, 95% confidence interval: 1.57 to 2.32), as was number of days in a gap (odds ratio = 1.04, 95% confidence interval: 1.02 to 1.05), and the proportion of months in the gap enrolled in Medicaid. CONCLUSIONS: Medicaid-insured individuals commonly receive ART during gaps in HIV primary care, but almost half do not. Retention measures based on visit frequency data that do not incorporate receipt of ART and/or viral suppression may misclassify individuals who remain suppressed on ART as not retained.

Closing the Gap in Antiretroviral Initiation and Viral Suppression: Time Trends and Racial Disparities.

BACKGROUND: In the current antiretroviral (ART) era, the evolution of HIV guidelines and emergence of new ART agents might be expected to impact the times to ART initiation and HIV virologic suppression. We sought to determine if times to AI and virologic suppression decreased and if disparities exist by age, race/ethnicity, and HIV risk. METHODS: We performed a retrospective cohort study of data from 12 sites of the HIV Research Network, a consortium of US clinics caring for HIV-infected patients. HIV-infected adults (≥18 year old) newly presenting for care between 2003 and 2013 were included in this study. Times to AI and virologic suppression were defined as time from enrollment to AI and HIV RNA <400 copies per milliliter, respectively. We conducted time-to-event analyses using competing risk regression in the HIV Research Network cohort from 2003 to 2012 in 2-year intervals, with follow-up through 2013. RESULTS: Among 15,272 participants, 76.9% were male, 48.4% black, and 10.9% were injection drug use with median age of 38 years (interquartile range: 29-46 years). The adjusted subdistribution hazards ratios (SHRs) for AI and virologic suppression each increased for years 2007-2008 [SHR 1.23 (1.16-1.30), and SHR 1.25 (1.17-1.34), respectively], 2009-2010 [1.55 (1.46-1.64), and 1.54 (1.43-1.65), respectively], and 2011-2012 [1.94 (1.83-2.07), and 1.73 (1.61-1.86), respectively] compared with 2003-2004. Blacks had a lower probability of AI than whites and Hispanics. CONCLUSIONS: Since 2007, times from enrollment to AI and virologic suppression have decreased significantly compared with 2003-2004, but persisting disparities should be addressed.

Healthcare Coverage for HIV Provider Visits Before and After Implementation of the Affordable Care Act.

BACKGROUND: Before implementation of the Patient Protection and Affordable Care Act (ACA) in 2014, 100 000 persons living with human immunodeficiency virus (HIV) (PLWH) lacked healthcare coverage and relied on a safety net of Ryan White HIV/AIDS Program support, local charities, or uncompensated care (RWHAP/Uncomp) to cover visits to HIV providers. We compared HIV provider coverage before (2011-2013) versus after (first half of 2014) ACA implementation among a total of 28 374 PLWH followed up in 4 sites in Medicaid expansion states (California, Oregon, and Maryland), 4 in a state (New York) that expanded Medicaid in 2001, and 2 in nonexpansion states (Texas and Florida). METHODS: Multivariate multinomial logistic models were used to assess changes in RWHAP/Uncomp, Medicaid, and private insurance coverage, using Medicare as a referent. RESULTS: In expansion state sites, RWHAP/Uncomp coverage decreased (unadjusted, 28% before and 13% after ACA; adjusted relative risk ratio [ARRR], 0.44; 95% confidence interval [CI], .40-.48). Medicaid coverage increased (23% and 38%; ARRR, 1.82; 95% CI, 1.70-1.94), and private coverage was unchanged (21% and 19%; 0.96; .89-1.03). In New York sites, both RWHAP/Uncomp (20% and 19%) and Medicaid (50% and 50%) coverage were unchanged, while private coverage decreased (13% and 12%; ARRR, 0.86; 95% CI, .80-.92). In nonexpansion state sites, RWHAP/Uncomp (57% and 52%) and Medicaid (18% and 18%) coverage were unchanged, while private coverage increased (4% and 7%; ARRR, 1.79; 95% CI, 1.62-1.99). CONCLUSIONS: In expansion state sites, half of PLWH relying on RWHAP/Uncomp coverage shifted to Medicaid, while in New York and nonexpansion state sites, reliance on RWHAP/Uncomp remained constant. In the first half of 2014, the ACA did not eliminate the need for RWHAP safety net provider visit coverage.

Expenditures for Persons Living With HIV Enrolled in Medicaid, 2006-2010.

BACKGROUND: Costs of care for persons living with HIV have been high historically. Cost estimates based on data from 1 health care site may underestimate total expenditures; using insurance claims avoids this limitation. We used Medicaid claims data to comprehensively assess payments for care for persons living with HIV between 2006 and 2010. METHODS: Five sites from the HIV Research Network (HIVRN) provided information on patients with Medicaid coverage. Medicaid data were obtained from the sites' states (MD, NY, and MA) and 3 surrounding states and matched to HIVRN medical record-based data. Individuals less than 18, those with Medicare, and those in Medicaid managed care plans were excluded. Medicaid and HIVRN data were compared to ascertain concordance in capturing any inpatient event and any antiretroviral (ART) medication use. RESULTS: Of 6892 unique HIVRN identifiers, 6196 (90%) were linked to Medicaid data. The analytic sample included 11,341 person-years of Medicaid claims data from 3695 individuals in fee-for-service (FFS) programs. The mean annual FFS payment for all services was $47,434; mean annual FFS payment for only medical services was $38,311. Concordance between Medicaid and HIVRN data was excellent for ART use, but HIVRN data did not record a substantial proportion of years in which Medicaid recorded inpatient use. CONCLUSIONS: Estimated Medicaid payment amounts in this study are higher than some previous estimates. More complete capture of expensive inpatient hospitalizations in Medicaid data may partially explain this finding. Although inpatient care and ART medications contribute the most, expenditures for nonmedical services are substantial.

Factors Associated With Retention Among Non-Perinatally HIV-Infected Youth in the HIV Research Network.

BACKGROUND: The transmission of human immunodeficiency virus (HIV) among youth through high-risk behaviors continues to increase. Retention in Care is associated with positive clinical outcomes and a decrease in HIV transmission risk behaviors. We evaluated the clinical and demographic characteristics of non-perinatally HIV (nPHIV)-infected youth associated with retention 1 year after initiating care and in the 2 years thereafter. We also assessed the impact retention in year 1 had on retention in years 2 and 3. METHODS: This was a retrospective analysis of treatment-naive nPHIV-infected 12- to 24-year-old youth presenting for care in 16 US HIV clinical sites within the HIV Research Network between 2002 and 2008. Multivariate logistic regression identified factors associated with retention. RESULTS: Of 1160 nPHIV-infected youth, 44.6% were retained in care during the first year, and 22.4% were retained in all 3 years. Retention in the first year was associated with starting antiretroviral therapy in the first year (adjusted odds ratio [AOR], 3.47 [95% confidence interval (CI), 2.57-4.67]), Hispanic ethnicity (AOR, 1.66 [95% CI, 1.08-2.56]), men who have sex with men (AOR, 1.59 [95% CI, 1.07-2.36]), and receiving care at a pediatric site (AOR, 5.37 [95% CI, 3.20-9.01]). Retention in years 2 and 3 was associated with being retained 1 year after initiating care (AOR, 7.44 [95% CI, 5.11-10.83]). CONCLUSION: A high proportion of newly enrolled nPHIV-infected youth were not retained for 1 year, and only 1 in 4 were retained for 3 years. Patients who were Hispanic, were men who have sex with men, or were seen at pediatric clinics were more likely to be retained in care. Interventions that target those at risk of being lost to follow up are essential for this high-risk population.

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression.

BACKGROUND: The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum. METHODS: We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥ 2 HIV medical visits separated by ≥ 90 days in the year. Persons not retained completed ≥ 1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤ 200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART. RESULTS: Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437). CONCLUSIONS: Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.

The lifetime medical cost savings from preventing HIV in the United States.

OBJECTIVE: Enhanced HIV prevention interventions, such as preexposure prophylaxis for high-risk individuals, require substantial investments. We sought to estimate the medical cost saved by averting 1 HIV infection in the United States. METHODS: We estimated lifetime medical costs in persons with and without HIV to determine the cost saved by preventing 1 HIV infection. We used a computer simulation model of HIV disease and treatment (CEPAC) to project CD4 cell count, antiretroviral treatment status, and mortality after HIV infection. Annual medical cost estimates for HIV-infected persons, adjusted for age, sex, race/ethnicity, and transmission risk group, were from the HIV Research Network (range, $1854-$4545/mo) and for HIV-uninfected persons were from the Medical Expenditure Panel Survey (range, $73-$628/mo). Results are reported as lifetime medical costs from the US health system perspective discounted at 3% (2012 USD). RESULTS: The estimated discounted lifetime cost for persons who become HIV infected at age 35 is $326,500 (60% for antiretroviral medications, 15% for other medications, 25% nondrug costs). For individuals who remain uninfected but at high risk for infection, the discounted lifetime cost estimate is $96,700. The medical cost saved by avoiding 1 HIV infection is $229,800. The cost saved would reach $338,400 if all HIV-infected individuals presented early and remained in care. Cost savings are higher taking into account secondary infections avoided and lower if HIV infections are temporarily delayed rather than permanently avoided. CONCLUSIONS: The economic value of HIV prevention in the United States is substantial given the high cost of HIV disease treatment.

Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts.

OBJECTIVES: Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention. METHODS: We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result). RESULTS: Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01-1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52-0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04-1.62). Patients with heterosexual (1.78, 1.20-2.65) and IDU (1.58, 1.06-2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01-1.04) and inpatient (1.09, 1.01-1.19) visits were at greatest risk of unnecessary HCV testing. CONCLUSIONS: Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.

Health insurance coverage for persons in HIV care, 2006-2012.

We examined trends in health insurance coverage among 36,999 HIV-infected adults in care at 11 US HIV clinics between 2006 and 2012. Aggregate health insurance coverage was stable during this time. The proportions of patient-years with private, Medicaid, Medicare, and no insurance during this period were 15.9%, 35.7%, 20.1%, and 28.4%, respectively. Medicaid coverage was more prevalent among women than men, blacks, and Hispanics than whites, and individuals with injection drug use risk compared with other transmission risk factors. Hispanics and younger age groups were more likely to be uninsured than other racial/ethnic and older age groups, respectively.

Disparities in receipt of antiretroviral therapy among HIV-infected adults (2002-2008).

OBJECTIVE: Prior research has documented sociodemographic disparities in the use of antiretroviral therapy (ART). Recent therapeutic developments and changing epidemiological profiles may have altered such disparities. We examine the extent to which sociodemographic differences in prescribed ART have changed between 2002 and 2008. METHODS: We analyzed data abstracted from medical records at 13 US sites participating in the Human Immunodeficiency Virus Research Network. Prescription of ART was assessed for each year in care for each patient. A total of 14,092 patients were followed up for 39,251 person-years. We examined ART use as a function of sex, race/ethnicity, human immunodeficiency virus risk group, age, and CD4 history (no test <500 cells/mm, one or more tests between 500 and 350 cells/mm, 1 test ≤350 cells/mm, and 2 or more tests ≤350 cells/mm). Using multiple logistic regression, we ascertained interactions between each of these variables and calendar year. RESULTS: The overall percentage prescribed ART increased from 60% to 80% between 2002 and 2008. Among those with 2 or more CD4 tests ≤350 cells/mm, the percentage increased from 82% to 92%. ART rates were higher for those with lower CD4 counts but increased over time for all CD4 groups and for all demographic groups. Nevertheless, sex and racial/ethnic disparities persisted. Significant interactions were obtained for CD4 history by year, age by year, and age by CD4 history. CONCLUSIONS: Although prescription of ART became more widespread from 2002 to 2008, patients who were female, black, or younger still had lower ART rates than male, white, or older patients.

The economic burden of late entry into medical care for patients with HIV infection.

CONTEXT: A large proportion of people with human immunodeficiency virus (HIV) infection enter care late in the HIV disease course. Late entry can increase expenditures for care. OBJECTIVE: To estimate direct medical care expenditures for HIV patients as a function of disease status at initial presentation to care. Late entry is defined as initial CD4 test result ≤ 200 cells/mm3, intermediate entry as initial CD4 counts >200, and ≤ 500 cells/mm3; and early entry as initial CD4 count >500. PATIENTS: The study included 8348 patients who received HIV primary care and who were newly enrolled between 2000 and 2006 at one of 10 HIV clinics participating in the HIV Research Network. DESIGN: We reviewed medical record data from 2000 to 2007. We estimated costs per outpatient visit and inpatient day, and monthly medication costs (antiretroviral and opportunistic illness prophylaxis). We multiplied unit costs by utilization measures to estimate expenditures for inpatient days, outpatient visits, HIV medications, and laboratory tests. We analyzed the association between cumulative expenditures and initial CD4 count, stratified by years in care. RESULTS: Late entrants comprised 43.1% of new patients. The number of years receiving care after enrollment did not differ significantly across initial CD4 groups. Mean cumulative treatment expenditures ranged from $27,275 to $61,615 higher for late than early presenters. After 7 to 8 years in care, the difference was still substantial. CONCLUSIONS: Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings.

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.

Using information on clinical conditions to predict high-cost patients.

OBJECTIVE: To compare the ability of different models to predict prospectively whether someone will incur high medical expenditures. DATA SOURCE: Using nationally representative data from the Medical Expenditure Panel Survey (MEPS), prediction models were developed using cohorts initiated in 1996-1999 (N=52,918), and validated using cohorts initiated in 2000-2003 (N=61,155). STUDY DESIGN: We estimated logistic regression models to predict being in the upper expenditure decile in Year 2 of a cohort, based on data from Year 1. We compared a summary risk score based on diagnostic cost group (DCG) prospective risk scores to a count of chronic conditions and indicators for 10 specific high-prevalence chronic conditions. We examined whether self-rated health and functional limitations enhanced prediction, controlling for clinical conditions. Models were evaluated using the Bayesian information criterion and the c-statistic. PRINCIPAL FINDINGS: Medical condition information substantially improved prediction of high expenditures beyond gender and age, with the DCG risk score providing the greatest improvement in prediction. The count of chronic conditions, self-reported health status, and functional limitations were significantly associated with future high expenditures, controlling for DCG score. A model including these variables had good discrimination (c=0.836). CONCLUSIONS: The number of chronic conditions merits consideration in future efforts to develop expenditure prediction models. While significant, self-rated health and indicators of functioning improved prediction only slightly.

Deriving SF-12v2 physical and mental health summary scores: a comparison of different scoring algorithms.

PURPOSE: Summary scores for the SF-12, version 2 (SF-12v2) health status measure are based on scoring coefficients derived for version 1 of the SF-36, despite changes in item wording and response scales and despite the fact that SF-12 scales only contain a subset of SF-36 items. This study derives new summary scores based directly on SF-12v2 data from a recent U.S. sample and compares the new summary scores to the standard ones. Due to controversy regarding methods for developing scoring coefficients for the summary score, we compare summary scores produced by different methods. METHODS: We analyzed nationally representative U.S. data, which provided 53,399 observations for the SF-12v2 in 2003-2005. In addition to the standard SF-12V2 scoring algorithm, summary scores were generated using exploratory factor analysis (EFA), principal components analysis (PCA), and confirmatory factor analysis (CFA), with orthogonal and oblique rotation. We examined correlations among different summary scores, their associations with demographic and clinical variables, and the consistency between changes in scale scores and in summary scores over time. RESULTS: The 8 scale means in the current data were similar to the 1998 SF-12v2 means, with the exception of the vitality scale. Correlations among the scales based on SF-12v2 data differed slightly from correlations derived from scales based on the SF-36 data. Correlations among summary scores derived using different methods were high (≥0.84). However, changes in summary scores derived using orthogonal rotation of components or factors were not consistent with changes in sub-scales, whereas changes in summary scores derived using oblique rotation were more consistent with patterns of change in sub-scales. CONCLUSIONS: Although the basic structure of the SF-12 is stable, summary scores derived from oblique rotation are preferable and more consistent with changes in individual scales. On empirical and conceptual grounds, we suggest using summary scores based on oblique CFA.

Self-rated mental health and racial/ethnic disparities in mental health service use.

BACKGROUND: Studies of health service use for emotional problems show that the majority of those with disorders do not seek professional help. In addition, mental health service use is lower among members of minority communities, compared with non-Hispanic whites. OBJECTIVE: To examine the role of self-reported mental health as an indicator of awareness of mental conditions and as an influence in the process of seeking mental health care. RESEARCH DESIGN: We conducted cross-sectional analyses of nationally representative data from the Medical Expenditure Panel Survey (MEPS) for 2000-2004. MEASURES: In-person interviews obtained data on self-rated mental health (SRMH), ambulatory mental health visits, and purchase of prescription medications to treat mental conditions. Respondents completed the SF-12 health status survey; analyses included the SF-12 mental component summary (MCS) as a measure of emotional symptoms. Analyses included only those who provided self-reports of MCS and SRMH. RESULTS: SRMH was related to any ambulatory visit and any medication purchase for mental health treatment, controlling for MCS, and other sociodemographic and clinical variables. The association between SRMH and service use was weaker for black and Hispanic respondents than for whites. In addition, the magnitude of the association between SRMH and MCS was weaker for black and Hispanic respondents than for whites. CONCLUSIONS: Racial/ethnic differences in service use may arise in part from different propensities to interpret emotional symptoms as reflecting one's mental health and then to seek professional intervention for emotional problems. SRMH may be useful as an indicator of the extent to which people acknowledge the existence of emotional problems.

Differential item functioning and health assessment.

Establishing measurement equivalence is important because inaccurate assessment may lead to incorrect estimates of effects in research, and to suboptimal decisions at the individual, clinical level. Examination of differential item functioning (DIF) is a method for studying measurement equivalence. An item (i.e., one question in a longer scale) exhibits DIF if the item response differs across groups (e.g., gender, race), controlling for an estimate of the construct being measured. A distinction between applications in health, as contrasted with other settings such as educational and aptitude testing, is that there are many health-related constructs and multiple measures of each, few of which have received much critical evaluation. Discussed in this article are several methods for detection of differential item functioning (DIF), including non-parametric and parametric methods such as logistic regression, and those based on item response theory. Basic definitions and criteria for DIF detection are provided, as are steps in performing the analyses. Recommendations are presented and future directions discussed.

Using the SF-12 health status measure to improve predictions of medical expenditures.

BACKGROUND: Relatively few studies have used self-reported health status in models to predict medical expenditures, and many of these have used the SF-36. OBJECTIVES: We sought to examine the ability of the briefer SF-12 measure of health status to predict medical expenditures in a nationally representative sample. METHODS: We used data from the 2000-2001 panel of the Medical Expenditure Panel Study. Respondents (n = 5542) completed the SF-12 in a questionnaire. Interviews obtained data on demographics and selected chronic conditions. Data on expenditures incurred subsequent to the interview were obtained in part from provider records. We examined different regression model specifications and compared different statistical estimation techniques. RESULTS: Adding the SF-12 to a regression model improved the prediction of subsequent medical expenditures. In a model with only age and gender, adding the SF-12 increased R from 0.06 to 0.13. The coefficients for the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the SF-12 for this model were -0.045 (P < 0.01) and -0.012 (P < 0.01), respectively. In a model including demographic characteristics, chronic conditions, and previous expenditures, adding the SF-12 increased the R from 0.26 to 0.29. The coefficients for the PCS and the MCS for this model were -0.025 (P < 0.001) and -0.005 (P = 0.15), respectively. A single general health status question performed almost as well as the full SF-12. Models estimated using ordinary least squares had undesirable properties. In terms of R, a generalized linear model (GLM) with a Poisson variance function was consistently superior to a GLM with a gamma variance function. CONCLUSIONS: Information on self-reported health status is useful in predicting medical expenditures. The extent to which the SF-12 adds predictive power over a comprehensive array of diagnostic data remains to be examined.

High rates of primary Mycobacterium avium complex and Pneumocystis jiroveci prophylaxis in the United States.

BACKGROUND: National data from the mid-1990s demonstrated that many eligible patients with HIV infection do not receive prophylaxis for opportunistic infections (OIs) and that racial and gender disparities existed in OI prophylaxis receipt. OBJECTIVE: We examined whether demographic disparities in use of OI prophylaxis persist in 2001 and if outpatient care is associated with OI prophylaxis utilization. RESEARCH DESIGN: Demographic, clinical, and pharmacy utilization data were collected from 10 U.S. HIV primary care sites in the HIV Research Network. SUBJECTS: This study consisted of adult patients (>or=18 years old) in longitudinal HIV primary care. MEASURES: Indications for Pneumocystis jiroveci pneumonia (PCP) or Mycobacterium avium complex (MAC) prophylaxis were 2 or more CD4 counts less than 200 or 50 cells/mm(3) during calendar year (CY) 2001, respectively. Using multivariate logistic regression, we examined demographic and clinical characteristics associated with receipt of PCP or MAC prophylaxis and the association of outpatient utilization with appropriate OI prophylaxis. RESULTS: Among eligible patients, 88.1% received PCP prophylaxis and 87.6% received MAC prophylaxis. Approximately 80% had 4 or more outpatient visits during CY 2001. Adjusting for care site, male gender (odds ratio [OR], 1.47), Medicare coverage (OR, 1.60), and having 4 or more outpatient visits in a year (OR, 2.34) were significantly associated with increased likelihood of PCP prophylaxis. Adjusting for care site, having 4 or more outpatient visits in a year (OR, 1.85) was associated with increased likelihood of receipt of MAC prophylaxis. There were no demographic or insurance characteristics associated with receipt of MAC prophylaxis. CONCLUSIONS: The overall prevalence of OI prophylaxis has increased since the mid-1990s, and previous racial and HIV risk factor disparities in receipt of OI prophylaxis have waned. Integration into the healthcare system is an important correlate of receiving OI prophylaxis.

Hospital and outpatient health services utilization among HIV-infected children in care 2000-2001.

BACKGROUND: The aging of the pediatric HIV cohort and advances in antiretroviral therapy for children may have resulted in recent changes in patterns of healthcare utilization. OBJECTIVES: The objectives of this study were to examine inpatient and outpatient HIV-related health service utilization in a multistate sample of HIV-infected children, and to assess sociodemographic and clinical correlates of utilization. DESIGN: Cohort study of pediatric patients with HIV. Demographic, clinical, and resource utilization data were collected from medical records for 2000 and 2001. SETTING: This study was conducted at 4 U.S. HIV primary pediatric and specialty care sites in different geographic regions. PATIENTS: Three hundred three HIV-positive children with at least one outpatient visit or CD4 test in either 2000 or 2001 were studied. MAIN OUTCOME MEASURES: Mean outcome measures were number of hospital admissions, mean length of hospital stay, and number of outpatient clinic/office visits. RESULTS: Hospitalization rates decreased significantly from 39.2 (95% confidence interval [CI], 28.4-50.1) to 25.3 (95% CI, 16.4-34.3) admissions per 100 patients between 2000 and 2001. Hospitalizations were higher among patients with greater immunosuppression, those 2 years and under, and those with AIDS, but were not significantly related to receipt of highly active antiretroviral therapy. Mean outpatient visits did not change significantly between 2000 and 2001 from 9.09 (95% CI, 8.3-9.9) to 9.06 (95% CI, 8.4-9.7) visits per child per year. Children 2 years and under, those on highly active antiretroviral therapy, those with AIDS, and those with Medicaid had significantly higher outpatient utilization. Those with higher HIV-1 RNA had higher outpatient utilization than those with less advanced disease. CONCLUSION: Inpatient utilization significantly decreased between 2000 and 2001, but outpatient utilization did not change over time. Compared with prior studies, utilization rates appear to be declining over time. Unlike adults, racial/ethnic or gender disparities in healthcare utilization are less pronounced for HIV-infected children.

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.