Afshin Rastegar

Expenditures for the Care of HIV-Infected Patients in the Era of Highly Active Antiretroviral Therapy

BACKGROUND The introduction of expensive but very effective antiviral medications has led to questions about the effects on the total use of resources for the care of patients with human immunodeficiency virus (HIV) infection. We examined expenditures for the care of HIV-infected patients since the introduction of highly active antiretroviral therapy. METHODS We interviewed a random sample of 2864 patients who were representative of all American adults receiving care for HIV infection in early 1996, and followed them for up to 36 months. We estimated the average expenditure per patient per month on the basis of self-reported information about care received. RESULTS The mean expenditure was

The Care of HIV-infected Adults in Rural Areas of the United States

1,792 per patient per month at base line, but it declined to

Underuse of primary Mycobacterium avium complex and Pneumocystis carinii prophylaxis in the United States

1,359 for survivors in 1997, since the increases in pharmaceutical expenditures were smaller than the reductions in hospital costs. Use of highly active antiretroviral therapy was independently associated with a reduction in expenditures. After adjustments for the interview date, clinical status, and deaths, the estimated annual expenditure declined from

Implementation of Medical Homes in Federally Qualified Health Centers

20,300 per patient in 1996 to

Evaluation of CMS' FQHC APCP Demonstration: Final First Annual Report

18,300 in 1998. Expenditures among subgroups of patients varied by a factor of as much as three. Pharmaceutical costs were lowest and hospital costs highest among underserved groups, including blacks, women, and patients without private insurance. CONCLUSIONS The total cost of care for adults with HIV infection has declined since the introduction of highly active antiretroviral therapy. Expenditures have increased for medications but have declined for other services. However, there are large variations in expenditures across subgroups of patients.

Evaluation of CMS's Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration: Final Report

Objective: This study describes the population of HIV‐infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. Methods: Interviews were conducted with a nationally representative sample of 367 HIV‐infected adults receiving health care in rural areas and 2806 HIV‐infected adults receiving health care in urban areas of the contiguous United States. Results: We estimate that 4800 HIV‐infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV‐infected patients (38% vs. 3%; p < .001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p < .001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p = .006). Conclusions: Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high‐quality HIV care.

Physician-reported barriers to referring cancer patients to specialists: prevalence, factors, and association with career satisfaction.

Background: Little is known about the rates of Mycobacterium avium complex (MAC) and Pneumocystis carinii (PCP) prophylaxis adherence to guidelines and how they have changed after introduction of effective antiretroviral therapy. Objective: To determine rates of primary prophylaxis for MAC and PCP and to evaluate the influence of sociodemographic characteristics, region, and provider experience. Design: National probability sample cohort of HIV patients in care. Setting: One hundred sixty HIV health care providers. Patients: A total of 2864 patients interviewed in 1996 to 1997 (68% response) and 2267 follow‐up interviews, representing 65% of surviving sampled patients (median follow‐up, 15.1 months). Measurements: Use of prophylactic drugs, most recent CD4 count, sociodemographics, and regional and total HIV patients/providers. Results: Of patients eligible for primary MAC prophylaxis (most recent CD4 count <50/mm3), 41% at baseline and 40% at follow‐up patients were treated. Of patients eligible for primary PCP prophylaxis (i.e., those with CD4 counts <200/mm3), 64% and 72% were treated, respectively. MAC prophylaxis at baseline was less likely in African American (adjusted odds ratio [OR], 35; 95% confidence interval [CI], 0.20‐ 0.59), Hispanic (OR, 27; 95% CI, 0.08‐0.94) and less‐educated (OR, 0.61; 95% CI, 0.36‐1.0) patients and more likely in U. S. geographic regions in the Pacific West (OR, 4.9; 95% CI, 1.0‐23) and Midwest (OR, 6.4; 95% CI, 1.2‐33) and in practices with more HIV patients. Conclusions: Most eligible patients did not receive MAC prophylaxis; PCP prophylaxis rates were better but still suboptimal. Our results support outreach efforts to African Americans, Hispanics, the less educated, and those in the northeastern United States and in practices with fewer HIV patients.

Neighborhood and School Effects on Children's Development and Well-Being

BACKGROUND From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical‐home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS We examined the achievement of medical‐home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients’ experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference‐in‐differences analyses, we compared changes in outcomes in the two groups of sites during a 3‐year period. RESULTS Level 3 medical‐home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures (

Evaluation of CMS' FQHC APCP Demonstration

37 more per beneficiary per year, P=0.02). Demonstration‐site participation was not associated with relative improvements in most measures of patients’ experiences. CONCLUSIONS Demonstration sites had higher rates of medical‐home recognition and smaller decreases in the number of patients’ visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.)

Evaluation of CMS's Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration: Final Second Annual Report

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