Christine Hartman

Retention in Care: A Challenge to Survival with HIV Infection

BACKGROUND Patients with human immunodeficiency virus (HIV) infection need lifelong medical care, but many do not remain in care. The effect of poor retention in care on survival is not known, and we sought to quantify that relationship. METHODS We conducted a retrospective cohort study involving persons newly identified as having HIV infection during 1997-1998 at any United States Department of Veterans Affairs hospital or clinic who started antiretroviral therapy after 1 January 1997. To be included in the study, patients had to have seen a clinician at least once after receiving their first antiretroviral prescription and to have survived for at least 1 year. Patients were divided into 4 groups on the basis of the number of quarters in that year during which they had at least 1 HIV primary care visit. Survival was measured through 2002. Because data were available for only a small number of women, female patients were excluded from the study. RESULTS A total of 2619 men were followed up for a mean of >4 years each. The median baseline CD4(+) cell count and median log(10) plasma HIV concentration were 228x10(6) cells/L and 4.58 copies/mL, respectively. Thirty-six percent of the patients had visits in <4 quarters, and 16% died during follow-up. In Cox multivariate regression analysis, compared with persons with visits in all 4 quarters during the first year, the adjusted hazard ratio of death was 1.42 (95% confidence interval, 1.11-1.83; P<.01), 1.67 (95% confidence interval, 1.24-2.25; P<.001), and 1.95 (95% confidence interval, 1.37-2.78; P<.001) for persons with visits in 3 quarters, 2 quarters, and 1 quarter, respectively. CONCLUSIONS Even in a system with few financial barriers to care, a substantial portion of HIV-infected patients have poor retention in care. Poor retention in care predicts poorer survival with HIV infection. Retaining persons in care may improve survival, and optimal methods to retain patients need to be defined.

Patients referred to an urban HIV clinic frequently fail to establish care: factors predicting failure

Abstract To measure the success with which patients newly entering outpatient care establish regular care, and assess whether race/ethnicity was a predictive factor, we conducted a medical record review of new patients seen 20 April 1998 to 31 December 1998 at The Thomas Street Clinic, a county clinic for uninsured persons. Patients were considered ‘not established’ if they never saw a physician in the 6 months after intake (the ‘initial period’), ‘poorly established’ if seen but a > 6-month gap in care began in the initial period, and ‘established’ if there were no such gaps. Of 404 patients, 11% were ‘not established’, 37% ‘poorly established’, and 53% ‘established’. Injection drug use as HIV risk factor (IDU), admitted current alcohol and drug use, age < 35 years, and CD4 count > / = 200 cells/mm3 were most common in the ‘not established’ group and least common in the ‘established’ group. In multivariate ordinal logistic regression, difficulty establishing care was associated with IDU, admitted current alcohol use, and admitted former drug use. Age > 35 years was protective. Half the indigent patients entering care in this single-site study fail to establish regular care. Substance use and younger age are predictors of failure to establish care.

Predictors of retention in HIV care among a national cohort of US veterans.

Abstract Background: Poor retention in HIV care leads to poor survival. The predictors of poor retention in HIV care are not well understood, especially from US nationwide datasets. We determined the predictors of poor retention in HIV care among a group of US veterans and examined whether poor retention was confounded by other predictors of survival. Methods: We conducted a retrospective cohort study of 2,619 male US veterans who started antiretroviral therapy after January 1, 1998. Poor retention in HIV care was defi ned as having had at least 1 quarter-year without any primary care visit in the year after starting antiretroviral therapy. Survival was assessed through 2002. Logistic regression and Cox models were constructed. Results: Thirty-six percent of patients had poor retention in care. In multivariable analysis, younger age, Black race/ethnicity, CD4 cell count >350 ×106/L, hepatitis C infection, and illicit drug use were predictive of poor retention in care. Having a chronic medical comorbidity and being identifi ed as a man having sex with men (MSM) were associated with improved retention in care. In multivariable survival analyses, poor retention in care was not a confounder or moderator for other variables that predicted survival. Conclusions: Retention in HIV care is an independent predictor of survival. As routine HIV screening increases, more people with the characteristics predictive of poor retention in care will be identifi ed. Interventions to improve retention in care are needed.

Effectiveness of National Provider Prescription of PPI Gastroprotection Among Elderly NSAID Users

OBJECTIVESOur aim was to quantify the effect of provider adherence on the risk of NSAID-related upper gastrointestinal events (UGIE).METHODSWe identified from national pharmacy records veterans >65 yr prescribed an NSAID, a coxib, or salicylate (>325 mg/day) at any Veterans Affairs (VA) facility (January 1, 2000 to December 31, 2002). Prescription fill data were linked in longitudinal fashion to VA inpatient, outpatient, and death files and merged with demographic, inpatient, outpatient, and provider data from Medicare. Each person-day of follow-up was assessed for exposure to NSAID alone, NSAID+proton pump inhibitor (PPI), coxib, or coxib+PPI. UGIE was defined using our published, validated algorithm. Unadjusted incidence density ratios were calculated for the 365 days following exposure. We assessed risk of UGIE using Cox proportional hazards models, while adjusting for demographics, UGIE risk factors, comorbidity, prescription channeling (i.e., propensity score), geographic location, and multiple time-dependent pharmacological covariates, including aspirin, steroids, anticoagulants, antiplatelets, statins, and selective serotonin reuptake inhibitors.RESULTSIn our cohort of 481,980 (97.8% male, 85.3% white, mean age 73.9, standard deviation 5.6), a safer strategy was prescribed for 19.8%, and 2,753 UGIE occurred in 220,662 person-years of follow-up. When adjusted for prescription channeling, confounders, and effect modification-associated PPI, risk of UGIE was 1.8 (95% confidence interval [CI] 1.6–2.0) on NSAID alone, 1.8 (95% CI 1.5–2.0) on coxib alone, 1.1 (95% CI 0.7–4.6) on NSAID+PPI, and 1.1 (0.6–5.2) on coxib+PPI. When the analysis was adjusted for cumulative percent time spent on a PPI, risk of UGIE decreased from HR 3.0 (95% CI 2.6–3.7) when a PPI was prescribed 0–20% of the time to 1.1 (95% CI 1.0–1.3) when a PPI was prescribed 80–100% of the time.CONCLUSIONSProvider adherence to safer NSAID prescribing strategies is associated with fewer UGIE among the elderly. An adherent strategy lowers, but does not eliminate, risk of an NSAID-related UGIE.

Risk of Lower and Upper Gastrointestinal Bleeding, Transfusions, and Hospitalizations with Complex Antithrombotic Therapy in Elderly Patients

Background— Complex antithrombotic therapy (CAT) prescribed to elderly patients increases the risk of gastrointestinal bleeding. We quantified upper (UGIE) and lower gastrointestinal (LGIE) events, transfusions, and hospitalizations in a national cohort of elderly veterans prescribed CAT. Methods and Results— Veterans ≥60 years of age prescribed anticoagulant-antiplatelet, aspirin (ASA)-antiplatelet, ASA-anticoagulant, or triple therapy (ie, TRIP, anticoagulant-antiplatelet-ASA) were identified from the national pharmacy database (October 1, 2002 to September 30, 2008). Prescription-fill data were linked to Veteran Affairs and Medicare encounter files, each person-day of follow-up was assessed for CAT exposure, and outcomes were defined by using diagnostic code algorithms derived following chart abstraction. Incidence density ratios (compared with the reference category of no CAT) and survival analysis was conducted. Among 78 133 veterans (98.6% white; mean age, 72.3 [standard deviation 7.7]), 64% were prescribed ASA-antiplatelet and anticoagulant-antiplatelet and 6% were prescribed TRIP. The incidence of UGIE was 20.1/1000 patient-years, and the incidence of LGIE was 70.1/1000 patient-years. ASA-anticoagulant and TRIP were associated with the highest incidence of transfusion and hospitalization. A 40% to 60% increased risk of UGIE was observed with all strategies. LGIE was 30% higher with anticoagulant-antiplatelet, and transfusion increased with ASA-anticoagulant (hazard ratio, 6.1; 95% confidence interval, 5.2–7.1) and TRIP (hazard ratio, 5.0; 95% confidence interval, 4.2–5.8). Increased risk of hospitalization was noted with all strategies. The number needed to harm for UGIE or LGIE ranged from 52 to 65 and 15 to 23, respectively. The number needed to harm for hospitalization was 39 (anticoagulant-antiplatelet), 34 (ASA-anticoagulant), 67 (ASA-antiplatelet), and 45 (TRIP) patients. Conclusions— Among elderly patients, CAT-related LGIE and UGIE are clinically relevant risks resulting in increased hospitalizations and transfusions.

Social Support as a Predictor of Early Diagnosis, Linkage, Retention, and Adherence to HIV Care: Results From The Steps Study

&NA; Social support predicts adherence to antiretroviral therapy (ART) in some settings but has not been well studied in persons newly diagnosed with HIV infection as a predictor of success through the cascade of HIV care. One hundred sixty‐eight persons newly diagnosed with HIV completed the Medical Outcomes Study Social Support Survey at diagnosis, and 129 were successfully followed for more than 12 months. Outcomes were earlier diagnosis of HIV infection, linkage to care, retention in care, ART use by 1 year, and adherence to ART. Higher social support scores (either overall or on a subscale) were associated with earlier HIV diagnosis, timely linkage to care, and adherence to ART. Social support did not predict use of ART or retention in HIV care. Success navigating some of the steps of HIV care is more likely with social support, but it is not sufficient to ensure success across the continuum of care.

Impact of antiretroviral dosing frequency and pill burden on adherence among newly diagnosed, antiretroviral-naive HIV patients.

There are few data on the impact of antiretroviral therapy (ART) regimen factors on adherence in ART-naïve HIV patients on contemporary once- or twice-daily regimens. Ninety-nine newly diagnosed patients in a prospective observational cohort study completed a visual analogue scale to assess their ART adherence. Adherence by type of ART and dosing frequency were compared by Brown–Mood median tests. Participants taking once-daily regimens had higher adherence (n = 70, 99.5%) compared with participants taking twice-daily regimens (n = 29, 94%; P = 0.01). Adherence of participants taking the fixed dose combination efavirenz–emtricitabine–tenofovir (n = 34, 100%) compared with those taking once-daily regimens of two or more pills was no different (n = 36, 99.3%; P = 0.34). Among a cohort of newly diagnosed ART-naïve patients, once-daily dosing of ART resulted in higher adherence than twice-daily dosing. Pill burden among once-daily regimens did not predict adherence, suggesting that factors other than pill burden should drive regimen selection.

Adapting the Rx-Risk-V for mortality prediction in outpatient populations

Objectives:We sought to operationalize, test, and validate an outpatient pharmacy-based case-mix adjuster. Methods:Outpatients from the Department of Veterans Affairs (VA) prescribed a nonsteroidal anti-inflammatory drug (NSAID) or cyclooxygenase-2 selective drug during 2002 were identified. We updated and extended the Rx-Risk-V by adding 26 additional disease categories and mapping them to VA drug-class codes; derived empirical weights for each from a logistic model of 1-year mortality; adjusted for age, race and sex; and scored the weights into 1 measure of comorbidity. We compared the weighted score to the Deyo diagnosis-based comorbidity index and validated it in a national cohort of 260,321 outpatients with chronic heart failure (CHF). Results:One-year mortality among the 724,270-outpatient NSAID cohort was 1.6% (n = 11,766). Using a baseline model of age, race, and gender (c-index = 0.716), we found that the Deyo measure improved the prediction of mortality (c-index = 0.765), and the pharmacy comorbidity score further improved the prediction (c-index = 0.782), an increase of 25.8%. Using both, we found further improvement (c-index = 0.792). Among the CHF cohort, 9.7% (n = 25,251) died within 1 year. Performance of the baseline model controlling for age, race, and gender (c index = 0.620) improved with addition of the pharmacy comorbidity score (c index = 0.689), compared with the addition of the Deyo measure (c index = 0.651), an increase of 55.1%. Together, they slightly improved prediction in CHF patients (c index = 0.695). Conclusions:The updated and extended Rx-Risk-V is useful for case-mix adjustment of mortality in an outpatient population.

Validity of self-report measures in assessing antiretroviral adherence of newly diagnosed, HAART-Naïve, HIV patients

Abstract Purpose: To compare the performance of self-report instruments assessing adherence to antiretroviral therapy (ART) in patients starting ART for the first time and in a predominately Hispanic population.Methods: Of 184 patients in a prospective observational cohort study of newly diagnosed, minority patients of low socioeconomic status, 54 were given Medication Event Monitoring System (MEMS) caps for their boosted protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI). They completed a 4’week recall visual analogue scale (VAS), the Adult AIDS Clinical Trial Group (AACTG) 4’day recall instrument, and a 1’month recall qualitative single-item measure every 3 months for up to 18 months in English or Spanish. Electronic pharmacy records recorded refill dates. Spearman correlation coefficients were calculated to compare self-report measures with MEMS data and pharmacy data.Results: Of 46 patients with MEMS data, mean adherence was 84.7% (SD 35.6) by MEMS, 84.5% (SD 15.1) by pharmacy, 95.4% (SD 11.9) by VAS, 95.8% (SD 17.2) by AACTG, and 87.6% (SD 28.2) by qualitative single item. The correlation coefficient (CC) of VAS with MEMS was 0.37 (P < .01), and with pharmacy it was 0.34 (P < .01). The CC of the AACTG with MEMS was 0.32 (P < .01), and with pharmacy it was 0.28 (P < .01). The qualitative single item had a CC with MEMS of 0.24 (P < .01) and with pharmacy of 0.32 (P < .01). Spanish-speaking patients’ VAS adherence had a CC of 0.40 (P < .01) with MEMS.Conclusions: The VAS, AACTG, and qualitative single-item measures correlated significantly with MEMS and pharmacy data. Our data support self-administration of the VAS, even in Span-ish speakers.

Increased thyroid cancer incidence corresponds to increased use of thyroid ultrasound and fine-needle aspiration: A Study of the veterans affairs health care system

Thyroid cancer incidence has increased in the last several decades and may represent either a true increase in the number of cases or increased screening. The objective of this study was to examine thyroid cancer incidence and the use of thyroid ultrasound and fine‐needle aspiration (FNA) screening in the Veterans Affairs (VA) health care system. The authors hypothesized that the incidence of thyroid cancer would correspond to increases in the use of these diagnostic modalities.