Christine Laine

Relationship of Gender, Depression, and Health Care Delivery With Antiretroviral Adherence in HIV‐infected Drug Users

BACKGROUND: Antiretroviral adherence is worse in women than in men, and depression can influence medication adherence.OBJECTIVE: To evaluate the relationship of gender, depression, medical care, and mental health care to adherence in HIV-infected drug users.DESIGN: Retrospective cohort study.SETTING: New York State Medicaid program.PARTICIPANTS: One thousand eight hundred twenty-seven female and 3,246 male drug users on combination antiretroviral therapy for more than 2 months in 1997.MAIN MEASURES: A pharmacy-based measure of adherence was defined as ≥95% days covered by at least 2 prescribed antiretroviral drugs. Independent variables were: depression, regular drug treatment (≥6 months), regular medical care (2+ and >35% of visits), HIV-focused care (2+ visits), psychiatric care (2+ visits), and antidepressant therapy.RESULTS: Women were less adherent than men (18% vs 25%, respectively, P<.001) and more likely to be diagnosed with depression (34% vs 29%). In persons with depression, the adjusted odds ratio (AOR) for adherence was greater for those with psychiatric care alone (AOR 1.52; 95% confidence interval [95% CI], 1.03 to 2.26) or combined with antidepressants (AOR 1.49; 95% CI, 1.04 to 2.15). In separate models by gender in persons with depression, psychiatric care plus antidepressants had a slightly stronger association with adherence in women (AOR 1.92; 95% CI, 1.00 to 3.68) than men (AOR, 1.26; 95% CI, 0.81 to 1.98). In drug users without depression, antidepressants alone were associated with greater adherence (AOR, 1.23; 95% CI, 1.02 to 1.49) with no difference by gender. Regular drug treatment was positively associated with adherence only in men.CONCLUSIONS: In this drug-using cohort, women had worse pharmacy-measured antiretroviral adherence than men. Mental health care was significantly associated with adherence in women, while regular drug treatment was positively associated with adherence in men.

Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis.

Objective To assess adherence to antiretroviral therapy with the use of Medicaid pharmacy claims data for human immunodeficiency virus (HIV)-infected pregnant women and to identify associated maternal and health care factors. Methods We retrospectively studied a cohort of 2714 HIV-infected women in New York State who delivered live infants from 1993–96. Among 682 women prescribed antiretroviral therapy in the last two trimesters, we studied 549 who started therapy more than 2 months before delivery. Adherence was defined as adequate if the supplied drug covered at least 80% of the days from the first prescription in the last two trimesters until delivery. Multivariable analyses were used to examine associations between maternal and health care factors and adherence. Results Only 34.2% of 549 subjects had at least 80% adherence based on pharmacy data, a rate that remained stable over time. The adjusted odds ratios (ORs) of adherence for black (OR 0.47, 95% confidence interval [CI] 0.30, 0.75) and Hispanic (OR 0.49, 95% CI 0.29, 0.82) women were nearly 50% lower than for white women. The OR of adherence was 0.32 (95% CI 0.12, 0.90) for teenagers compared with women aged 25–29 years and 0.56 (95% CI 0.34, 0.92) for women in New York City versus those residing elsewhere. Women on antiretroviral therapy before pregnancy were more likely to adhere (OR 1.55, 95% CI 1.02, 2.35). Conclusion Teenagers, women of minority groups, and women living in New York City had greater risks of poor antiretroviral adherence, whereas women already prescribed antiretrovirals before pregnancy had better adherence. Our conservative pharmacy data–based measure showed that most HIV-infected women adhered poorly and adherence did not improve over the 4-year study.

The relationship of clinic experience with advanced HIV and survival of women with AIDS

Objective:Hospital and physician experience have been linked to improved outcomes for persons with HIV. Because many HIV-infected patients receive care in clinics, we studied clinic HIV experience and survival for women with AIDS. Design:Retrospective cohort study of women with AIDS whose dominant sources of care were clinics. Clinic HIV experience was estimated as the cumulative number of Medicaid enrollees with advanced HIV who used a particular clinic as their dominant provider up to the year of the patients AIDS diagnosis: low experience (< 20 patients), medium (20–99 patients), high (≥ 100 patients). Proportional hazards models examined relationships between experience and survival. Setting:A total of 117 New York State clinics. Patients:A total of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989–1992. Main outcome measure:Survival after AIDS diagnosis. Results:In later study years (1991–1992), patients in high experience clinics had an approximately 50% reduction in the relative hazard of death (0.53; 95% confidence interval, 0.35–0.82) compared with patients in low experience clinics. Adjusting for demographic and clinical variables, 71% of patients in high experience clinics were alive 21 months after diagnosis compared with 53% in low experience clinics. Experience and survival were not significantly associated in the early study years (1989–1990). Conclusions:In more recent years, women with AIDS receiving care in high experience clinics survived longer after AIDS diagnosis than those in low experience clinics, providing further evidence of a relationship between provider HIV experience and outcomes.

Availability of medical care services in drug treatment clinics associated with lower repeated emergency department use.

Background:Drug users rely heavily on emergency departments (EDs) for care. Medical and other services in outpatient drug treatment clinics may reduce demand for ED care. Objective:The objective of this study was to examine the association of services in drug treatment clinics with repeated ED use by clinic patients. Design:This study consisted of telephone interviews of directors of a stratified random sample of 125 New York state outpatient drug treatment clinics linked to Medicaid claims for patients with long-term (≥6 months) treatment at these clinics. Patients:This study comprised a total of 8397 Medicare enrollees in surveyed clinics in 1996 to 1997. Measurements:The surveys addressed drug treatment; general medical, HIV, alcohol, and social support services; location of selected services; primary care, HIV specialty, and mental health provider staffing levels; accessibility; and academic affiliation. From Medicaid claims, we defined patient demographic, clinical, and healthcare variables. Logistic regression models examined associations of availability of onsite medical services with repeated (2 or more) ED visits in 1997, adjusted for patient characteristics and patient clustering in clinics. Results:Repeated ED visits occurred in 15% of the cohort and were less likely when medical services were all onsite versus more distant (12.9% vs 16.8%, P < 0.001). An interaction showed that onsite medical care was associated with less ED use only in low-volume (≤1350 visits/wk, adjusted odds ratio [AOR] 0.64 [0.47–0.88]) and moderate volume (1351–2500 visits/wk, AOR 0.79 [0.64–0.97]) clinics. The availability of preventive services and HIV specialists onsite appear to mediate the beneficial effect of onsite medical care. Conclusions:Greater onsite medical care in low- and moderate-volume drug treatment clinics was associated with less repeated ED use.

PREVENTING COMPLICATIONS IN DIABETES MELLITUS: The Role of the Primary Care Physician

Many Americans, knowingly or unknowingly, are afflicted with diabetes. Because of a lack of awareness or a disbelief that aggressive treatment benefits patients on the part of both patients and physicians, diabetes, particularly NIDDM, remains underdiagnosed and undertreated despite complications that can dramatically diminish quality of life. Increasing evidence that good glycemic control forestalls if not prevents these outcomes makes it the primary care physicians imperative to diagnose diabetes before complications develop. Physicians, through targeted screening and aggressive treatment of patients in whom they diagnose this chronic disease, can markedly reduce diabetes-related morbidity and mortality.

Outpatient patterns of care and longitudinal intensity of antiretroviral therapy for HIV-infected drug users

Objective. To examine the association of drug users’ outpatient patterns of care with subsequent intensity of antiretroviral therapy (ART). Materials and methods. Annual types of ART in 8897 New York State Medicaid drug users who were prescribed ART for ≥6 months in 1996 or 1997 were determined. From pharmacy claims, intensity was classified from changes in annual type of ART in 1996 to 97 and 1997 to 98 as: optimal (ie, on or starting highly active ART [HAART]), acceptable (ie, on or starting 2+ non-HAART drugs), or suboptimal (ie, none, <6 months, one drug, or change from HAART to non-HAART). In both 1996 and 1997, outpatient pattern of care was defined including regular medical care, regular drug treatment, both, and neither and categories of visits for HIV-focused care. Predictors of adequate ART intensity were examined among the group with suboptimal or adequate intensity (model 1) and predictors of optimal ART intensity among the group with adequate or optimal intensity (model 2). Results. The adjusted odds ratios (AOR) of acceptable ART intensity in model 1 were increased for those with HIV-focused care (AOR, 2.9; 95% CI, 2.6, 3.3 for 4+ visits 1.7; 95% CI, 1.5, 1.9 for 1–3 visits) or regular medical care (AOR, 1.2 [1.1, 1.4]. Adjusted odds ratios (AOR) of optimal intensity in model 2 were increased for those with regular substance abuse care with (AOR, 1.4 [1.2, 1.7]) or without (AOR, 1.2 [1.1, 1.4]) regular medical care whereas HIV-focused visits had no effect. Conclusion. Care from an HIV-focused provider was predictive of a drug user receiving at least adequate intensity of ART for more than 2 years whereas regular drug abuse treatment, especially with regular medical care, was associated with optimal intensity of ART.

Clinic characteristics associated with reduced hospitalization of druc users with aids

ObjectiveTo identify features of ambulatory care associated with reduced hospitalization among drug users with acquired immunodeficiency syndrome (AIDS).MethodsA nonconcurrent prospective study of hospital use by 1,369 drug users with AIDS was conducted using data from New York State Medicaid research data files linked to telephone interview data from directors of ambulatory care clinics serving this group.ResultsFollow-up averaged 29 months, during which 88% of subjects were hospitalized at least once. On average, those hospitalized spent 14% of follow-up time as inpatients. Hospitalization was less likely for patients in clinics with case managers (adjusted odds ratio=0.42, 95% confidence interval 0.25, 0.68) or high director’s rating of coordination of care (adjusted odds ratio=0.50, 95% confidence interval 0.29, 0.89). Multivariate analysis showed significantly less time in hospital for patients in clinics with methadone maintenance, case managers, high continuity ratings, and clinic physicians attending for hospitalized clinic patients.ConclusionsDrug users with AIDS rely heavily on inpatient care, but those followed in clinics featuring greater coordination and offering special services, including methadone treatment and case management, appear to have significantly less hospital use.

HIV-1 RNA viral load monitoring in HIV-infected drug users on antiretroviral therapy: Relationship with outpatient care patterns

HIV-1 viral load (VL) testing is a standard component of HIV care. We examined the use and predictors of VL testing in drug users, a group at risk for problematic care. Using 1996 to 1998 New York State (NYS) Medicaid files, we studied drug users who had been enrolled >10 months, had been prescribed antiretroviral agents in 1997 and 1998, and who had undergone any VL testing in 1997. Our outcome was regular VL testing shown by two or more paid claims for this test in 1998. Patterns of care in 1997 were defined as: regular source of medical care (>35% of visits to one provider), and/or regular drug treatment of >6 months, or neither. We counted visits in 1997 to a provider offering HIV-focused care. Adjusted odds ratios (AORs) of VL testing were assessed. Of 3131 drug users, 73.9% had at least one VL test, whereas 56.2% had two or more VL tests in 1998. The AORs of two or more VL tests were increased for those with regular drug abuse care alone (AOR, 1.50; 95% confidence interval [CI], 1.21-1.84) or with regular medical care (AOR, 1.27; 95% CI, 1.03-1.57) versus those with neither. HIV-focused care was positively associated with two or more VL tests (AOR, 1.38; 95% CI, 1.05-1.81 for 1-3 visits; AOR, 1.94; 95% CI, 1.50-2.51 for four or more visits). We found that nearly half this cohort of drug users did not have regular VL testing. Drug users with HIV-focused care or with regular drug treatment are more likely to have regular VL testing.

Effect of medical, drug abuse, and mental health care on receipt of dental care by drug users.

We examined the association of patterns of health care in 1996 with subsequent dental care in 1997 or 1998 for 47,260 drug users enrolled in New York State Medicaid. From Medicaid files, we identified psychiatric care, prescribed antidepressants, a regular source of medical care, regular drug treatment (6+ contiguous months), and clinical conditions. Of this cohort, 58% received dental care. The adjusted odds ratios (AOR) of dental care were increased for drug users receiving psychiatric care and antidepressants (1.66 [1.55, 1.77]), psychiatric care alone (1.48 [1.41, 1.56]), or only antidepressants (1.18 [1.10, 1.27]), vs. neither. AORs of dental care were also higher for those with a regular source of medical care alone (1.27 [1.23, 1.35]) or with regular drug treatment (1.33 [CI 1.25, 1.41]) vs. neither. Mental health care and, to a lesser extent, a regular source of medical care and regular drug treatment may promote dental care in this vulnerable population.

Models of care in New York State Medicaid substance abuse clinics. Range of services and linkages to medical care.

PURPOSE To explore the range of health care services in substance abuse clinics. METHODS Survey of directors of a stratified random sample of 125 substance abuse treatment clinics offering methadone, drug-free therapy, or both, representing 344 clinics participating in the New York State (NYS) Medicaid program. Survey asked about clinic services and referral patterns. We defined five categories of linkage of substance abuse to medical care ranging from unlinked (e.g. referral to distant sites) to highly linked (e.g. on site). To estimate the number of patients served, State data on licensed patient capacity for each clinic were used. RESULTS This sample represented 344 clinics statewide serving an estimated 60,914 patients. For patients with acute, chronic, or HIV-related medical conditions, weighted analyses showed highly linked care in 54 of the 344 (16%) clinics statewide, serving an estimated 13,741 patients. Unlinked care for all these medical conditions was found for 28% of statewide clinics, serving an estimated 8866 patients. Clinics offering both methadone and drug-free therapy were generally more likely to have medically related services on site. IMPLICATIONS The extent of medical care services available at substance abuse clinics varies widely. Over one-quarter of clinics offered only loosely connected medical and substance abuse care.