Fred J. Hellinger

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001

Background: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization. Methods: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART. Results: In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm3 in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm3 received HAART; and 77% of those with no CD4 counts below 350 cells/mm3 received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm3 (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART. Conclusions: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

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

The Impact of Medical Errors on Ninety-Day Costs and Outcomes: An Examination of Surgical Patients

19 912, with an interquartile range from US

Hospital and outpatient health services utilization among HIV-infected patients in care in 1999

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

The impact of state laws limiting malpractice damage awards on health care expenditures.

40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US

Estimating the national cost of treating people with HIV disease: Patient, payer, and provider data

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.

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

OBJECTIVE To estimate the effect of medical errors on medical expenditures, death, readmissions, and outpatient care within 90 days after surgery. DATA SOURCES 2001-2002 MarketScan insurance claims for 5.6 million enrollees. STUDY DESIGN The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were used to identify 14 PSIs among 161,004 surgeries. We used propensity score matching and multivariate regression analyses to predict expenditures and outcomes attributable to the 14 PSIs. PRINCIPAL FINDINGS Excess 90-day expenditures likely attributable to PSIs ranged from

Trends in HIV-related inpatient admissions from 1993 to 1997: a seven-state study.

646 for technical problems (accidental laceration, pneumothorax, etc.) to

The changing pattern of hospital care for persons living with HIV: 2000 through 2004.

28,218 for acute respiratory failure, with up to 20 percent of these costs incurred postdischarge. With a third of all 90-day deaths occurring postdischarge, the excess death rate associated with PSIs ranged from 0 to 7 percent. The excess 90-day readmission rate associated with PSIs ranged from 0 to 8 percent. Overall, 11 percent of all deaths, 2 percent of readmissions, and 2 percent of expenditures were likely due to these 14 PSIs. CONCLUSIONS The effects of medical errors continue long after the patient leaves the hospital. Medical error studies that focus only on the inpatient stay can underestimate the impact of patient safety events by up to 20-30 percent.

Putting Practice into Research

Background: The evolving epidemiology and therapeutic management of HIV disease has important implications for health care resource utilization in HIV‐infected patients, and health care resource use data are also needed to support policy and financial decision making. Methods: Demographic, clinical, and resource utilization data were collected from 9 U.S. HIV primary and specialty care sites in calendar year 1999. Rates of resource use were calculated for hospital admission, length of hospital stay, and outpatient clinic/office visits. Results: The sample included 5255 patients from HIV primary care sites in 3 eastern, 3 midwestern, and 3 western areas of the United States. Hospital admissions accounted for an annual mean of 297 days per 100 persons/y in 1999. Hospital days ranged from a low of 165 per 100 persons/mo for a CD4 > 500 cells/mm3 to 840 per 100 persons/mo for a CD4 < 50 cells/mm3 (p < .01). Mean annual outpatient clinic/office visits were 10.7 per person in 1999. A declining CD4 level and an increasing HIV‐1 RNA level were both associated with higher hospital and outpatient utilization. HAART use was associated with fewer hospital days, and a higher outpatient visit rate. Injecting drug use risk was associated with an increase in hospital days. African American race was associated with a higher number of hospital days, but a lower outpatient visit rate. Female gender was associated with higher outpatient utilization. Mean monthly inpatient and outpatient expenditures in 1999 were