Linda J. McKee

Factors associated with intention to undergo annual prostate cancer screening among African American men in Philadelphia

This study assesses whether African American men in Philadelphia are receptive to annual prostate cancer screening. Factors associated with intention to undergo prostate cancer screening are also identified.

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.

AIDS SPECIALIST VERSUS GENERALIST AMBULATORY CARE FOR ADVANCED HIV INFECTION AND IMPACT ON HOSPITAL USE

We examined patterns of ambulatory care in the year before diagnosis of acquired immune deficiency syndrome (AIDS) for 5,720 persons infected with human immunodeficiency virus (HIV) who were continuously enrolled in the New York State Medicaid program and diagnosed in 1984–90. For 3,175 persons followed ≥ 6 months after AIDS, we also examined the change between the year before AIDS diagnosis and the 6 months afterward in the predominant provider who was seen most frequently and at least twice. Approximately 75% of the population had a predominant provider identified. Of this group, 43% of the patients had a generalist as their predominant provider before AIDS diagnosis, falling to only 25% after diagnosis. The proportion with an AIDS specialist predominant provider increased from 22% before AIDS diagnosis to 39% afterward (P < 0.001). Patients with a generalist predominant provider before AIDS diagnosis had higher odds of switching providers and of hospitalization after AIDS diagnosis than patients with an AIDS specialist predominant provider. If generalists are to be encouraged to manage patients with advanced HIV disease, a better understanding of factors contributing to these outcomes is needed.

Health care delivery, zidovudine use, and survival of women and men with AIDS.

SummaryThe aim of this study was to define predictors of survival for women and men after AIDS diagnosis. We examined health care delivery and drug therapy in the year before AIDS diagnosis for continuously enrolled New York State Medicaid beneficiaries with AIDS in 1988–1990. We examined the association of these factors with survival after AIDS diagnosis. Of 1,077 women and 1,871 men, 60% of both gender groups were drug users. In both risk groups, women had more outpatient visits than men but were equally likely to visit an AIDS specialist. In those who were not drug users, men were twice as likely as women to receive either zidovudine or Pneumocystis carinii pneumonia prophylaxis. No difference appeared among drug users. Survival after AIDS diagnosis was similar by gender for those who were not drug users (RR = 1.09; 95% CI = 0.90–1.33). In drug users, women had a slightly lower risk of death than men (RR = 0.84; 95% CI = 0.72–0.98). Risk of death after AIDS diagnosis was higher for persons starting zidovudine earlier in both risk groups. Among drug users, women received more ambulatory care and survived slightly longer than men. Among those who were not drug users, survival was similar by gender even after adjusting for differences in care.

Prenatal care and birth outcomes of a cohort of HIV-infected women

Adequate prenatal care has been linked to improved birth outcomes in general populations but has not been assessed in HIV-infected women. We examined longitudinal claims files and vital statistics records for women in the New York State Medicaid HIV/AIDS data base delivering a singleton from 1985 through 1990. Adequacy of the self-reported number of prenatal visits was assessed by the Kessner index. In logistics models, we estimated the association of prenatal care, illicit drug use, and other maternal characteristics with three outcomes; low birth weight, preterm birth, and small-for-gestational-age. Of 2,254 singletons delivered by this HIV-infected cohort, 28% were low birth weight, 23% were preterm birth, and 20% were small for gestational age. Two-thirds had inadequate prenatal care. Non-drug users had 57 and 26% lower adjusted odds of low birth weight and preterm delivery than drug users. The adjusted odds of low birth weight and preterm birth for women with an adequate number of prenatal visits were, respectively, 48 and 21% lower than for women with inadequate care. Adequate prenatal care was also associated with a 43% reduction in the odds of small-for-gestational-age. An adequate number of prenatal visits by women in this HIV cohort was associated with a significant reduction in all three adverse birth outcomes, but most had inadequate prenatal care. These data support strengthening efforts to bring pregnant, HIV-infected women into care.

A population-based comparison of the clinical course of children and adults with AIDS

ObjectiveTo examine the association of clinical complications and age at diagnosis with survival for a cohort of children and adults with AIDS. DesignA population-based analysis of 734 children and 5584 adults diagnosed with AIDS from 1985 to 1990 in New York State. ResultsThe initial AIDS-defining diagnoses for 68% of children were lymphoid interstitial pneumonitis or infections specified in the Centers for Disease Control and Preventions (CDC) pediatric AIDS case definition but not the CDCs 1987 adult AIDS case definition. Of opportunistic infections in both case definitions, Pneumocystis carinii pneumonia (PCP) was the most common initial AIDS diagnosis, occurring in 53% of adults, 47% of children aged < 6 months at diagnosis (n = 122) and 14% aged ≥6 months at diagnosis (n = 612). Median survival after AIDS diagnosis was 62 months for all children compared with 11 months for adults. For children initially diagnosed with conditions only in the pediatric case definition, median survival ranged from 27 to 62 months compared with less than 12 months for children and adults with PCP. Compared with children aged 6–54 months, the estimated hazards of death for younger and older children were 2.06 [95% confidence interval (Cl), 1.48–2.86] and 1.54 (95% Cl, 1.10–2.16), respectively. ConclusionChildren survived significantly longer than adults after AIDS diagnosis, but their survival varied by age at diagnosis. Differences in the types of common initial AIDS-defining diagnoses appear to contribute to the observed differences in survival.