Thomas Fanning

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.

A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population.

Objective: Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use. Method: This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York (n = 125,837) or New Jersey Medicaid (n = 139,405). Results: During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users. Conclusions: State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

Repeated emergency department use by HIV-infected persons: Effect of clinic accessibility and expertise in HIV care

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patients clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patients clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for 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 retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in medicaid patients with chronic psychiatric and neurologic disorders

BACKGROUND Benzodiazepines are treatment mainstays for several disorders, but there is often concern about dependency and addiction. In January 1989, New York implemented regulations requiring physicians to order benzodiazepines using state-monitored triplicate prescription forms. OBJECTIVE The purpose of this study was to assess the effects of the triplicate prescription program (TPP) on changes in use of benzodiazepines and other psychoactive drugs in clinically vulnerable Medicaid populations. METHODS Using an interrupted time series with comparison series design, psychoactive medication use was examined in the New York (intervention) and New Jersey (control) Medicaid programs before and after implementation of the New York benzodiazepine TPP among community-dwelling Medicaid beneficiaries aged >/=19 years continuously enrolled from January 1988 through December 1990 in New York or New Jersey with diagnoses of schizophrenia, schizophreniform disorder, schizoaffective disorder, schizoid personality disorder, or schizotypal personality disorder; bipolar disorder; epilepsy; and/or panic disorder, agoraphobia without history of panic disorder, social phobia, or specific phobia. RESULTS A total of 125,837 New York and 139,405 New Jersey Medicaid beneficiaries were continuously enrolled and met the study inclusion criteria. Of these, there were 6054 Medicaid enrollees in New York and 6875 enrollees in New Jersey who were clinically vulnerable patients with >/=1 of the specified diagnoses. New York Medicaid patients with any of these diagnoses experienced a -48.1% relative change (95% CI, -50.0% to -46.2%) in benzodiazepine use at 6 months after TPP implementation, with no decline in use in New Jersey patients. The largest reduction in benzodiazepine use was seen among patients with seizure disorder (-59.9% at 6 months; 95% CI, -63.9% to -55.9%). Although use of substitute drugs increased slightly in New York after the TPP, it did not offset reductions in benzodiazepine use. The effects of TPP were sustained for 7 years of follow-up and had the greatest impact on nonproblematic benzodiazepine use. CONCLUSIONS During the time period studied in this analysis, the New York TPP reduced benzodiazepine use among chronically ill patients for whom these agents represent effective treatment. Our findings suggest that many patients previously receiving benzodiazepines did not receive any pharmacologic intervention.

Translating clinical trial results into practice: the effect of an AIDS clinical trial on prescribed antiretroviral therapy for HIV-infected pregnant women.

Community practitioners have usually been slow to adopt advances from clinical trials, and serious deficiencies in the use of these advances can continue for years (1-3). Because of the urgent need to make major advances in combating HIV and the serious consequences of a slow response to such advances, policymakers, medical leaders, and community activists have strenuously promoted their adoption in community practice. Few clinical trials have received as much widespread publicity and attention as Pediatric AIDS Clinical Trials Group (PACTG) Protocol 076 (4). This trial resulted in the first major breakthrough in HIV prevention: Vertical transmission of HIV decreased by two thirds when women received zidovudine therapy in the second and third trimester of pregnancy, as well as intrapartum, and their children received a short course of zidovudine after delivery. Because of these dramatic findings, the trial was terminated in February 1994 after its first interim analysis, and the results were announced. Diverse approaches were used to educate patients and providers about PACTG Protocol 076, including news media (5), state and Public Health Service expert panel endorsement and treatment guidelines (6), direct mailings to practitioners, and community-based educational efforts that targeted women with or at risk for HIV infection (7). Publication of the trials findings in November 1994 was met with further efforts to ensure that this preventive intervention would be used in community practice. We sought to evaluate the pace at which prescribed antiretroviral treatment for HIV-infected pregnant women enrolled in the New York State Medicaid program changed after PACTG Protocol 076 and to identify factors of health care delivery associated with early adoption of this new standard of care. We expected that women whose providers were under state contract to deliver HIV-focused ambulatory services and coordination of care (8, 9) would be more likely to receive antiretroviral therapy because of the beneficial effect of HIV-experienced care on survival (10, 11) and on appropriate use of HIV-related treatments (12). We also predicted that women who were treated at an institution conducting trials to prevent vertical transmission would be more likely to benefit from the PACTG Protocol 076 advance. More frequent use of prenatal care and receipt of enhanced prenatal services (13) were predicted to be associated with being prescribed antiretroviral therapy because these two factors indicate increased access to comprehensive prenatal care and more opportunities for providers to initiate treatment. Among women who used illicit drugs, we hypothesized that those receiving methadone treatment would be more likely to receive antiretroviral therapy during pregnancy because of improved access to care (14). We also discuss potentially important approaches that can ensure expeditious integration of important clinical breakthroughs into community practice. Methods Study Sample On the basis of physician review, we updated a tested method of identifying HIV-infected women [15] to account for changes in coding of HIV infection, treatments, and services. The review encompassed more than 1000 randomly selected clinical and treatment histories of women who were enrolled in the New York State Medicaid program; had delivered children from 1993 through 1994; and had at least one International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, treatment, or service code that suggested HIV disease. The revised HIV case finding required 1) one inpatient or two outpatient diagnoses of HIV seropositivity or infection, 2) one outpatient diagnosis of HIV seropositivity or infection with one HIV care rate code, 3) an AIDS-defining diagnosis, or 4) receipt of antiretroviral therapy. We created a file on claims and eligibility longitudinal data for women who were enrolled in the New York State Medicaid program, were identified as HIV-infected, and had one or more deliveries (total deliveries, n=3037) from January 1993 through September 1996. The files included data from 3 years before and 1 year after each womans last delivery and were stripped of patient identifiers for analysis. For women who had multiple deliveries in the study years, we selected the last delivery for analysis; thus, 261 deliveries were eliminated. We then linked vital statistics birth certificates for 2655 of 2776 deliveries (95%) by using Social Security number, date of admission for delivery, site of delivery, childs date of birth, and fathers name. Vital statistics records offered demographic data, education, parity, gestational age at delivery, birth weight, and self-reported substance use during pregnancy. Claims provided information on diagnoses (up to five per inpatient claim and two per outpatient claim), procedures, payment rates, and filled prescriptions. Because key data were missing or sample size was small, we excluded the few persons who lacked data on ethnicity (n=32) or were Asian or Native American (n=16). Outcome Measures We identified pharmacy claims during the study period for all antiretroviral drugs approved by the Food and Drug Administration. Gestational age at delivery was usually determined from physician estimate or, when this estimate was unavailable (3.3% of persons), from the mothers estimate of the date of her last menstrual cycle. From these data, we determined prescribed antiretroviral therapy during the second or third trimester. Maternal and Health Care Measures We did not have access to the results of laboratory tests, such as data on viral load or CD4 cell count. To evaluate maternal HIV disease stage, we identified diagnoses that strongly predicted mother-to-child HIV transmission (16). The three clinical groups of HIV status were the following: severe (one or more AIDS-defining conditions, such as Pneumocystis carinii pneumonia, before or<1 year after delivery), moderate (bacterial or unspecified pneumonia or anemia during pregnancy), and mild (no moderate or severe conditions). Chronic medical conditions, including hypertension, asthma, and diabetes, were identified from claims made during, before, and after pregnancy. We determined use of illicit drugs by applying a tested approach to the claims [17]. This approach searched for methadone maintenance service codes, medically supervised nondrug treatment service codes, or diagnoses for illicit drug use. Self-reported illicit drug use was also identified from vital statistics. Pregnant women were divided into four categories of drug use: 1) use of regulated methadone, 2) current use of illicit drugs, 3) history of use of illicit drugs, and 4) no evidence of use of illicit drugs. Smoking and drinking during pregnancy were determined from self-reported vital statistics. We assessed the adequacy of the timing and number of prenatal care visits by using Kotelchucks Adequacy of Prenatal Care Utilization (APNCU) measures (18) and by following a previously reported approach (19). We applied the APNCU measures to visits to primary care physicians, obstetricians or gynecologists, or HIV-specific physicians or clinics (that is, physicians or clinics specializing in infectious disease, allergy or immunology, oncology, or HIV-focused care). The APNCU categories of intermediate care (50% to 79% of expected visits) and adequate care (80% to 109% of expected visits) were grouped together, as recommended (20). The APNCU category of adequate-plus care ( 110% of expected visits) was also included with the adequate care group because prescribed antiretroviral therapy was similarly expected to be greater. To determine receipt of services from providers who were likely to have greater expertise in HIV care, we examined receipt of HIV-focused services and provider specialty. We identified any visit to any provider who was under contract to New York State to offer many HIV-specific services and to coordinate care in exchange for increased Medicaid payment (8, 9). We also created a variable for at least one visit to a provider in an HIV-related specialty (infectious disease, hematology, oncology, or allergy and immunology). We then created dummy variables for the four combinations of these variables. Because only nine women received HIV-focused services but no specialty care, we grouped these women with those who received both, leaving three dummy variables. We also flagged women who had one or more visits to centers that participated in any federally sponsored trials of antiretroviral therapy for prevention of mother-to-child transmission. Finally, we identified any visit to a provider in the Prenatal Care Assistance Program who was under contract to the state to deliver many prenatal services, such as case management, health education, assessment or prevention of adverse outcomes, and nutritional services, to Medicaid enrollees (13). Statistical Analysis We determined the proportion of women delivering in each study month who were prescribed antiretroviral therapy. Nonparametric (lowess) smoothed averages over calendar time were plotted. We divided our analysis into three time periods: period 1January 1993 through February 1994 (the month when the trial results were announced), period 2March 1994 through November 1994 (the month when the trial results were published), and period 3December 1994 through September 1996. We used the chi-square test to examine bivariate associations of maternal demographic, clinical, and health care characteristics with receipt of antiretroviral therapy during pregnancy. Age was grouped into five categories. For each time period, a series of multivariable logistic regression models were estimated to determine the independent effects of maternal and health care variables on outcome. We first fit a baseline multivariate model including only maternal variables in any of the time periods that were bivariately associated with outcome (P<0.2). To examine the effect

Improved birth outcomes associated with enhanced Medicaid prenatal care in drug-using women infected with the human immunodeficiency virus.

Objective To evaluate the effectiveness of an intervention designed to enhance Medicaid prenatal care in improving birth outcomes of drug-using women infected with the human immunodeficiency virus (HIV). Methods Medicaid and vital statistics records were linked for 353 HIV-infected drug-using women delivering in 1993 and 1994 while enrolled in New York State Medicaid. Of these, 68% were treated by providers participating in the Prenatal Care Assistance Program, designed to provide case management, improved continuity, referral services, and behavioral risk reduction counseling. In a series of logistic models, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of low birth weight (less than 2500 g) and preterm delivery (before 37 weeks), comparing women using and not using the program. Results Women using the Prenatal Care Assistance Program were significantly less likely, after adjustments were made for maternal characteristics, to have low birth weight infants and preterm deliveries (OR 0.52, 95% CI 0.31, 0.89; and OR 0.57, 95% CI 0.34, 0.97, respectively). Adding measures of greater adequacy and continuity of prenatal care to the models explained just over 20% of the Prenatal Care Assistance Programs protective effect. The addition of maternal high-risk behavior, HIV-focused care, and drug use treatment variables altered program effect estimates less profoundly (together accounting for 4 and 9% of the programs protection against low birth weight and preterm delivery, respectively). Conclusion The Prenatal Care Assistance Program appeared to be successful in reducing the incidence of low birth weight and preterm delivery in this high-risk population. The programs success can be attributed, in part, to increased adequacy and continuity of prenatal care and, to a lesser extent, to more frequent receipt of special services and reduced maternal high-risk behaviors.

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.

Effect of enhanced prenatal and HIV-focused services for pregnant women who are infected by human immunodeficiency virus on emergency department use.

OBJECTIVES This study examines whether the receipt of enhanced prenatal or human immunodeficiency virus (HIV) medical services is associated with in-pregnancy emergency department (ED) utilization by HIV-infected women. METHODS Medicaid and vital statistics records were linked for 1,826 women who are infected by HIV and who were delivered from 1993 to 1995 while receiving New York State Medicaid. The authors examined two types of ambulatory care--the Prenatal Care Assistance Program (PCAP) and enhanced care focused on HIV--that offer additional services in exchange for increased Medicaid reimbursement. From logistic regression models, the authors estimated adjusted associations of these types of care with ED use during pregnancy not leading directly to hospitalization. RESULTS Fifty-three percent of pregnant women visited the ED. Women with ED use averaged 2.0 visits (SD = 1.1). After adjustment for demographic and substance use factors, enhanced care focused on HIV was not associated with any ED use (OR = 1.11, 95% CI 0.94, 1.30) or, among those using the ED at least once, with number of visits (P = 0.84). Interactions of receipt of PCAP care with the Adequacy of Prenatal Care Utilization Index (APNCU) and having a usual source of care in pregnancy improved model fit (P < 0.001 and P = 0.06, respectively). PCAP was associated with increased ED use only among women with inadequate APNCU or no usual source of prenatal care. CONCLUSION Pregnant women infected with HIV receiving Medicaid relied heavily on ED care. Use of the ED was not associated with services focused on HIV but was positively associated with enhanced prenatal care. The association of enhanced prenatal care with greater ED use was curbed for women with more timely and adequate prenatal care visits or a usual source of prenatal care.

Relationship Between Ambulatory Care Accessibility and Hospitalization for Persons With Advanced HIV Disease

Specific features of ambulatory care, such as accessibility, may influence hospital use for patients with HIV infection. To identify clinic features associated with a lower risk of hospitalization, 6,280 New York state Medicaid enrollees diagnosed with AIDS in 1987-1992 and managed by one of 157 surveyed clinics were studied. The odds of hospitalization in the year before AIDS diagnosis were associated with five clinic features that facilitate the accessibility of care: (1) evening/weekend hours, (2) case manager, (3) appointments within 48 hours, (4) telephone consultation, and (5) whether the clinic handled urgent care. Hospitalization in the year before AIDS diagnosis occurred for 49 percent of patients. Three of the five accessibility features had unadjusted associations with lower hospitalization rates. The adjusted odds of hospitalization were lower for patients in clinics with extended hours (OR = 0.77, 95% CI = 0.63,0.93) and for patients in clinics with four or more accessibility features compared with those in clinics with less than two features (OR = 0.67; 95% CI = 0.50, 0.89).