Thomas Fanning

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.

Cigarette smoking and maternal-child HIV transmission.

We investigated the association of cigarette smoking with maternal-child HIV transmission, adjusting for illicit drug use, maternal clinical status, and delivery factors. Vital statistics birth data were linked to the New York State Medicaid HIV/AIDS Research Database for HIV-infected women delivering a liveborn singleton from 1988 through 1990. Follow-up of these children was accomplished by Medicaid data > or = 2 years after birth, and their HIV status was ascertained by a clinically based classification. The adjusted relative risk or hazard (RH) of transmission for maternal factors was determined from Cox models. The overall transmission was 24.5% for the 901 maternal-child pairs. Smokers comprised 40% of women with data on smoking (n = 768); their transmission rate was 31% versus 22% for nonsmokers (p = 0.02). In the entire cohort, the adjusted RH of transmission for smokers was 1.45 (95% confidence interval [CI] 1.07-1.96); among women with advanced HIV, the adjusted RH was even higher (RH = 1.71; 95% CI 1.14-2.58). Users of cocaine (15% of the cohort) or of mixed or unspecified illicit drugs (28%) had higher transmission rates in unadjusted analysis (33%, p = 0.06 and 31%, p = 0.06 respectively); after adjustment for smoking and other maternal factors, neither cocaine (RH = 1.04 (95% CI 0.66-1.63)) nor mixed nor unspecified drug use (RH = 1.13 (95% CI = 0.75-1.70)) was significantly associated with transmission. Our data document an association of cigarette smoking during pregnancy with an increased risk of maternal-child HIV transmission that can be added to the growing list of complications caused by cigarette smoking.

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.

Survival experience of 789 children with the acquired immunodeficiency syndrome

To define predictors of survival we studied longitudinal histories of 789 New York State Medicaid-enrolled children diagnosed with acquired immunodeficiency syndrome (AIDS) from 1983 to 1989 and followed through 1990. Median survival times for 3 severity groups of AIDS-defining conditions were 66, 48 and 9 months. In a proportional hazards model, the relative risk of death for the most vs. least severe group was 3.33 (95% confidence interval, 2.53, 4.37) and the relative risk for children < 6 months old at diagnosis vs. older children was 1.81 (95% confidence interval, 1.41, 2.34). We increased our ability to predict death by using a 4-category severity index that assesses both the AIDS-defining diagnosis and clinical complications within 3 months of diagnosis (relative risk, 5.27; 95% confidence interval, 3.16, 8.78 for most vs. least severe). These analyses offer new clinical severity measures and reveal that, regardless of the AIDS-defining diagnosis, children with AIDS who are < 6 months old have a poor prognosis.

Prenatal care of HIV-infected women : analysis of a large New York state cohort

We examined the effect of methadone treatment, duration of Medicaid enrollment during pregnancy, and other maternal characteristics on receipt of prenatal care by 2,254 women infected with human immunodeficiency virus (HIV) delivering a singleton in New York state from 1985 through 1990. Data were obtained from the New York State Medicaid HIV/AIDS Research Data Base and vital statistics records. Adequacy of the number of prenatal visits reported by the mother on vital statistics records was assessed with use of the Kessner Index, which adjusts for gestational age at delivery. Too few visits were reported by 65% of the study population. Illicit drug users had higher odds of having too few visits [1.64, 95% confidence interval (CI) 1.24-2.17] than methadone-treated women but the odds were similar for non-drug users and methadone-treated women (0.79, 95% CI 0.60-1.25). Women with brief Medicaid enrollment (< or = 25% of pregnancy) had 45% higher odds of having too few visits than did longer enrollees. Treatment for drug addiction and longer Medicaid enrollment during pregnancy may offer important interventions to increase prenatal care of HIV-infected women. Approaches to increase prenatal care of HIV-infected women are especially important given trials showing a reduction in vertical transmission from zidovudine treatment during pregnancy.

Duration of Medicaid AIDS hospitalizations - Variation by season, stage, and year

Using New York State Medicaid data from 1984 to 1987, we analyzed hospital length-of-stay patterns for acquired immunodeficiency syndrome (AIDS) patients. We found an overall decline in monthly average length of stay, with seasonal fluctuations producing longer stays in the fall and winter months. These findings suggest that hospital utilization for AIDS patients is changing over time and may vary by season.