Healthcare utilization among persons living with hiv with attention to the influences of hepatitis
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AcknowledgmentsHIVRN Participating Sites Alameda County Medical Center, Oakland, California (Howard Edelstein, M.D.) Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Richard Rutstein, M.D.) Community Health Network, Rochester, New York (Roberto Corales, D.O.) Drexel University, Philadelphia, Pennsylvania (Jeffrey Jacobson, M.D., Sara Allen, C.R.N.P.) Fenway Health, Boston, Massachusetts (Stephen Boswell, M.D.) Johns Hopkins University, Baltimore, Maryland (Kelly Gebo, M.D., Richard Moore, M.D., Allison Agwu M.D.) Montefiore Medical Group, Bronx, New York (Robert Beil, M.D.) Montefiore Medical Center, Bronx, New York (Lawrence Hanau, M.D.) Oregon Health and Science University, Portland, Oregon (P. Todd Korthuis, M.D.) Parkland Health and Hospital System, Dallas, Texas (Ank Nijhawan, M.D., Muhammad Akbar, M.D.) St. Jude's Children's Hospital and University of Tennessee, Memphis, Tennessee (Aditya Gaur, M.D.) St. Luke's Roosevelt Hospital Center, New York, New York (Victoria Sharp, M.D., Stephen Arpadi, M.D.) Tampa General Health Care, Tampa, Florida (Charurut Somboonwit, M.D.) University of California, San Diego, California (W. Christopher Mathews, M.D.)
Agency for Healthcare Research and Quality, Rockville, Maryland (Fred Hellinger, Ph.D., John Fleishman, Ph.D., Irene Fraser, Ph.D.) Health Resources and Services Administration, Rockville, Maryland (Robert Mills, Ph.D., Faye Malitz, M.S.)
Johns Hopkins University (Richard Moore, M.D., Jeanne Keruly, C.R.N.P., Kelly Gebo, M.D., Cindy Voss, M.A., Nikki Balding, M.S.) References1. Martin EG, Schackman BR. What does U.S. health reform mean for HIV clinical care? Journal of acquired immune deficiency syndromes. May 1 2012;60(1):72-76. 2. Konopnicki D, Mocroft A, de Wit S, et al. Hepatitis B and HIV: prevalence, AIDS progression, response to highly active antiretroviral therapy and increased mortality in the EuroSIDA cohort. Aids. Mar 24 2005;19(6):593-601. 3. Thomas DL, Leoutsakas D, Zabransky T, Kumar MS. Hepatitis C in HIV-infected individuals: cure and control, right now. Journal of the International AIDS Society. 2011;14:22. 4. Weber R, Sabin C, Reiss P, et al. HBV or HCV coinfections and risk of myocardial infarction in HIV-infected individuals: the D:A:D Cohort Study. Antiviral therapy. 2010;15(8):1077-1086. 5. Thio CL, Seaberg EC, Skolasky R, Jr., et al. 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The Journal of infectious diseases. Aug 15 2012;206(4):469-477. 15. Bedimo R, Westfall AO, Mugavero M, Drechsler H, Khanna N, Saag M. Hepatitis C virus coinfection and the risk of cardiovascular disease among HIV-infected patients. HIV medicine. Aug 2010;11(7):462-468. 16. Satapathy SK, Lingisetty CS, Williams S. Higher prevalence of chronic kidney disease and shorter renal survival in patients with chronic hepatitis C virus infection. Hepatology international. Jun 23 2011. 17. Naing C, Mak JW, Ahmed SI, Maung M. Relationship between hepatitis C virus infection and type 2 diabetes mellitus: meta-analysis. World journal of gastroenterology : WJG. Apr 14 2012;18(14):1642-1651. 18. Clifford DB, Evans SR, Yang Y, Gulick RM. The neuropsychological and neurological impact of hepatitis C virus co-infection in HIV-infected subjects. Aids. Oct 2005;19 Suppl 3:S64-71. 19. Brau N, Fox RK, Xiao P, et al. Presentation and outcome of hepatocellular carcinoma in HIV-infected patients: a U.S.-Canadian multicenter study. Journal of hepatology. Oct 2007;47(4):527-537. 20. Gebo KA, Diener-West M, Moore RD. Hospitalization rates differ by hepatitis C satus in an urban HIV cohort. Journal of acquired immune deficiency syndromes. Oct 1 2003;34(2):165-173. 21. Goedert JJ, Eyster ME, Lederman MM, et al. End-stage liver disease in persons with hemophilia and transfusion-associated infections. Blood. Sep 1 2002;100(5):1584-1589. 22. Puoti M, Torti C, Bruno R, Filice G, Carosi G. Natural history of chronic hepatitis B in co-infected patients. Journal of hepatology. 2006;44(1 Suppl):S65-70. 23. Salmon-Ceron D, Rosenthal E, Lewden C, et al. Emerging role of hepatocellular carcinoma among liver-related causes of deaths in HIV-infected patients: The French national Mortalite 2005 study. Journal of hepatology. Apr 2009;50(4):736-745. 24. Smith C, Sabin CA, Lundgren JD, et al. Factors associated with specific causes of death amongst HIV-positive individuals in the D:A:D Study. Aids. Jun 19 2010;24(10):1537-1548. 25. Palella FJ, Jr., Baker RK, Moorman AC, et al. Mortality in the highly active antiretroviral therapy era: changing causes of death and disease in the HIV outpatient study. Journal of acquired immune deficiency syndromes. Sep 2006;43(1):27-34. 26. Crowell TA, Gebo KA, Balagopal A, Fleishman JA, Agwu AL, Berry SA. Impact of Hepatitis Coinfection on Hospitalization Rates and Causes in a Multicenter Cohort of Persons Living With HIV. Journal of acquired immune deficiency syndromes. Apr 1 2014;65(4):429-437. 27. Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology. Jun 2006;43(6):1317-1325. 28. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. 2013; http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed 28 October 2013. 29. Gale HB, Gitterman SR, Hoffman HJ, et al. Is frequent CD4+ T-lymphocyte count monitoring necessary for persons with counts >=300 cells/muL and HIV-1 suppression? Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. May 2013;56(9):1340-1343. 30. Aberg JA, Gallant JE, Ghanem KG, Emmanuel P, Zingman BS, Horberg MA. Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Nov 13 2013. 31. Olfson M, Marcus SC. National trends in outpatient psychotherapy. The American journal of psychiatry. Dec 2010;167(12):1456-1463. 32. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Archives of general psychiatry. Jun 2005;62(6):629-640. 33. Alegria M, Chatterji P, Wells K, et al. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv. Nov 2008;59(11):1264-1272. 34. Thomas DL, Astemborski J, Rai RM, et al. The natural history of hepatitis C virus infection: host, viral, and environmental factors. Jama. Jul 26 2000;284(4):450-456. 35. Reiberger T, Obermeier M, Payer BA, et al. Considerable under-treatment of chronic HCV infection in HIV patients despite acceptable sustained virological response rates in a real-life setting. Antiviral therapy. 2011;16(6):815-824. 36. Scott JD, Wald A, Kitahata M, et al. Hepatitis C virus is infrequently evaluated and treated in an urban HIV clinic population. AIDS patient care and STDs. Nov 2009;23(11):925-929. 37. Vellozzi C, Buchacz K, Baker R, et al. Treatment of hepatitis C virus (HCV) infection in patients coinfected with HIV in the HIV Outpatient Study (HOPS), 1999-2007. Journal of viral hepatitis. May 2011;18(5):316-324.
Table 3-: Population Demographic and Clinical Characteristics at Study Entry
*Age was assessed on July 1 of the year of study entry. †Patients who reported sex with both men and women were categorized as MSM. ‡Patients who reported IDU in addition to any other risk factor were categorized as IDU.
Table 3 : Multivariable Analysis of Risk Factors for Healthcare Utilization
*Age was assessed annually on July 1. †Patients who reported sex with both men and women were categorized as MSM. ‡Patients who reported IDU in addition to any other risk factor were categorized as IDU. #CD4, HIV-1 RNA, and insurance data are the first available for each year. §ART refers to concurrent use of ≥3 antiretroviral medications from ≥2 classes at any time during the calendar year. The unit of analysis for all models was person-year. Incidence rate ratios (IRRs) are interpreted as the relative number of visits compared to the reference group after adjusting for other listed characteristics and clinical care site. Statistically significant results (p≤0.05) are shown in bold. Table 3 : Healthcare Utilization Rates by Hepatitis Serostatus.
Mean utilization rate was calculated by dividing the aggregate number of visits by the aggregate person-time for each hepatitis serostatus and year combination. These rates were multiplied by 100 for mental health and inpatient visits. Poisson regression was used to estimate standard errors of the mean, modeling utilization rate as a function of time, stratified by hepatitis serostatus. Standard errors were scaled using square root of Pearson chi-squared-based dispersion. Table 3-4: Percentage of Patients Utilizing Healthcare Services, by Hepatitis Serostatus.
All study participants had at least one HIV primary care visit during each year of observation. For each hepatitis serostatus group, annual percentages were calculated by dividing the number of participants with at least one visit by the total number of participants categorized into that hepatitis serostatus group during the calendar year. For each hepatitis serostatus group, percentage of patients ever utilizing each healthcare service was calculated by dividing the number of participants with at least one visit while contributing person-time to that hepatitis serostatus group by the total number of participants ever categorized in that hepatitis serostatus group. 
Figure 3 : Healthcare Utilization Rates by Hepatitis Serostatus. Rates are standardized as hospitalizations per person-year of follow-up for primary HIV care visits and per 100 person-years of follow-up for mental health and inpatient visits. Tests of trend were performed using negative binomial regression with categorical calendar year indicators to detect differences in utilization between start of study in 2006 and end of study in 2011. “NC” indicates that model was non-convergent due to the small number of events in the HIV/HBV/HCV tri-infected group.
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