Quality of Care for HIV Infected Veterans
Todd Korthuis, MD, MPH Oregon Health and Science University
Sponsors & Collaborators
• Sponsor: VA HIV Quality Enhancement Research Initiative (HIV-QUERI) • Collaborators:
• • • • • • Steven Asch, MD, MPH Sam Bozzette, MD, PhD Henry Anaya, PhD Charles Brinkerhoff, MS Martha Mancewicz, MS Mingming Wang, MPH
Introduction
Rationale
• Improved HIV treatment has increased survival, making HIV a chronic illness1,2 • Increasingly need to close quality gaps • VA quality of care for other chronic illnesses exceeds that of Medicare3 • The VA is the largest HIV provider in US4 • Little is known about the quality of HIV care
1. 2. 3. 4. Palella FJ, NEJM 1998;338:853 Hecht FM, Ann Intern Med 1999;131:136 Jha AK, NEJM 2003;348:2218 Backus L, J Clin Epidem 2001;54:S12
Introduction
• Study question:
• What is the quality of care for HIV-infected veterans?
• Hypotheses:
• Quality indicators will be lower for vulnerable populations, and those with fewer outpatient visits • Quality of care for HIV-infected veterans is comparable to that of non-veterans
Methods
VA
• Design
• Cross-sectional study
• Sample
• HIV positive veterans 2001 - 2002 at 16 VA sites who agreed to participate in a QUERI intervention • 20% of all HIV-infected veterans.
• Data Source
• Quality Enhancement Database (VA) = Immunology Case Registry (ICR) + VA National Patient Care Database5
5. Bozzette SA, NEJM 2003;348:702
Methods
HIV Cost & Services Utilization Study (HCSUS)
• Design
• Cross-sectional study 1995-1997
• Sample
• Stratified national probability sample of HIV-infected
• Data Source
• Abstracted medical records from final follow-up Interview respondents
Method
Key Variables: Dependent
• Therapy Quality Indicators
• Receipt of HAART (CD4 < 350, VL > 55K) • Receipt of PCP prophylaxis (CD4 < 200) • Receipt of MAC prophylaxis (CD4 < 50)
• Screening Quality Indicators
• • • • • • Syphilis (RPR) Toxoplasmosis serology Hep A serology Hep B serology Hep C serology Lipids
Methods
Independent Variables
• • • • • • • • CD4 count Age Gender Race/ethnicity Mode of HIV exposure Number of HIV clinic visits Volume of HIV-infected patients at facility Region
Method
Analytic Strategies
• Descriptive statistics for each quality indicator • Assessed associations between independent variables and QI’s using multivariable logistic regression, adjusting for all independent variables and clustering • VA compared to HCSUS using logistic regression in pooled dataset with VA/HCSUS dummy variable added to models
Results
Patient Characteristics
VA N=3840 408 (269) 49.6 (9.2) 98.3 53.5 30.4 HCSUS N=1874 315 (238) 38.5 (8.5) 70.7 30.6 47.7
Mean CD4 (sd) Mean Age (sd) % Male % African Am % MSM
VA Results
Quality Indicator HAART PCP MAC Toxoplasmosis Syphilis Hepatitis A Hepatitis B Hepatitis C Lipids Percent Received 78 65 98 44 74 55 67 75 67
Results
Percent Receiving Indicated Care
HAART
PCP proph.
VA 78
65
HCSUS 76*
79*
MAC proph. Toxoplasmosis Syphilis
98 44 74
68* 39* 49*
*P < .05
Adjusted Results
Adjusted Results:
• Younger age group
• Less HAART: OR=0.66 (.47-.92) • Less Lipid screening: OR=0.47 (.36-.62)
• Females
• Less HAART: OR=.37 (.16-.87)
• IVD
• Less HAART: OR=.61 (.43-.87) • Less Lipid Screening: OR=.58 (.39-.85) • More Syphilis screening: OR=1.58 (1.18-2.11)
Adjusted Results:
Minorities Received More Screening
• African Americans:
• • • • • Toxo: Syph: Hep A: Hep B: Hep C: OR 1.24 (1.06 - 1.44) OR 1.64 (1.29 - 2.08) OR 1.39 (1.20 - 1.62) OR 1.55 (1.21 - 1.99) OR 1.43 (1.11 - 1.83)
• Hispanics:
• Hep B: OR 1.35 (1.06 - 1.73) • Hep C: OR 1.44 (1.09 - 1.91)
Adjusted Results:
Less care among persons with < 3 visits • • • • HAART: PCP: Toxo: Hep A: OR=.08 (.03 - .20) OR=.22 (.11 - .44) OR=.63 (.40 – 1.0) OR=.54 (.41 - .92)
Limitations
• Differences in time between HCSUS and VA data collection • Limited number of quality indicators • Lack of outcome data
Summary
• The majority of HIV-infected veterans receive recommended therapy and screening care, important gaps persist, particularly among persons with IVD and fewer than 3 visits per year. • Proportion of veterans receiving indicated care was comparable or exceeded that of HCSUS for 4/5 QI’s • Minority race/ethnicity received more screening-based care than whites.
Significance
• Quality improvement interventions should focus on closing gaps and disparities in care, particularly for persons with IVD and those with fewer than 3 visits/year. • Further studies indicated to identify the provider, cultural, & organizational factors that impact variations in screening by race/ethnicity.