The Impact of Integrated HIV The Impact of Integrated HIV Care on Patient Health OutcomesCare on Patient Health Outcomes

Tuyen Hoang, PhDTuyen Hoang, PhD

Matthew B. Goetz, MD, Elizabeth Yano, PhD, Matthew B. Goetz, MD, Elizabeth Yano, PhD,

Barbara Rossman, PhD, Henry D. Anaya, PhD, Barbara Rossman, PhD, Henry D. Anaya, PhD,

Herschel Knapp, PhD, Steven M. Asch, MD MPHHerschel Knapp, PhD, Steven M. Asch, MD MPH

BackgroundBackground

• The key factor to control HIV is The key factor to control HIV is adherence to HIV medicationsadherence to HIV medications

• Co-morbidities impede adherenceCo-morbidities impede adherence

Mental disordersMental disorders

Substance abuseSubstance abuse

Hepatitis CHepatitis C

Integrated HIV Care in the VAIntegrated HIV Care in the VA

PHARMACISTPHARMACIST

HIV SPECIALISTHIV SPECIALIST

PSYCHIATRISTPSYCHIATRIST

SOCIAL WORKERSOCIAL WORKER

PSYCHOLOGISTPSYCHOLOGIST

Research QuestionsResearch Questions

• Would integrated HIV care enable Would integrated HIV care enable providers to manage co-morbidities more providers to manage co-morbidities more effectively?effectively?

• Would access to Would access to more comprehensivemore comprehensive integrated care lead tointegrated care lead to better control better control of of HIV?HIV?

Study DesignStudy Design

Study populationStudy population– Retrospective cohort of HIV-infected veteransRetrospective cohort of HIV-infected veterans– Five VA facilities in western U.S.Five VA facilities in western U.S.– Oct 2000 to April 2006Oct 2000 to April 2006

Eligibility criteriaEligibility criteria– Receiving HIV treatment in the VAReceiving HIV treatment in the VA– Sufficient baseline severity Sufficient baseline severity – 3+ months of follow-up3+ months of follow-up

Data SourcesData Sources

QuantitativeQuantitative– VA regional data warehouse: demographics, VA regional data warehouse: demographics,

visits, lab tests, diagnoses, pharmacy visits, lab tests, diagnoses, pharmacy prescriptions and refillsprescriptions and refills

QualitativeQualitative– Interviews with chiefs of the HIV clinics to Interviews with chiefs of the HIV clinics to

obtain descriptions of integrated servicesobtain descriptions of integrated services

Four Levels of ComprehensivenessFour Levels of Comprehensiveness

Components of HIV clinicsComponents of HIV clinics Comprehensive LevelComprehensive Level

44 33 22 11Physician assistant, nurse practitionersPhysician assistant, nurse practitioners xx xx xx xx

Clinical coordinatorClinical coordinator xx xx xx xx

HIV physician specialist HIV physician specialist xx xx xx

Dedicated pharmacist Dedicated pharmacist xx xx xx

PsychiatristPsychiatrist xx xx

Social worker Social worker xx xx

Psychologist Psychologist xx

Distribution of Integrated HIV Care Users Distribution of Integrated HIV Care Users (N=1,069)(N=1,069)

3%3%

I onlyI only

Multi-level usersMulti-level users

II onlyII only III onlyIII only IV onlyIV only

27%27%

5%5% 8%8%

57%57%

Single-level usersSingle-level users

Utilization IndexUtilization Index

PatientPatient ComprehensivenessComprehensiveness ScoreScore

Level 4Level 4 Level 3Level 3 Level 2Level 2 Level 1Level 1

AA 00 00 11 11 33

BB 00 11 00 11 44

CC 00 22 00 22 88

Survival AnalysesSurvival Analyses

First analysisFirst analysis (N=459 single-level users) (N=459 single-level users)

Time to viral suppression Time to viral suppression comprehensive levelscomprehensive levels

Second analysisSecond analysis (N=610 multi-level users) (N=610 multi-level users)

Time to viral suppression Time to viral suppression utilization indexutilization index

Demographics of Study PatientsDemographics of Study Patients

CharacteristicsCharacteristics Statistics Statistics

Eligible patients, N Eligible patients, N

1,0691,069

Age, mean (SD)Age, mean (SD) 51 (9.4)51 (9.4) Caucasian, African A. (%)Caucasian, African A. (%) 34, 2434, 24 Never married (%)Never married (%) 5757 Low income (%)Low income (%) 7676 Homeless (%)Homeless (%) 1818

Clinical characteristics of PatientsClinical characteristics of Patients

CharacteristicsCharacteristics Statistics Statistics

Had co-morbidities (%) Had co-morbidities (%)

9393

No. of co-morbidities per patientNo. of co-morbidities per patient 33 Mental disorders (%)Mental disorders (%) 5656 Hepatitis B (%)Hepatitis B (%) 4949 Hepatitis C (%)Hepatitis C (%) 3333 Drug use (%)Drug use (%) 3131

FactorsFactors Adjusted Hazard ratiosAdjusted Hazard ratios

Multi-level usersMulti-level users(n=610)(n=610)

Single-level usersSingle-level users(n=459)(n=459)

AgeAge 0.960.96 1.001.00

Marital status (Single)Marital status (Single) MarriedMarried Widow/divorced/separatedWidow/divorced/separated

1.211.211.331.33

1.121.12

1.351.35

Low incomeLow income 0.760.76 0.850.85HomelessHomeless 0.730.73 0.990.99

STDSTD 1.061.06 1.55 1.55

Number of co-morbiditiesNumber of co-morbidities 1.041.04 0.960.96

Baseline HIV viral loadBaseline HIV viral load 0.960.96 0.930.93

Baseline CD4Baseline CD4+ + countscounts 1.001.00 1.061.06

Factors Associated with Viral SuppressionFactors Associated with Viral Suppression

Factors Associated withFactors Associated with Viral SuppressionViral Suppression

FactorsFactors Adjusted Hazard ratiosAdjusted Hazard ratios

Multi-level usersMulti-level users(n=610)(n=610)

Single-level usersSingle-level users(n=459)(n=459)

Access to medicationAccess to medication 2.042.04 1.911.91

Utilization indexUtilization index 1.121.12 n/an/a

Compared to Level 2Compared to Level 2 Level 1Level 1 Level 3Level 3 Level 4Level 4

n/an/a0.940.94

1.621.62

2.632.63

Visit frequencyVisit frequency n/an/a 1.431.43

ConclusionsConclusions

HepatitisHepatitisPsychiatric Psychiatric

PsychologicalPsychologicalSocial services Social services

HIV HIV primary primary

carecare

ViralViralsuppressionsuppression

2.6 times2.6 timesmore likelymore likely++

ImplicationsImplications

• Resources should be allocated to Resources should be allocated to channel patients toward comprehensive channel patients toward comprehensive integrated HIV care clinicsintegrated HIV care clinics

• Findings may be relevant for other Findings may be relevant for other chronic conditions that require principle chronic conditions that require principle care in subspecialty clinicscare in subspecialty clinics