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AHRQ researchers examine use of hospital, emergency, and outpatient care among patients with HIV disease

The advent of highly active antiretroviral therapy (HAART) in 1996 has transformed infection with the human immunodeficiency virus (HIV) from a fatal illness to a chronic disease. It also allowed many HIV-infected people to be treated on an outpatient basis.

HIV-related hospitalizations declined during the early years of HAART. However, the rate of hospitalizations has leveled off in more recent years, according to a study by John A. Fleishman, Ph.D., of the Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, and Fred H. Hellinger, Ph.D., of AHRQ's Center for Delivery, Organization, and Markets. A second study by Dr. Fleishman and Liliana Pezzin, Ph.D., formerly of AHRQ and now with the Medical College of Wisconsin, suggests that more outpatient care may reduce use of inpatient and emergency department (ED) services for patients with more advanced stages of HIV disease. The studies are summarized here.

Fleishman, J.A., and Hellinger, F.H. (2003, September). "Recent trends in HIV-related inpatient admissions, 1996-2000: A 7-State study." Journal of Acquired Immunodeficiency Syndrome 34, pp. 102-110.

These researchers used comprehensive hospital discharge data from seven States to examine trends in HIV-related hospital admissions and length of stay from 1996, when HAART was first introduced, through 2000. They used data from the State Inpatient Database (SID), a component of AHRQ's Healthcare Cost and Utilization Project (HCUP). HCUP represents a Federal-State-industry partnership that is building a standardized, multi-State health data system.

The researchers assessed differential patterns of change over time, depending on State, patient sex, race/ethnicity, and insurance status. They found that HIV-related hospital admissions declined by 22 percent between 1996 and 1997, but they declined only 4 percent between 1999 and 2000.

Admissions for white male patients and patients with private insurance showed the greatest decreases and the least leveling of the trend. For white men, the annual number of admissions dropped by 45 percent between 1996 and 2000. For black and Hispanic men, the proportional decline was not as great (28 percent and 38 percent, respectively). Among women, blacks showed the smallest decline (17 percent) in HIV-related hospital admissions. A similar pattern held for trends in hospital length of stay.

Presumably, the diffusion of HAART in 1996 and 1997 led to improved clinical status and reduced need for hospitalization among HIV patients. The trends toward fewer HIV-related hospitalizations and shorter lengths of stay in recent years are welcome, but the possible bottoming out of the trend raises serious questions, note the researchers. For example, the possible effects of increased rates of treatment failure and complications of HAART on hospitalizations need further scrutiny.

Reprints (AHRQ Publication No. 04-R008) are available from the AHRQ Publications Clearinghouse.

Pezzin, L.E., and Fleishman, J.A. (2003, November). "Is outpatient care associated with lower use of inpatient and emergency care? An analysis of persons with HIV disease." Academic Emergency Medicine 10, pp. 1228-1238.

To a limited extent, outpatient care may offset inpatient and emergency department (ED) services during more advanced HIV disease, concludes this study. The investigators used data from the AIDS Costs and Service Utilization Survey (ACSUS) of HIV-infected individuals to estimate how the probability and number of HIV-related hospital admissions and ED visits varied with the number of outpatient visits, controlling for several individual and illness-specific factors. ACSUS provides detailed information on a wide range of demographic, health (including HIV disease stage), and economic characteristics for a nationally diverse sample of HIV-infected people at 26 care sites. ACSUS data were collected in 1991-1992, prior to the introduction of HAART.

Analysis of ACSUS data revealed that higher use of outpatient medical services was not significantly associated with lower probability of inpatient admissions or ED visits. However, for the subgroup of patients who were diagnosed with AIDS during the study period, more frequent outpatient visits were significantly associated with fewer hospital admissions and a lower probability of an ED visit. Despite controls for outpatient care use, disease stage, and sociodemographic factors, blacks still were more likely to use inpatient care than whites. Also, those with less education had significantly more ED use than their better-educated counterparts.

The findings of limited substitution of outpatient for inpatient and ED care does not necessarily imply that initiatives designed to expand community-based programs for people with HIV disease, such as the Ryan White Act, are not valuable. The better access to care and maintenance of quality of life provided by community-based care are important in their own right, note the researchers.

Reprints (AHRQ Publication No. 04-R018) are available from the AHRQ Publications Clearinghouse.

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