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High Standards of Care Associated with Reduced Mortality Risk for Veterans with HIV

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Quality of care (QOC) during the first 12 months after entering HIV care is associated with longer-term mortality risk, investigators from the U.S. Department of Veterans Affairs report in the September 3 online edition of Clinical Infectious Diseases. Patients who received at least 80% of recommended quality of care indicators were 25% less likely to die during follow-up when compared to those who received less than 80%. Good outcomes were observed for people with drug or alcohol problems who received a high level of care.

[Produced in collaboration with Aidsmap.com]

"The current study finds that HIV-infected patients who receive high QOC experience improved mortality," commented the study authors. "High quality care provided by healthcare systems and providers may translate into decreased mortality for their patients."

But good quality of care was unable to overcome mortality deficits associated with disease severity and co-morbid conditions, they noted.

Moreover, the author of an accompanying editorial suggests that quality of care indicators may need to change in order to keep pace with the ever-evolving medical needs associated with HIV.

Healthcare providers in the U.S. are encouraged to track and report on quality of care measures. Although QOC indicators for HIV infection are well established, the relationship between care indicators and subsequent mortality risk has not been well described. Importantly, it is not known if good quality of care can overcome the higher mortality risk observed in HIV-positive patients with drug or alcohol problems.

To answer these questions, investigations with the Veterans Aging Cohort Study compared mortality risk among HIV-positive patients according to the quality of care provided in the first 12 months after entering HIV care. Patients who entered care between 2002 and 2008 were recruited to the study.

The researchers assessed 9 quality of care indicators:

  • Receipt of antiretroviral therapy;
  • Pneumocystispneumonia (PCP) prophylaxis if warranted by low CD4 count;
  • Mycobacterium avium(MAC) prophylaxis if warranted by low CD4 count;
  • Pneumococcal vaccination;
  • Annual influenza vaccination;
  • Regular screening for high blood lipid levels;
  • Ongoing monitoring for hepatitis C virus (HCV) coinfection;
  • Appropriate HIV clinic visits;
  • CD4 T-cell count monitoring;

Data were also gathered on drug and alcohol use and co-morbid conditions. Patients were followed until 2014.

The investigators compared mortality risk between individuals who received 80% or more of the quality of care indicators during the first 12 months of care and individuals who did not receive this standard of care.

A total of 3038 patients were recruited to the study. Most were male (98%) and black (67%). Average age at enrollment was 49 years. 28% were classified as having problematic alcohol use and 26% reported other substance use; 11% reported both drug and alcohol problems.

Study participants were followed for a mean of 8 years. There were 902 total deaths (30% of cohort) during 24805 person-years of follow-up.

Approximately 70% of patients received 80% or more of the quality of care indicators in the first year.

Overall, receiving 80% or more of recommended quality of care indicators was associated with a 25% reduction in mortality risk compared to lower standards of care (age-adjusted hazard ratio 0.75).

The association between higher quality of care and lower mortality risk was seen irrespective of drug or alcohol use. However, quality of care was unable to overcome the enhanced mortality risk associated with disease severity (age-adjusted hazard ratio 1.18).  

"The 2010 U.S. National HIV/AIDS Strategy identifies improving the QOC [quality of care] for persons living with HIV as a national priority," conclude the researchers. "The current study suggests that this policy may further improve survival among HIV-infected patients who engage in care, but that increased adherence to quality of care measure may not be sufficient for improving mortality without addressing underlying conditions."

The accompanying editorial, by Michael Horberg of Kaiser Permanente, described the lower mortality associated with good quality care soon after entering HIV care as "laudable." But he noted that the results "do not offer an indication of sustained quality care." Moreover, because HIV has become a chronic life-long condition, for most patients it is no longer appropriate to monitor outcomes based solely on care during the first year of follow-up. "Our indicators of quality of care will have to change," he wrote.

10/1/15

References

PT Korthuis, KA McGinnis, KL Kraemer, et al (Veterans Aging Cohort Study). Quality of HIV Care and Mortality Rates in HIV-Infected Patients. Clinical Infectious Diseases. September 3, 2015 (online ahead of print).

MA Horberg MA. HIV Quality Measures and Outcomes: The Next Phase. Clinical Infectious Diseases. September 3, 2015 (online ahead of print).