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JAMA The Journal of the American Medical Association 07/2012; 308(4):339-42. · 30.03 Impact Factor
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ABSTRACT: We evaluated highly active antiretroviral therapy (HAART) utilization in youth infected with HIV through risk behaviors who met treatment criteria for HAART. We assessed the impact of receiving care at an adult or pediatric HIV clinical site on initiation and discontinuation of the first HAART regimen in behaviorally infected youth (BIY).
This was a retrospective analysis of treatment-naive BIY, aged 12-24 years, who enrolled in the HIV Research Network between 2002 and 2008 and who met criteria for HAART. The outcomes were time from meeting criteria to initiation of HAART and time to discontinuation of the first HAART regimen. Analyses were conducted using Cox proportional hazards regression.
Of 287 treatment-eligible youth, 198 (69%) received HAART; of these 198 youth, 58 (29.3%) subsequently discontinued HAART. In multivariable analyses, there was no significant difference in the time between meeting treatment criteria and initiating HAART for BIY followed at adult or pediatric HIV clinical sites. However, BIY followed at adult sites discontinued HAART sooner than BIY followed at pediatric HIV clinical sites (adjusted hazard ratio [AHR]: 3.19 [1.26-8.06]).
Two-thirds of treatment-eligible BIY in the HIV Research Network cohort initiated HAART; however, one-third who initiated HAART discontinued it during the study period. Identifying factors associated with earlier HAART initiation and sustainability can inform interventions to enhance HAART utilization among treatment-eligible youth. The finding of earlier HAART discontinuation for youth at adult care sites deserves further study.
Journal of Adolescent Health 05/2012; 50(5):471-7. · 3.33 Impact Factor
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ABSTRACT: For optimal clinical benefit, HIV-infected patients should receive periodic outpatient care indefinitely. However, initially establishing HIV care and subsequent retention in care are problematic. This study examines establishment, retention, and loss to follow-up (LTFU) in a large multi-site cohort over a 2-8 year period.
Medical record data were reviewed for 22,984 adult HIV patients receiving care at 12 clinics in the HIV Research Network between 2001 and 2009. Three dichotomous outcome measures were based on each patient's history of outpatient visits. Establishment reflects whether the patient made outpatient visits for longer than 6 months after initial enrollment. The retention measure reflects whether the patient had at least 2 outpatient visits separated by 90 days in each year in care. LTFU reflects whether the patient had no outpatient visits for more than 12 months without returning. Multiple logistic regression examined demographic and clinical correlates of each outcome and the combined outcome of meeting all 3 measures.
Overall, 21.7% of patients never established HIV care after an initial visit. Among established patients, 57.4% did not meet the retention criterion in all years, and 34.9% were LTFU. Only 20.4% of all patients met all 3 criteria. The odds of successfully meeting all 3 criteria were higher for women, for older patients, for Hispanics compared with whites, and for those with CD4 levels ≤50 cells per cubic millimeter.
These data highlight the need to improve establishment and retention in HIV care.
JAIDS Journal of Acquired Immune Deficiency Syndromes 04/2012; 60(3):249-59. · 4.43 Impact Factor
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ABSTRACT: BACKGROUNDPatient-centered care—including the domains of access and communication—is an important determinant of positive clinical outcomes.
OBJECTIVETo explore associations between race and HIV-infected patients’ experiences of access and communication.
DESIGNThis was a cross-sectional survey.
PARTICIPANTSNine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics.
MEASUREMENTSDependent variables included patients’ reports of travel time to their HIV care site and waiting time to see their HIV provider
(access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with
them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent
variables, and random effects models to estimate site-level contributions.
RESULTSPatients traveled a median 30 minutes (range 1–180) and waited a median 20 minutes (range 0–210) to see their provider. On
average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated
this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult
to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported
more positive experiences with provider communication.
CONCLUSIONSWe observed racial disparities in patients’ experience of access to care but not in patient–provider communication. Disparities
were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected
patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient–provider
interactions.
Journal of General Internal Medicine 04/2012; 23(12):2046-2052. · 2.83 Impact Factor
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ABSTRACT: Prior research has documented sociodemographic disparities in the use of antiretroviral therapy (ART). Recent therapeutic developments and changing epidemiological profiles may have altered such disparities. We examine the extent to which sociodemographic differences in prescribed ART have changed between 2002 and 2008.
We analyzed data abstracted from medical records at 13 US sites participating in the Human Immunodeficiency Virus Research Network. Prescription of ART was assessed for each year in care for each patient. A total of 14,092 patients were followed up for 39,251 person-years. We examined ART use as a function of sex, race/ethnicity, human immunodeficiency virus risk group, age, and CD4 history (no test <500 cells/mm, one or more tests between 500 and 350 cells/mm, 1 test ≤350 cells/mm, and 2 or more tests ≤350 cells/mm). Using multiple logistic regression, we ascertained interactions between each of these variables and calendar year.
The overall percentage prescribed ART increased from 60% to 80% between 2002 and 2008. Among those with 2 or more CD4 tests ≤350 cells/mm, the percentage increased from 82% to 92%. ART rates were higher for those with lower CD4 counts but increased over time for all CD4 groups and for all demographic groups. Nevertheless, sex and racial/ethnic disparities persisted. Significant interactions were obtained for CD4 history by year, age by year, and age by CD4 history.
Although prescription of ART became more widespread from 2002 to 2008, patients who were female, black, or younger still had lower ART rates than male, white, or older patients.
Medical care 03/2012; 50(5):419-27. · 3.24 Impact Factor
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ABSTRACT: The US National HIV/AIDS Strategy identifies retention in care as an important quality performance measure. There is no gold standard to measure retention in care. This study is the first to compare different measures of retention, using a large geographically diverse sample.
A prospective cohort of 17,425 HIV-infected adults enrolled in care at 12 US HIV clinics between 2001 and 2008.
We compared three measures of retention for each patient: proportion of time not spent in a gap of more than 6 months between successive outpatient visits; proportion of 91-day quarters in which at least one visit occurred; proportion of years in which two or more visits separated by at least 90 days occurred. Associations among measures and effects of sociodemographic and clinical characteristics were examined.
The three measures of retention were moderately to strongly correlated. Averaging across patients, 71% of time in care was not spent in a gap more than 6 months; 73% of all quarters had at least one visit; and 75% of all years had at least two visits separated by at least 90 days. For all measures, retention was significantly higher for women, whites, older individuals, men who had sex with men (MSM)-related HIV transmission, and initial CD4 cell counts 50 cell/μl or less.
This is one of the first studies to provide a national estimate of retention in HIV care in the US, which ranged from 71 to 75% using any of the accepted retention measures. Future studies should assess how well different measures predict clinical outcomes and establish acceptable target levels for retention.
AIDS (London, England) 02/2012; 26(9):1131-9. · 4.91 Impact Factor
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ABSTRACT: Hospitalization rates for comorbid conditions among persons living with HIV in the current highly active antiretroviral therapy era are unknown.
Hospitalization data from 2001 to 2008 were obtained on 11,645 adults receiving longitudinal HIV care at 4 geographically diverse US HIV clinics within the HIV Research Network. Modified clinical classification software from the Agency for Healthcare Research and Quality assigned primary ICD-9 codes into diagnostic categories. Analysis was performed with repeated measures negative binomial regression.
During 2001 to 2008, the rate of AIDS-defining illness (ADI) hospitalizations declined from 6.7 to 2.7 per 100 person-years, incidence rate ratio per year, 0.89 (0.87, 0.91). Among the other diagnostic categories with average rates >2 per 100 person-years, cardiovascular hospitalizations increased over time [1.07 (1.03, 1.11)], whereas non-AIDS-defining infection [0.98 (0.96, 1.00)], psychiatric [0.96 (0.93, 1.00)], and gastrointestinal/liver [0.96 (0.92, 1.00)] were slightly decreasing or stable. Although less frequent overall, renal and pulmonary admissions also increased over time in univariate and multivariate analyses. Of all diagnostic categories, ADI admissions had the longest mean length of stay, 10.5 days.
ADI hospitalizations have continued to decline in recent years but are still relatively frequent and potentially costly given long lengths of stay. Increases or stability in the rates of chronic end-organ disease admissions imply a need for broader medical knowledge among individual clinicians and/or teams who care for persons living with HIV and a need for long-term access to medications for these conditions.
JAIDS Journal of Acquired Immune Deficiency Syndromes 01/2012; 59(4):368-75. · 4.43 Impact Factor
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ABSTRACT: Increasing numbers of youth are becoming HIV-infected and need highly active antiretroviral therapy (HAART). We hypothesized that behaviorally HIV-infected youth (BIY) ages 18 to 24 years are less likely than adults (25 years or older) to receive HAART and, once initiated, more likely to discontinue their first HAART regimen.
Longitudinal analysis of treatment-naïve patients (age 18 years or older) meeting criteria for HAART and followed at HIV Research Network sites (2002-2008). Time from meeting criteria to HAART initiation and duration on first regimen were assessed using Cox proportional hazards regression.
A total of 3127 (268 youth, 2859 adult) treatment-naïve, HIV-infected patients met criteria. BIY were more likely to be black (66.8% vs 51.1%; P < 0.01) and less likely to identify injection drug use HIV risk (1.1% vs 8.8%; P < 0.01) than adults 25 years of age or older. Nearly 69% of BIY started HAART versus 79% of adults (P < 0.001). Adults 25 to 29 years of age (adjusted hazards ratio [AHR], 1.39; 95% confidence interval [CI], 1.12-1.73) and 50 years of age or older (AHR, 1.24; 95% CI, 1.00-1.54), but not 30 to 49 years (AHR, 1.19; 95% CI, 0.99-1.44) were more likely to initiate HAART than BIY. Attending four or more HIV provider visits within 1 year of meeting criteria was associated with HAART initiation (AHR, 1.91; 1.70-2.14). CD4 200 to 350 versus less than 200 cells/mm (AHR, 0.57; 95% CI, 0.52-0.63), and injection drug use (AHR, 0.80; 95% CI, 0.69-0.92) were associated with a lower likelihood of HAART initiation. There were no age-related differences in duration of the first regimen.
BIY are less likely to start HAART when meeting treatment criteria. Addressing factors associated with this disparity is critical to improving care for youth.
JAIDS Journal of Acquired Immune Deficiency Syndromes 06/2011; 58(1):100-7. · 4.43 Impact Factor
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ABSTRACT: Geographic location may be related to the receipt of quality HIV health care services. Clinical outcomes and health care utilization were evaluated in rural, urban, and peri-urban patients seen at high-volume US urban-based HIV care sites.
Zip codes for 8773 HIV patients followed in 2005 at seven HIV Research Network sites were categorized as rural (population <10,000), peri-urban (10,000-100,000), and urban (>100,000). Clinical and demographic characteristics, inpatient and outpatient (OP) utilization, AIDS-defining illness rates, receipt of highly active antiretroviral therapy (HAART), opportunistic infection (OI) prophylaxis usage, and virologic suppression were compared among patients, using χ(2) tests for categorical variables, t-tests for means, and logistic regression for HAART utilization.
HIV-infected rural (n=170) and peri-urban (n=215) patients were less likely to be Black or Hispanic than urban HIV patients. Peri-urban subjects were more likely to report MSM as their HIV risk factor than rural or urban subjects. Age, gender, CD4 or HIV-RNA distribution, virologic suppression, HAART usage, or OI prophylaxis did not differ by geographic location. In multivariate analysis, rural and peri-urban patients were less likely to have four or more annual outpatient visits than urban patients. Rural patients were less likely to receive HAART if they were Black. Overall, geographic location (as defined by home zip code) did not affect receipt of HAART or OI prophylaxis.
Although demographic and health care utilization differences were seen among rural, peri-urban, and urban HIV patients, most HIV outcomes and medication use were comparable across geographic areas. As with HIV care for urban-dwelling patients, areas for improvement for non-urban HIV patients include access to HAART among minorities and injection drug users.
AIDS Care 03/2011; 23(8):971-9. · 1.60 Impact Factor
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ABSTRACT: The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management.
We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/μl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care.
Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/μl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/μl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/μl or less, for whom inpatient costs were highest.
HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.
AIDS (London, England) 11/2010; 24(17):2705-15. · 4.91 Impact Factor
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ABSTRACT: A large proportion of people with human immunodeficiency virus (HIV) infection enter care late in the HIV disease course. Late entry can increase expenditures for care.
To estimate direct medical care expenditures for HIV patients as a function of disease status at initial presentation to care. Late entry is defined as initial CD4 test result ≤ 200 cells/mm3, intermediate entry as initial CD4 counts >200, and ≤ 500 cells/mm3; and early entry as initial CD4 count >500.
The study included 8348 patients who received HIV primary care and who were newly enrolled between 2000 and 2006 at one of 10 HIV clinics participating in the HIV Research Network.
We reviewed medical record data from 2000 to 2007. We estimated costs per outpatient visit and inpatient day, and monthly medication costs (antiretroviral and opportunistic illness prophylaxis). We multiplied unit costs by utilization measures to estimate expenditures for inpatient days, outpatient visits, HIV medications, and laboratory tests. We analyzed the association between cumulative expenditures and initial CD4 count, stratified by years in care.
Late entrants comprised 43.1% of new patients. The number of years receiving care after enrollment did not differ significantly across initial CD4 groups. Mean cumulative treatment expenditures ranged from $27,275 to $61,615 higher for late than early presenters. After 7 to 8 years in care, the difference was still substantial.
Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings.
Medical care 11/2010; 48(12):1071-9. · 3.24 Impact Factor
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ABSTRACT: To compare the ability of different models to predict prospectively whether someone will incur high medical expenditures.
Using nationally representative data from the Medical Expenditure Panel Survey (MEPS), prediction models were developed using cohorts initiated in 1996-1999 (N=52,918), and validated using cohorts initiated in 2000-2003 (N=61,155).
We estimated logistic regression models to predict being in the upper expenditure decile in Year 2 of a cohort, based on data from Year 1. We compared a summary risk score based on diagnostic cost group (DCG) prospective risk scores to a count of chronic conditions and indicators for 10 specific high-prevalence chronic conditions. We examined whether self-rated health and functional limitations enhanced prediction, controlling for clinical conditions. Models were evaluated using the Bayesian information criterion and the c-statistic. Principal
Medical condition information substantially improved prediction of high expenditures beyond gender and age, with the DCG risk score providing the greatest improvement in prediction. The count of chronic conditions, self-reported health status, and functional limitations were significantly associated with future high expenditures, controlling for DCG score. A model including these variables had good discrimination (c=0.836).
The number of chronic conditions merits consideration in future efforts to develop expenditure prediction models. While significant, self-rated health and indicators of functioning improved prediction only slightly.
Health Services Research 04/2010; 45(2):532-52. · 2.16 Impact Factor
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ABSTRACT: Mental illness (MI) and illicit drug use (DU) frequently co-occur. We sought to determine the individual and combined effects of MI and DU on highly active antiretroviral therapy (HAART) receipt and HIV-RNA suppression among individuals engaged in HIV care. Using 2004 data from the HIV Research Network (HIVRN), we performed a cross-sectional study of HIV-infected patients followed at seven primary care sites. Outcomes of interest were HAART receipt and virological suppression, defined as an HIV-RNA <400 copies/ml. Independent variables of interest were: (1) MI/DU; (2) DU only; (3) MI only; and (4) Neither. We used chi-squared analysis for comparison of categorical variables, and logistic regression to adjust for age, race, sex, frequency of outpatient visits, years in clinical care, CD4 nadir, and study site. During 2004, 10,284 individuals in the HIVRN were either on HAART or HAART eligible defined as a CD4 cell count < or =350. Nearly half had neither MI nor DU (41%), 22% MI only, 15% DU only, and 22% both MI and DU. In multivariate analysis, co-occurring MI/DU was associated with the lowest odds of HAART receipt (Adjusted Odds Ratio: 0.63 (95% CI: (0.55-0.72]), followed by those with DU only (0.75(0.63-0.87)), compared to those with neither. Among those on HAART, concurrent MI/DU (0.66 (0.58-0.75)), DU only (0.77 (0.67-0.88)), were also associated with a decreased odds of HIV-RNA suppression compared to those with neither. MI only was not associated with a statistically significant decrease in HAART receipt (0.93(0.81-1.07)) or viral suppression (0.93 (0.82-1.05)) compared to those with neither. Post-estimation testing revealed a significant difference between those with MI/DU and DU only, and MI/DU and MI only. Co-occurring MI and DU is associated with lower HAART receipt and viral suppression compared to individuals with either MI or DU or neither. Integrating HIV, substance abuse, and mental healthcare may improve outcomes in this population.
AIDS Care 06/2009; 21(5):655-63. · 1.60 Impact Factor
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ABSTRACT: HIV infection and substance use disorders are chronic diseases with complex contributions to health-related quality of life (HRQOL). We conducted a cross-sectional survey of 951 HIV-infected adults receiving care at 14 HIV Research Network sites in 2003 to estimate associations between HRQOL and specific substance use among HIV-infected patients. HRQOL was assessed by multi-item measures of physical and role functioning, general health, pain, energy, positive affect, anxiety, and depression. Mental and physical summary scales were developed by factor analysis. We used linear regression to estimate adjusted associations between HRQOL and current illicit use of marijuana, analgesics, heroin, amphetamines, cocaine, sedatives, inhalants, hazardous/binge alcohol, and drug use severity. Current illicit drug use was reported by 37% of subjects. Mental HRQOL was reduced for current users [adjusted beta coefficient -9.66, 95% confidence interval [(CI]) -13.4, -5.94] but not former users compared with never users. Amphetamines and sedatives were associated with large decreases in mental (amphetamines: beta = -22.8 [95% CI -33.5, -12.0], sedatives: beta = -18.6 [95% CI -26.2, -11.0]), and physical HRQOL (amphetamines: beta = -11.5 [95% CI -22.6, -0.43], sedatives: beta = -13.2 [95% CI -21.0, -5.36]). All illicit drugs were associated with decreased mental HRQOL: marijuana (beta = -7.72 [95% CI -12.0, -3.48]), non-prescription analgesics (beta = -13.4 [95% CI -20.8, -6.07]), cocaine (beta = -10.5 [95% CI -16.4, -4.67]), and inhalants (beta = -14.0 [95% CI -24.1, -3.83]). Facilitating sobriety for patients with attention to specific illicit drugs represents an important avenue for elevating HRQOL in patients living with HIV.
AIDS patient care and STDs 12/2008; 22(11):859-67. · 2.68 Impact Factor
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ABSTRACT: Studies of health service use for emotional problems show that the majority of those with disorders do not seek professional help. In addition, mental health service use is lower among members of minority communities, compared with non-Hispanic whites.
To examine the role of self-reported mental health as an indicator of awareness of mental conditions and as an influence in the process of seeking mental health care.
We conducted cross-sectional analyses of nationally representative data from the Medical Expenditure Panel Survey (MEPS) for 2000-2004.
In-person interviews obtained data on self-rated mental health (SRMH), ambulatory mental health visits, and purchase of prescription medications to treat mental conditions. Respondents completed the SF-12 health status survey; analyses included the SF-12 mental component summary (MCS) as a measure of emotional symptoms. Analyses included only those who provided self-reports of MCS and SRMH.
SRMH was related to any ambulatory visit and any medication purchase for mental health treatment, controlling for MCS, and other sociodemographic and clinical variables. The association between SRMH and service use was weaker for black and Hispanic respondents than for whites. In addition, the magnitude of the association between SRMH and MCS was weaker for black and Hispanic respondents than for whites.
Racial/ethnic differences in service use may arise in part from different propensities to interpret emotional symptoms as reflecting one's mental health and then to seek professional intervention for emotional problems. SRMH may be useful as an indicator of the extent to which people acknowledge the existence of emotional problems.
Medical care 10/2008; 46(9):915-23. · 3.24 Impact Factor
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ABSTRACT: To examine the prospective association between frequency of outpatient visits and subsequent inpatient admissions.
Medical record data on 13,942 patients with HIV infection seen in 10 HIV speciality care sites across the United States.
This observational study followed a cohort of HIV-infected patients who were in care in the first half of 2001. Numbers of inpatient admissions and outpatient visits were calculated for each patient for each 3-month period, from 2001 through 2004.
Negative binomial and logistic regression analyses using random-effects models examined the effects of inpatient admissions and outpatient visits in the previous period on inpatient and outpatient service utilization, controlling for background characteristics and HIV disease stage.
For 3-month periods, between 5 and 9 percent of patients had an inpatient admission. The linear association between number of outpatient visits and any inpatient admission in the subsequent period was positive (adjusted odds ratio=1.05; 95 percent confidence interval [CI]=1.04, 1.06). However, patients with zero prior outpatient visits had significantly greater admission rates than those with one prior visit. Hospitalization rates were also higher among those with a prior hospitalization and those with more advanced HIV disease.
These results suggest a J-shaped relationship between outpatient use and inpatient use among persons with HIV disease. Those in worse health have greater utilization of both inpatient and outpatient care. However, having no outpatient visits may also increase the likelihood of subsequent hospitalization. Although outpatient care cannot be justified as a cost-saving mechanism, maintaining regular clinical monitoring of patients is important.
Health Services Research 03/2008; 43(1 Pt 1):76-95. · 2.16 Impact Factor
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ABSTRACT: A large body of research shows that global self-rated health is related to important outcome variables. Increasingly, studies also obtain a single global self-rating of mental health, but understanding of what this item measures is limited.
To clarify interpretation of self-reported mental health, we examine its associations with other validated measures of mental health and role functioning.
We conducted cross-sectional analyses of nationally representative data from the Medical Expenditure Panel Survey.
In-person household interviews obtained data on global self-reported mental health and any limitations in work, school, or housekeeping activities. Adult respondents (N = 11,109) completed the SF-12 health status survey, the K6 scale of nonspecific psychologic distress, and the Patient Health Questionnaire (PHQ-2) depression screener in a self-administered questionnaire. We used the SF-12 Mental Component Summary and the mental health subscale. Analyses examined associations among mental health measures and regressed activity limitations, and the SF-12 physical and emotional role functioning scales on mental health measures, controlling for demographics and selected chronic conditions.
The 4 multi-item mental health measures were strongly correlated with each other (r > 0.69), but correlated less strongly with the self-reported mental health item (r approximately 0.4). In an exploratory factor analysis, self-reported mental health loaded on both mental and physical health factors. In multivariate analyses, each mental health variable was significantly associated with activity limitations and with role functioning, but the association of self-reported mental health with emotional role functioning was relatively weak.
Although global self-rated mental health is related to symptoms of psychologic distress, it cannot be considered to be a substitute for them.
Medical Care 07/2007; 45(7):602-9. · 3.41 Impact Factor
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ABSTRACT: Research on the distribution of health care expenditures among the U.S. population has shown that a small proportion of individuals, many of whom have chronic health conditions, accounts for a disproportionate share of total expenses. Previous work by Berk and Monheit showed that in both 1987 and 1996 the top 1% of individuals in the expenditure distribution accounted for more than one-quarter of all expenses, and the top 5% accounted for more than half. They found this distribution had been constant for more than 20 years, despite significant changes in the U.S. health care system during that period. Previous research has also shown that more than three-quarters of all medical expenditures are associated with the care of persons with chronic conditions. Recent efforts to contain medical care costs in the U.S. have focused on what might be done to obviate some of this disproportionate spending, either through more effective use of preventive care, or better management of care for persons with chronic medical conditions. These efforts are complicated, however, by the fact that research has shown that being in the top of the expenditure distribution is not something that is highly persistent over time. Although expenditures in one year are correlated with expenditures in the next, there are a number of factors that determine individuals' levels of spending from one year to the next, and simply knowing base year expenditures does not mean insurers or providers can identify which individuals are most appropriate for additional attention. Nonetheless, to the extent there are specific, treatable conditions that are associated with persistently high expenditures there may be opportunities to develop methods of managing treatment that can enhance efficiency without sacrificing, or perhaps even improving, quality of care. This analysis builds on previous work on the prediction and concentration of expenditures to examine which health conditions and health status measures, in addition to demographic characteristics, are most associated with high medical care costs. The focus will be on chronic conditions, such as heart disease, cancer, diabetes, and depression, and combinations of those chronic conditions, to determine which set of conditions and other factors, including overall health status measures such as risk scores and self assessed health, are the best predictors of being in the upper tail of the expenditure distribution. For this study we pool data from the 1996 through 2004 Medical Expenditure Panel Survey (MEPS) and predict annual expenditures for individuals with single and multiple chronic conditions. The focus will be on identifying the subset of chronic conditions or combination of conditions that appear to have the greatest potential for efficiency improvement due to the level of expenditures associated with them.
HEN: Consumer Behavior (Topic). 06/2007;
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ABSTRACT: Receipt of highly active antiretroviral therapy (HAART) differs by gender and racial/ethnic group and may reflect an effect of mood disorders.
We examined the effects of dysthymia and major depression on HAART use by 6 groups defined by gender and race/ethnicity (white, black, Hispanic).
Self-reported HAART use in the past 6 months.
Interview data from the HIV Cost and Services Utilization Study (HCSUS). Independent variables measured in or before the first half of 1997, and HAART use measured in the second half of 1997.
Multivariate logistic regression of depression and dysthymia on HAART use by 6 patient groups.
One thousand nine hundred and eighty-two HIV-infected adults in HIV care in 1996 and with a CD4 count <500 in 1997.
Highly active antiretroviral therapy receipt was the highest for white men (68.6%) and the lowest for Hispanic women (52.7%) and black women (55.4%). Dysthymia was more prevalent in women (Hispanic, 46%; black, 27%; white, 31%) than men (Hispanic, 23%; black, 18%; white, 15%). The prevalence of major depression was greater in whites (women, 35%; men, 31%) than minorities (women, 26%; men, 21%). Compared with white men without dysthymia, the adjusted odds ratios (AORs) of HAART were significantly lower for black women (0.50 [95% confidence interval [95% CI] 0.29 to 0.87]) and Hispanic women (0.45 [95% CI 0.25, 0.79]). Among patients with depression and no dysthymia, minority women had HAART use (AOR=1.28 [95% CI 0.48 to 3.43]) similar to white men.
Self-report data from the early era of HAART use; causation cannot be proven; mental health diagnoses may not meet full DSM IV criteria.
Dysthymia is highly prevalent in minority women and associated with a 50% reduction in the odds of receiving HAART. This underrecognized condition may contribute more than depression to the "gender disparity" in HAART use.
Journal of General Internal Medicine 12/2006; 21(12):1235-41. · 2.83 Impact Factor
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ABSTRACT: Relatively few studies have used self-reported health status in models to predict medical expenditures, and many of these have used the SF-36.
We sought to examine the ability of the briefer SF-12 measure of health status to predict medical expenditures in a nationally representative sample.
We used data from the 2000-2001 panel of the Medical Expenditure Panel Study. Respondents (n = 5542) completed the SF-12 in a questionnaire. Interviews obtained data on demographics and selected chronic conditions. Data on expenditures incurred subsequent to the interview were obtained in part from provider records. We examined different regression model specifications and compared different statistical estimation techniques.
Adding the SF-12 to a regression model improved the prediction of subsequent medical expenditures. In a model with only age and gender, adding the SF-12 increased R from 0.06 to 0.13. The coefficients for the Physical Component Summary (PCS) and the Mental Component Summary (MCS) of the SF-12 for this model were -0.045 (P < 0.01) and -0.012 (P < 0.01), respectively. In a model including demographic characteristics, chronic conditions, and previous expenditures, adding the SF-12 increased the R from 0.26 to 0.29. The coefficients for the PCS and the MCS for this model were -0.025 (P < 0.001) and -0.005 (P = 0.15), respectively. A single general health status question performed almost as well as the full SF-12. Models estimated using ordinary least squares had undesirable properties. In terms of R, a generalized linear model (GLM) with a Poisson variance function was consistently superior to a GLM with a gamma variance function.
Information on self-reported health status is useful in predicting medical expenditures. The extent to which the SF-12 adds predictive power over a comprehensive array of diagnostic data remains to be examined.
Medical Care 06/2006; 44(5 Suppl):I54-63. · 3.41 Impact Factor
