Triply-diagnosed patients in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study: patterns of home care use
Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA. AIDS Care
(Impact Factor: 1.6).
07/2008; 20(10):1177-89. DOI: 10.1080/09540120801918644
Although AIDS is a chronic illness, little is known about the patterns and correlates of long-term care use among triply diagnosed HIV patients. We examined nursing and home care use among 1,045 participants in the HIV/AIDS Treatment Adherence, Health Outcomes and Cost Study, a multi-site study of HIV-positive patients with at least one mental health and one substance disorder. Patient interviews and medical record review data were used to examine the average monthly cost of nursing home, formal home and informal home care. Multinomial logit and two-part regression models were used to identify correlates of the use of formal and informal home care and the number of informal home care hours used. During the three months prior to baseline, 2, 7 and 23% of participants used nursing home, formal home and informal home care, respectively. Patients who were better-educated, had higher incomes, had Medicaid insurance (with or without Medicare coverage) and whose transmission mode was homosexual sex had higher regression-adjusted probabilities of receiving any formal home care; Latinos and physically healthier patients had lower probabilities. Women and patients who abused drugs or alcohol (but not both) were more likely to receive informal care only. Overall, patients who were female, better-educated, physically or mentally sicker or single-substance abusers were more likely to receive any home care (either formal or informal), while those contracting HIV through heterosexual sex were less likely. Women received 28 more monthly hours of informal care than men and married patients received 31 more hours than unmarried patients. We conclude that at least one mutable policy factor (Medicaid insurance) is strongly associated with formal home care use among triply diagnosed patients. Further research is needed to explore possible implications for access among this vulnerable subpopulation.
Available from: Peter S. Arno
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ABSTRACT: Triply diagnosed patients, who live with HIV and diagnosed mental health and substance abuse disorders, account for at least 13% of all HIV patients. This vulnerable population has substantial gaps in their care, attributable in part to the need for treatment for three illnesses from three types of providers.
The HIV/AIDS Treatment Adherence, Health Outcomes and Cost study (HIV Cost Study) sought to evaluate the cost-effectiveness of integrated HIV primary care, mental health, and substance abuse services among triply diagnosed patients. The analysis was conducted from a health sector budget perspective.
Patients from four sites were randomly assigned to intervention group (n=232) or control group (n=199) that received care-as-usual. Health service costs were measured at baseline and three, six, nine and 12 months and included hospital stays, emergency room visits, outpatient visits, residential treatment, formal long-term care, case management, and both prescribed and over-the-counter medications. Costs for each service were the product of self-reported data on utilization and unit costs based on national data (2002 dollars). Quality of life was measured at baseline and six and 12 months using the SF-6D, as well as the SF-36 physical composite score (PCS) and mental composite score (MCS).
During the 12 months of the trial, total average monthly cost of health services for the intervention group decreased from USD 3235 to USD 3052 and for the control group decreased from USD 3556 to USD 3271, but the decreases were not significant. For both groups, the percentage attributable to hospital care decreased significantly. There were no significant differences in annual cost of health services, SF-6D, PCS or MCS between the intervention and control group.
The results of this randomized controlled trial did not demonstrate that the integrated interventions significantly affected the health service costs or quality of life of triply diagnosed patients. Professionals could pursue coordination or integration of care guided by the evidence that it does not increase the cost of care. The results do not however, provide an imperative to introduce multi-disciplinary care teams, adherence counseling, or personalized nursing services as implemented in this study.
There is not enough evidence to either limit continued exploration of integration of care for triply diagnosed patients or adopt policies to encourage it, such as financial reimbursement, grants regulation or licensing.
Future trials with interventions with lower baseline levels of integration, longer duration and larger sample sizes may show improvement or slow the decline in quality of life. Future researchers should collect comprehensive cost data, because significant decreases in the cost of hospital care did not necessarily lead to significant decreases in the total cost of health services.
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ABSTRACT: The objective of the study is to evaluate the impact of the new highly active antiretroviral biotechnology medicines (tenofovir disoproxil, emtricitabin and darunavir) on the clinical centre health care budget for AIDS in 2011 for a one year time horizon. A computer simulated budget impact model is created to calculate the budget impact of the new biotechnology medicines as a difference among the cost of illness based on current practice monus the cost of illness based on new practice after the new medicines inclusion in the clinic. The cost of therapy is calculated as a sum of mean annual medicines cost for all patients on the therapeutic regime, yearly cost of physician's consultation, and laboratory tests. Two scenarios have been considered depending on the line of therapy - Ist line (140 patients in the current state and 20 in the new state) and IInd line (2 patients in the current state and 26 in the new state). The yearly cost per patient in the current state on Ist line therapy, which did not involve the use of the new biotechnology products varied between 3000 and 12 000 euro. In the new state the budget impact varies from 8000 to 13000 euro for treatment naïve patient, and for the switched - therapy patients it varies between 5000 and 13 000 euro. Thus the addition of the new medicines let to the increase in the yearly budget per patient with 1000 to 5000 euro. The IInd line therapy is usually started when adverse drug events or resistance against the first line therapy is observed. The addition of the new medicines increases total budget more evidently for the patients on first line therapy, than for the patients on IInd line. The budget impact of the new highly active antiretroviral therapy depends mainly on the new biotechnology medicines cost.
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ABSTRACT: Increasing number of people living with HIV (PLHIV) will require expanded access to health services. Countries need robust and contemporary strategic information on the cost of care to monitor and evaluate the effectiveness, efficiency, equity, and acceptability of services. Published HIV cost literature from July 1999 to December 2008 was reviewed. Articles were identified using specific databases and scored, based on explicit criteria relating to the services covered, utilization data, cost data used and quality of the study.
One hundred and fifteen articles were identified, 47% came from North America, 29% from Europe, 17% from Africa and 8% from Asia; no studies from Latin America could be identified. The mean score across all studies was 33.7 out of a maximum of 64, with a median of 34 and a range of 11-51. Mean score did not change significantly over time (Pearson's R8 = 0.3; P > 0.05).
Great variation was observed in the methods used to estimate cost data across the studies identified, including range of services, patients covered and outcomes costed. Progress in the quantity and quality of studies published since 1999 has been limited. More consistent costing methods and more comprehensive coverage - both by country and level of care - are needed in order for policymakers and other stakeholders to be able to optimally monitor and evaluate the cost and cost-effectiveness of country services for HIV treatment and care, especially as population costs are likely to increase with more PLHIV on antiretroviral therapy.
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