'Substantial Insufficiencies' in Preventive Care for Older People With HIV

January 24, 2017

By several guideline measures, HIV-positive Medicare and Medicaid patients received significantly better care if their provider had a large HIV caseload, according to the results of an 11,000-person analysis. But, overall, the study found "substantial insufficiencies" in some aspects of preventive care for people with HIV.

With antiretroviral-treated people surviving longer, clinical care is evolving to include more primary prevention measures aimed at age-related comorbidities, which may arise at an earlier age and with greater frequency in people with HIV. At the same time, a growing number of patients with HIV means more primary care providers will supervise their management. To guide clinicians in refining HIV care, the U.S. Health Resources and Services Administration (HRSA) recently expanded its list of HIV/AIDS Care Performance Measures. Clinical investigators conducted this study to determine how closely providers follow some of those guidelines in Medicare and Medicaid patients with HIV.

The researchers used Medicare and Medicaid claims data to identify HIV-positive Californians using fee-for-service public insurance in 2010. All patients were in care for the full years of 2009 and 2010. From this analysis, the investigators created two groups: patients using Medicare with or without Medicaid (the Medicare group) and patients using only Medicaid (the Medicaid-only group). The investigators used medical records to assess eight HRSA-recommended quality-of-care outcomes: visit frequency, CD4-cell assessment, viral load (HIV RNA) assessment, influenza vaccination, tuberculosis (TB) testing, lipid profiling, blood glucose testing and Pap testing for women. They divided providers into those who saw 50 or more HIV patients (high-volume providers), those who saw five to 49 HIV patients (medium-volume providers) and those who saw fewer than five HIV patients (low-volume providers). They used logistic regression to assess rates of meeting guidelines according to provider characteristics.

The analysis included 9377 Medicare enrollees, 6650 of whom (71%) also used Medicaid, and 2076 Medicaid-only enrollees. The Medicare and Medicaid-only groups had, respectively, median ages of 52 and 49 years, 17% and 33% were black and 19% and 18% were Hispanic. Proportions of Medicare patients who saw providers with high, medium and low HIV caseloads were 63%, 24% and 13%; respective proportions of Medicaid-only patients in those three groups were 66%, 21% and 13%. High proportions of Medicare enrollees (93%) and Medicaid-only enrollees (90%) made the appropriate number of guideline-recommended visits. Among patients who had the recommended number of visits, high proportions of Medicare and Medicaid-only enrollees (89% and 89%) had CD4 counts at least twice in two years, and 85% and 82% had viral load assays at least twice in two years.

While more than 94% of patients in both the Medicare and Medicaid-only groups had a glucose test, only 72% and 64% had a lipid panel, only 47% and 34% had an annual flu shot and only 19% and 35% were tested for TB. Fewer than half of women in either group had been screened for cervical cancer.

Analyses controlling for patient demographics and clinical characteristics determined that Medicare and Medicaid-only patients seeing low-volume HIV providers met several guidelines significantly less often than patients seeing high-volume providers. For Medicare and Medicaid-only patients seeing low-volume providers, 60% and 45% met visit guidelines, compared with 98% and 97% of those seeing high-volume providers. For Medicare and Medicaid-only patients, 78% and 75% of those seeing low-volume providers had recommended CD4 tests, compared with 91% and 90% of those seeing high-volume providers. Among Medicare patients, 76% seeing low-volume providers versus 87% seeing high-volume providers had guideline-recommended viral load testing.

Lower proportions of Medicare patients seeing low-volume HIV providers than high-volume providers had influenza vaccinations (36% versus 47%) or TB testing (9% versus 22%). For Medicaid-only recipients, 13% seeing a low-volume provider versus 39% seeing a high-volume provider met TB-test guidelines. Among women using Medicaid, fewer with a low-volume provider than a high-volume provider had a Pap test for cervical cancer screening (19% versus 48%).

The researchers conclude that Medicare/Medicaid patients seeing high-volume HIV providers were more likely to receive quality HIV care (as indicated by clinical visit frequency and CD4-cell and viral load testing) and also to receive "preventive care for conditions with greater prevalence" in people with HIV (flu, TB, cervical cancer, high glucose).

The authors note that, as comorbidities increase in aging people with HIV, teams of subspecialists may be needed to manage their care. But such teams, they argue, should include experienced HIV providers because they are more likely to offer both "guideline-consistent HIV care" and screening for conditions linked to HIV. The investigators believe their results "suggest that HIV specialists have weathered the evolution ... of HIV care from a practice largely focused on opportunistic infection management and end-of-life care, to one of highly specialized and nuanced antiretroviral management, to the current era ever-more focused on preventive care and long-term toxicity management."

Mark Mascolini writes about HIV infection.

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This article was provided by TheBodyPRO.

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