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Improved quality of care reduces mortality among HIV patients
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Improving quality of care could have a positive influence on mortality rates among patients with HIV, according to data recently published in Infection Control and Hospital Epidemiology.
“The link between a group of disease-specific process measure [quality indicators (QIs)] and outcomes has been difficult to demonstrate in clinical practice,” the researchers wrote. “The few chronic illnesses that have done so, including diabetes and acute myocardial infarction, have not focused on vulnerable populations such as patients with HIV infection or substance abuse. Little is known regarding the association between aggregate receipt of care process measures … and outcomes such as mortality.”
Researchers conducted a longitudinal survival analysis of HIV patients enrolled in the Veterans Aging Cohort Study (VACS) from June 2002 to June 2008. Enrollees completed baseline surveys and allowed access to data including diagnostic, health care and mortality information. Quality of HIV care was assessed 12 months after enrollment by examining the numbers of QIs a patient was eligible for and how many they received. QI receipt then was calculated as a percentage, resulting in dichotomous groups of patients who received more or less than 80% of available QIs.
The primary outcome was death, which was assessed for up to 11 years. Information concerning other relevant variables, including unhealthy alcohol or illicit drug use, were self-reported at enrollment. Examined QIs focused on the receipt of medications, screening, prevention through vaccination and HIV infection monitoring.
The mean age of the cohort (n = 3,038) was 49 years and primarily included male (97.5%) and black (66.8%) patients. At enrollment, 83.9% were prescribed combination ART, 76.7% demonstrated 200 or more CD4 cells/mL3, and 55.6 % were virally suppressed. At baseline, 25.9% of participants reported unhealthy alcohol use within the past year, 28.4% reported illicit drug use, and 11.2% reported both.
Through 24,805 patient-years of follow-up, death occurred in 29.8% of cases. A reduction in mortality was observed among HIV patients who received 80% or more of eligible QIs, compared with those who received less than 80% (age-adjusted mortality = 0.75; 95% CI, 0.65-0.86). This benefit was seen regardless of patients’ substance use status; however, additional analysis adjusting for the VACS index suggested that improved quality of care may not be enough to overcome illness severity as the dominant influence on mortality.
“These findings support policies that promote monitoring and reporting of QIs, suggesting that high-quality care provided by health care systems and providers may translate into decreased mortality for their patients,” the researchers wrote. “Improving [quality of care] alone, however, may be insufficient for overcoming the contribution of underlying disease severity to mortality.”
Michael A. Horberg
This sentiment was echoed in a related editorial by Michael A. Horberg, MD, MAS, director of HIV/AIDS for Kaiser Permanente. Along with advocating the impact of quality care, he wrote that future research will need to identify and explore factors such as comorbidity and substance use that are influencing mortality among this population.
“The work by Korthuis and colleagues clearly demonstrates that receipt of a large majority of quality of care indicators is associated with lower mortality risk,” he wrote. “But that risk is not absolute, and there are many mediating factors. How we measure those mediating factors and draw attention to them will be critical going forward as we better define and measure quality HIV care.” – by Dave Muoio
Disclosure: The researchers and Horberg report no relevant financial disclosures.
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