Geographic variation in the costs of medical care for people living with HIV in British Columbia, Canada

Benjamin Enns,Jeong Eun Min,Dimitra Panagiotoglou,Bohdan Nosyk,Julio S G Montaner

doi:10.1186/s12913-019-4391-8

Abstract

BackgroundRegional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. We aimed to estimate regional variation in medical costs for people living with HIV (PLHIV), adjusting for demographics and case-mix.MethodsWe conducted a retrospective cohort study using linked health administrative databases of PLHIV, from 2010 to 2014, in British Columbia (BC), Canada. Quarterly health care costs (2018 CAD) were derived from inpatient, outpatient, prescription drugs, antiretroviral therapy (ART), and HIV diagnostics. We used a two-part model with a logit link for the probability of incurring costs, and a log link and gamma distribution for observations with positive costs. We also estimated quarterly utilization rates for hospitalization-, physician billing- and prescription drug-days. Primary variables were indicators of individuals’ Health Service Delivery Area (HSDA). We adjusted cost and utilization estimates for demographic characteristics, HIV-disease progression, and comorbidities.ResultsOur cohort included 9577 PLHIV (median age 45.5 years, 80% male). Adjusted total quarterly costs for all 16 HSDAs were within 20% of the provincial mean, 8/16 for hospitalization costs, 16/16 for physician billing costs and 10/16 for prescription drug costs. Northern Interior and Northeast HSDAs had 38 and 44% lower quarterly non-ART prescription drug costs, and 2 and 5% higher quarterly inpatient costs, respectively.ConclusionsWe observed limited variation in medical care costs and utilization among PLHIV in BC. However, lower levels of outpatient care and higher levels of inpatient care indicate possible barriers to accessing care among PLHIV in the most rural regions of the province.

Highlights

Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery
We presented each of these analyses separately, as differential rates of antiretroviral therapy (ART) uptake across Health Service Delivery Area (HSDA), combined with the high relative costs of antiretroviral medication, could potentially obscure differences in health care costs that indicated divergence from clinical practice standards or higher intensity of service provision among people living with HIV (PLHIV)
Across HSDAs, the proportion of female personquarters ranged from 14.2–42.0%, men who have sex with men (MSM) person-quarters ranged from 3.8–44.9% and people who inject drugs (PWID) person-quarters ranged from 18.1–59.0%

Summary

Introduction

Regional variation in medical care costs can indicate heterogeneity in clinical practice, inequities in access, or inefficiencies in service delivery. Regional variation in health care costs after adjustment for demographic and clinical factors can be indicative of inequities or a lack of well-defined clinical practice [1, 2]. This topic has been the subject of considerable research in the United States and elsewhere [1, 3,4,5], primarily to facilitate performance-based reimbursement or identify potentially inefficient health care providers [1]. ART engagement and viral suppression rates in 2016 were 7 and 23 percentage points lower, respectively, in the Northern HA compared to Vancouver Coastal HA which is home to over 50% of people living with HIV (PLHIV) in BC and 25% of the provincial population [16, 17]

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