Receipt Of Primary Care Research Articles

Effects of Medicaid expansion on insurance coverage and health services use among adults with disabilities newly eligible for Medicaid.

To estimate the effects of Affordable Care Act (ACA) Medicaid expansion on insurance and health services use for adults with disabilities who were newly eligible for Medicaid. 2008-2018 Medical Expenditure Panel Survey data. We used the Agency for Healthcare Research and Quality (AHRQ) PUBSIM model to identify adults aged 26-64 years with disabilities who were newly Medicaid-eligible in expansion states or would have been eligible in non-expansion states had those states opted to expand. Outcomes included insurance coverage; access to care; receipt of primary care, outpatient specialty physician services, and preventive services; and out-of-pocket health care spending. To estimate the effects of Medicaid expansion, we used two-way fixed effects models and a triple differences framework to compare pre-post changes in each outcome in expansion and non-expansion states for adults with and without disabilities. We simulated Medicaid eligibility with the AHRQ PUBSIM model, which uses state-specific Medicaid rules and MEPS data on family relationships, state of residence, and income. Among adults with disabilities who were newly eligible for Medicaid, Medicaid expansion was associated with significant increases in full-year Medicaid coverage (35.9 percentage points [pp], p < 0.001), receipt of primary care (15.5pp, p < 0.01), and receipt of flu shots (19.2pp, p < 0.01), and a significant decrease in out-of-pocket spending (-$457, p < 0.01). There were larger improvements for adults with disabilities compared to those without disabilities in full-year Medicaid coverage (11.0pp, p < 0.01) and receipt of flu shots (18.0pp, p < 0.05). Medicaid expansion was associated with improvements in full-year insurance coverage, receipt of primary and preventive care, and out-of-pocket spending for adults with disabilities who were newly eligible for Medicaid. For insurance coverage, preventive care, and some primary care measures, there were differentially larger improvements for adults with disabilities than for those without disabilities.

Primary care provider payment models and adherence to anticoagulation in patients with atrial fibrillation.

BACKGROUND: Oral anticoagulation (OAC) is recommended for the prevention of stroke in atrial fibrillation (AF). However, only 50%-60% of AF patients in the United States are treated with OAC, and 60% of them adhere to OAC therapy over time. OBJECTIVES: To (1) compare adherent use of OAC between AF patients who received primary care from practices involved in shared-savings models and patients who received care from practices not involved in shared savings and (2) examine the trend of adherence to OAC over time. Because OAC can save downstream medical costs associated with averted stroke events, we hypothesized that OAC adherence would be higher among patients receiving care from practices involved in shared savings. METHODS: Using 2014-2019 claims data from a health insurer in western Pennsylvania, we identified 20,637 AF patients from 2015-2018. Patients were followed from the first AF diagnosis (index date) for 12 months or until disenrollment. We categorized patients according to the payment model of the practice from which they received primary care: shared savings (n = 8,844) and no shared savings (n = 11,793). The primary outcome was adherent use of OAC therapy, which was defined as having at least 80% of the followup period covered with OAC. Secondary outcomes included adherent use of direct oral anticoagulants (DOACs) and adherent use of warfarin. We constructed logistic regression models to assess the association between involvement in shared savings and adherent use of OAC, while controlling for demographics, clinical characteristics, and index year. RESULTS: 34% of patients in the shared-savings group adhered to OAC, compared with 32.7% in the no shared-savings group (P = 0.04). After adjustment, adherence was higher for the shared-savings group for OAC (adjusted odds ratio [aOR] = 1.07, 95% CI = 1.01-1.14) and warfarin (aOR = 1.11, 95% CI = 1.02-1.20) compared with the no shared-savings group. However, the odds of adherent use of DOACs did not statistically differ between shared savings and no shared savings (aOR = 0.99, 95% CI = 0.91-1.08). The odds of adherent OAC use increased over time: the aOR of adherent use of OAC was 1.21 (95% CI = 1.09-1.34) for index year 2016; 1.50 (95% CI = 1.36-1.67) for 2017; and 1.78 (95% CI 1.60-1.98) for 2018, all compared with 2015. CONCLUSIONS: Receipt of primary care from a practice involved in shared savings was associated with a higher adherent use of OAC and warfarin for patients with atrial fibrillation. Furthermore, adherent use of OAC improved over time for both treatment groups. Our research demonstrates that the alignment of financial incentives between providers and insurers may improve the use of therapies with downstream cost-saving potential. DISCLOSURES: This project was funded by the National Heart, Lung and Blood Institute (grant number K01HL142847). Hernandez has received consulting fees from Pfizer and BMS, outside of the submitted work. The other authors have nothing to disclose.

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis

The beneficial impact of primary care, focused on all aspects of a patient's health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower use of emergency care and hospitalization for ambulatory care-sensitive conditions, and decreased early mortality. Although the importance of primary care and care coordination at the primary care/specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving in-center maintenance hemodialysis remains ill-defined. In this perspective article, we will describe: (1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among these patients; (2) the key challenges to delivery of primary care in these complex cases, including suboptimal care coordination between nephrology and primary care providers, the intensity of dialysis care, and the limited capacity of nephrologists and primary care providers to meet the broad health needs of hemodialysis patients; (3) potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and (4) future research requirements to improve primary care delivery for this high-risk population.

Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study.

To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

222. Using Reproductive Health Visits to Engage Adolescent and Young Adult Women in Primary Care.

Adolescent/Young Adult (AYA) primary care visits are an opportune time to address physical, psychological, and social influences on developing health behaviors. However, many AYAs do not receive primary care despite available guidelines for screening, immunizations, and annual physical exams. Frequent interactions with the healthcare system by AYA women for family planning and other reproductive health services may be used to improve engagement in care and promote wellness; however, less cumbersome methods may require less interaction with the healthcare system. The purpose of this research is to examine differences in clinic engagement, receipt of primary care, STI/HIV screening, and immunizations by contraceptive use.

Quality and Experience of Outpatient Care in the United States for Adults With or Without Primary Care

The US health care system is typically organized around hospitals and specialty care. The value of primary care remains unclear and debated. To determine whether an association exists between receipt of primary care and high-value services, low-value services, and patient experience. This is a nationally representative analysis of noninstitutionalized US adults 18 years or older who participated in the Medical Expenditure Panel Survey. Propensity score-weighted quality and experience of care were compared between 49 286 US adults with and 21 133 adults without primary care from 2012 to 2014. Temporal trends were also analyzed from 2002 to 2014. Patient-reported receipt of primary care, determined by the 4 "Cs" of primary care: first-contact care that is comprehensive, continuous, and coordinated. Thirty-nine clinical quality measures and 7 patient experience measures aggregated into 10 clinical quality composites (6 high-value and 4 low-value services), an overall patient experience rating, and 2 experience composites. From 2002 to 2014, the mean annual survey response rate was 58% (range, 49%-65%). Between 2012 and 2014, compared with respondents without primary care (before adjustment), those with primary care were older (50 [95% CI, 50-51] vs 38 [95% CI, 38-39] years old), more often female (55% [95% CI, 54%-55%] vs 42% [95% CI, 41%-43%]), and predominately white individuals (50% [95% CI, 49%-52%] vs 43% [95% CI, 41%-45%]). After propensity score weighting, US adults with or without primary care had the same mean numbers of outpatient (6.7 vs 5.9; difference, 0.8 [95% CI, -0.2 to 1.8]; P = .11), emergency department (0.2 for both; difference, 0.0 [95% CI, -0.1 to 0.0]; P = .17), and inpatient (0.1 for both; difference, 0.0 [95% CI, 0.0-0.0]; P = .92) encounters annually, but those with primary care filled more prescriptions (mean, 14.1 vs 10.7; difference, 3.4 [95% CI, 2.0-4.7]; P < .001) and were more likely to have a routine preventive visit in the past year (mean, 72.2% vs 57.5%; difference, 14.7% [95% CI, 12.3%-17.1%]; P < .001). From 2012 to 2014, Americans with primary care received more high-value care in 4 of 5 composites. For example, 78% of those with primary care received high-value cancer screening compared with 67% without primary care (difference, 10.8% [95% CI, 8.5%-13.0%]; P < .001). Americans with or without primary care received low-value care with similar frequencies on 3 of 4 composites, although Americans with primary care received more low-value antibiotics (59% vs 48%; difference, 11.0% [95% CI, 2.8%-19.3%] P < .001). Respondents with primary care also reported significantly better health care access and experience. For example, physician communication was highly rated for a greater proportion of those with (64%) vs without (54%) primary care (difference, 10.2%; 95% CI, 7.2%-13.1%; P < .001). Differences in quality and experience between Americans with or without primary care were essentially stable between 2002 and 2014. Receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience. Policymakers and health system leaders seeking to improve value should consider increasing investments in primary care.

Commentaries on health services research

Commentaries on health services research

Osteoporosis-Related Health Services Utilization Following First Hip Fracture Among a Cohort of Privately-Insured Women in the United States, 2008-2014: An Observational Study.

Timely identification and treatment of osteoporosis following hip fracture is recommended to mitigate future fracture risk, yet prior work has demonstrated a disconnect between evidence-based recommendations and real-world implementation. We sought to describe contemporary patterns of osteoporosis screening and initiation of pharmacotherapy following hip fracture based on medical and pharmacy claims in the OptumLabs™ Data Warehouse. From a national sample, we identified 8349 women aged 50+ years enrolled in private commercial or Medicare Advantage plans with no prior history of osteoporosis diagnosis, osteoporosis pharmacotherapy, or hip fracture who experienced a hip fracture between 2008 and 2013. Just 17.1% and 23.1% of these women had evidence of osteoporosis assessment and/or treatment within 6 or 12 months of their fractures, respectively. Women aged 80+ years were one-third less likely to utilize recommended services within 6 months, compared to those aged 50 to 79 years (13.8% versus 20.8%; p < 0.001). Utilization of bone mass measurement increased significantly among women aged 65+ years over the study period (p < 0.001) while declining among those aged 50 to 64 years (p = 0.2). In contrast, rates of osteoporosis pharmacotherapy remained steady among women aged 50 to 64 years (p = 0.8) yet declined among women aged 65 to 79 years and aged 80+ years (p = 0.07 and p = 0.004, respectively). Accounting for differences in all measured characteristics, receipt of primary care was the strongest and most consistent predictor of osteoporosis assessment or treatment following fracture. © 2017 American Society for Bone and Mineral Research.

O-193 A Decade Of Change In The Primary Care Experiences Of Children In The Us Will Reform Align The Us More Closely With Europe?

Purpose To understand national changes in the quality of primary care reported by families of children and to estimate the potential benefits of recent health insurance expansions to children’s receipt of primary care. Methods A comparison of three iterations of the National Survey of Children’s Health from 2003 to 2012 for children ages 0–18 years on measures of primary care experience (access, continuity, comprehensiveness and coordination). Trend analyses are stratified by insurance status and socio-demographics in order to assess the potential contribution of expanded coverage through health care reform to primary care experiences. Results The results show very little change overall in primary care experiences for children nationally. Some significant gains were made in access and continuity for children considered more vulnerable (i.e., from families with lower-incomes and lower educational attainment), but were mostly explained by changes in insurance coverage over time. Conclusion Insurance in the US remains a major factor in improving the primary care experience of children. The recent health care reforms have the potential to improve children’s primary care access and continuity, but even with the intended goal of near universal insurance coverage for children, the US is not likely to reach the levels of paediatric primary care experience reported among studies in major European economies.

Antidepressant Medication Management Among Older Patients Receiving Home Health Care.

Antidepressant management for older patients receiving home health care (HHC) may occur through two pathways: nurse-physician collaboration (without patient visits to the physician) and physician management through office visits. This study examines the relative contribution of the two pathways and how they interplay. Retrospective analysis was conducted using Medicare claims of 7,389 depressed patients aged 65 years or older who received HHC in 2006-2007 and who possessed antidepressants at the start of HHC. A change in antidepressant therapy (versus discontinuation or refill) was the main study outcome and could take the form of a change in dose, switch to a different antidepressant, or augmentation (addition of a new antidepressant). Logistic regressions were estimated to examine how use of home health nursing care, patient visits to physicians, and their interactions predict a change in antidepressant therapy. About 30% of patients experienced a change in antidepressants versus 51% who refilled and 18% who discontinued. Receipt of mental health specialty care was associated with a statistically significant, 10- to 20-percentage-point increase in the probability of antidepressant change; receipt of primary care was associated with a small and statistically significant increase in the probability of antidepressant change among patients with no mental health specialty care and above-average utilization of nursing care. Increased home health nursing care in absence of physician visits was not associated with increased antidepressant change. Active antidepressant management resulting in a change in medication occurred on a limited scale among older patients receiving HHC. Addressing knowledge and practice gaps in antidepressant management by primary care providers and home health nurses and improving nurse-physician collaboration will be promising areas for future interventions.

Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value

Accountable Care Organizations: A Challenging Opportunity for Primary Care to Demonstrate its Value

The Impact of Assertive Community Treatment on Utilization of Primary Care and Other Outpatient Health Services

A number of states have implemented Assertive Community Treatment (ACT) teams statewide. The extent to which team-based care in ACT programs substitutes or complements primary care and other types of health services is relatively unknown outside of clinical trials. To analyze whether investments in ACT yield savings in primary care and other outpatient health services. Patterns of medical and mental health service use and costs were examined using Medicaid claims files from 2000 to 2002 in North Carolina. Two-part models and negative binomial models compared individuals on ACT (n = 1,065 distinct individuals) with two control groups of Medicaid enrollees with severe mental illness not receiving ACT services (n = 1,426 and n = 41,717 distinct individuals). We found no evidence that ACT affected utilization of other outpatient health services or primary care; however, ACT was associated with a decrease in other outpatient health expenditures (excluding ACT) through a reduction in the intensity with which these services were used. Consistent with prior literature, ACT also decreased the likelihood of emergency room visits and inpatient psychiatric stays. Given the increasing emphasis and efforts toward integrating physical health and behavioral health care, it is likely that ACT will continue to be challenged to meet the physical health needs of its consumers. To improve primary care receipt, this may mean a departure from traditional staffing patterns (e.g., the addition of a primary care doctor and nurse) and expansion of the direct services ACT provides to incorporate physical health treatments.

Retail clinic visits and receipt of primary care.

An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. To assess the association between retail clinic use and receipt of key primary care functions. We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.

Family Practice Enhancements for Patients with Severe Mental Illness

Individuals with severe mental health disorders experience difficulty maneuvering the complexity encountered in primary care (PC). This study describes the impact of three components of primary care practice enhancements on: changes in missed appointments, changes in health outcomes, number of ER visits and hospitalization days, and perceptions of integrated care. Missed PC appointments: baseline to post practice enhancement changed from 42 to 11, statistically significant (p<.01). Changes in health outcomes: SF-12 scores had no significant change nor did ER utilization and hospitalization; however, outcomes are low-base rate and assessment period was short. Integration of care: liaison was most helpful in accessing and navigating PC, educating and reconciling medication lists. Behavioral health staff voiced relief regarding access and felt better informed. Strategies focusing on increasing communication, staff education, and reducing barriers to access and receipt of PC may improve integration and continuity of care.

A National Profile of the Health Care Experiences and Family Impact of Autism Spectrum Disorder Among Children in the United States, 2005–2006

We sought to examine the health care experiences of children with autism spectrum disorder and the impact of autism spectrum disorder on the family and to assess whether having a medical home is associated with less family impact. We used the 2005-2006 National Survey of Children With Special Health Care Needs to compare 2088 children with special health care needs, aged 3 to 17 years, reported by their parents to have autism spectrum disorder, with children with special health care needs with "other emotional, developmental, or behavioral problems" (excluding autism spectrum disorder; n=9534) and 26751 other children with special health care needs. We used weighted logistic regression to examine unmet needs for specific health care and support services, delayed care, no usual care source or personal physician, difficulty receiving referrals, and financial, employment, or time problems because of child's care. Nationally, an estimated 535000 children have special health care needs and autism spectrum disorder, a prevalence of 86 per 10000 children aged 3 to 17 years. Among children with special health care needs, 5.6% have autism spectrum disorder. Compared with other children with special health care needs without emotional, developmental, or behavioral problems, children with special health care needs with autism spectrum disorder were more likely to have unmet needs for specific health care services, family support services, delayed or foregone care, difficulty receiving referrals, and care that is not family centered. Children with special health care needs with autism spectrum disorder were more likely to live in families that report financial problems, need additional income for the child's medical care, reduce or stop work because of the child's condition, spend >or=10 hours per week providing or coordinating care, and paid more than $1000 in the previous year for the child's care. The financial impacts of autism spectrum disorder were significantly more burdensome when children with special health care needs did not have a medical home. Children with special health care needs with autism spectrum disorder are significantly more likely to have problems regarding access to care and unmet needs, and their families have greater financial, employment, and time burdens compared with other children with special health care needs. Receipt of primary care in a medical home may reduce these burdens.

Major depression, depression treatment and quality of primary medical care

Objective This study investigated the association between diagnosis of major depression, treatment for major depression and receipt of appropriate primary medical care. Method As part of the 1999 National Health Interview Survey, a nationally representative sample of 30,801 adults was administered the Composite International Diagnostic Interview — Short Form. Multivariate analyses examined the association between 12-month major depression and each of the four cardinal features of primary care (access, comprehensiveness, coordination and continuity) stratified by whether depressed individuals received care for depression in primary care, specialty mental health care or no treatment. Results Overall, persons with depression had statistically significant problems in all four domains of primary care (8/10 indicators in total). However, patterns differed substantially based on depression treatment status. Persons with untreated depression had difficulties in access to (3/3 measures) and comprehensiveness of (5/5 measures) care, but not with coordination (0/1 measure) and continuity (0/1 measure). In contrast, persons with depression who received specialty treatment had more difficulties in coordination (1/1 measure) and continuity (1/1 measure) of primary care. Persons treated for depression in primary care reported the least difficulties in any of the four domains of primary care (0/10 measures). Conclusions Major depression was associated with significant challenges in receipt of primary care; however, these problems varied based on whether and where depression treatment is received.

Primary Medical Care and Reductions in HIV Risk Behaviors in Adults with Addictions

Human immunodeficiency virus (HIV) risk behaviors are prevalent in persons with addictions. Objectives: To assess whether exposure to primary medical care is associated with decreases in HIV risk behaviors. Design: Prospective 2-year cohort of 298 adults with addictions. Outcomes: Sex and drug-related HIV risk behaviors, measured by the Risk Assessment Battery. Predictors: Cumulative number of primary care visits (0, 1, p ⩽ 2). Associations were tested using regression models for correlated data. Results: In women, receipt of primary care was associated with less sex risk behavior (mean decrease 2.1, p ⩽0.1). Among women and men, ⩾2 primary care visits was associated with lower odds of any drug risk behavior (OR = 0.37, p = 0.03). Conclusions: Exposure to primary care can impact HIV risk behavior favorably among adults with addictions.

Use of Primary Care and by Middle Aged and Older Persons with Schizophrenia.

INTRODUCTION: Comorbid medical conditions and receipt of primary medical care are important aspects of healthcare for older persons with schizophrenia. This study describes the prevalence of comorbid medical conditions and the factors associated with the use of primary care treatment in a group of middle-aged and older persons with schizophrenia. METHODS: Using baseline data from an ongoing study of functional skills training (N= 236), we determined the self-reported prevalence of 8 common medical conditions. In addition, patients who did (n= 146) versus those who did not (n= 90) receive primary care treatment were compared on demographic characteristics, psychiatric symptoms, and comorbid medical conditions using both univariate and multivariate analyses. RESULTS: The most common medical conditions were hypertension (31%), arthritis (25%), and diabetes (14%) and almost 60% of the patients had one or more medical conditions. More than 60% of the patients had received primary care treatment during the prior 3 months. Patients who used primary care were older, more likely to have received mental health treatment, and more likely to have a medical condition, especially, diabetes. There were no differences between the groups, however, in the severity of psychopathologic symptoms or cognitive deficits. Multivariate logistic regression analysis found that older age and diabetes were associated with greater utilization of primary care treatment. DISCUSSION: In middle-aged and older patients with schizophrenia, comorbid medical conditions were common and a majority of the patients did receive primary care treatment in the prior 3 months. Older patients and those with comorbid medical conditions were more likely to receive primary care, but there was no relationship between severity of psychiatric symptoms and receipt of primary care. Additional research is needed to determine sociodemographic and clinical factors associated with use of primary care utilization in groups of participants with a broader range of psychiatric symptom severity and supportive environments.

Risk of Mortality during Four Years after Substance Detoxification in Urban Adults

The objective of this analysis was to assess the mortality rate and risk factors in adults, with substance dependence, who are not receiving primary medical care (PC). Date and cause of death were identified using the National Death Index data and death certificates for 470 adults without PC over a period of almost 4 years after detailed clinical assessment after detoxification. Factors associated with risk of mortality were determined using stepwise Cox proportional hazards models. Subjects were 76% male, 47% homeless, and 47% with chronic medical illness; 40% reported alcohol, 27% heroin, and 33% cocaine as substance of choice. Median age was 35. During a period of up to 4 years, 27 (6%) subjects died. Median age at death was 39. Causes included: poisoning by any substance (40.9% of deaths), trauma (13%), cardiovascular disease (13.6%), and exposure to cold (9.1%). The age adjusted mortality rate was 4.4 times that of the general population in the same city. Among these individuals without PC in a detoxification unit, risk factors associated with death were the following: drug of choice [heroin: hazard ratio (HR) 6.9 (95% confidence interval (CI) 1.6-31.1]; alcohol: HR 3.7 (95% CI 0.79-16.9) compared to cocaine); past suicide attempt (HR 2.1, 95% CI 0.96-4.5); persistent homelessness (HR 2.4, 95% CI 1.1-5.3); and history of any chronic medical illness (HR 2.1, 95% CI 0.93-4.7). Receipt of primary care was not significantly associated with death (HR 0.85, 95% CI 0.34-2.1). Risk of mortality is high in patients with addictions and risk factors identifiable when these patients seek help from the health care system (i.e., for detoxification) may help identify those at highest risk for whom interventions could be targeted.

Case Management Is Associated with Improved Antiretroviral Adherence and CD4+Cell Counts in Homeless and Marginally Housed Individuals with HIV Infection

Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection. We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM in <or=25% of quarters in the study), moderate (>25% but <or=75%), or consistent (>75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count of >or=50% and geometric mean HIV load of <or=400 copies/mL). In multivariate models, CM was not associated with increased primary care, emergency department use, or hospitalization. Moderate CM, compared with no or rare CM, was associated with an adjusted beta coefficient of 0.13 (95% confidence interval [CI], 0.02-0.25) for improved antiretroviral adherence. Consistent CM (adjusted odds ratio [AOR], 10.7; 95% CI, 2.3-49.6) and moderate CM (AOR, 6.5; 95% CI, 1.3-33.0) were both associated with >or=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load <400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization. CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.