Hospital admits, ER visits decline in HIV-infected

Women, blacks, IDUs fare worse

A new study shows a continued decline in hospitalizations and emergency department visits among HIV-infected adults in the United States. This improvement has occurred within the highly active antiretroviral therapy (HAART) era, possibly reflecting improvements in standard treatment regimens.1

Investigators found that annual inpatient hospitalization rates significantly decreased from 35 to 27 per 100 persons from 2002 to 2007.

"We analyzed who was hospitalized and the hospitalization rate," says Baligh R. Yehia, MD, a co-author of the new study and an infectious diseases fellow at the University of Pennsylvania in Philadelphia, PA. "The next step is to look at what are the actual hospital admissions. This study showed hospitalization admissions decreased, and we want to do a follow-up study to look at what are the new reasons why people are hospitalized."

The goal is to see if HIV patients' hospital admission diagnoses have changed over time.

"We think it's changing," Yehia says. "People in the pre-HAART era mostly were admitted for opportunistic infections, and that's less likely these days."

It's possible that more HIV patients now are admitted for metabolic complications or other general health problems, he adds.

Investigators have seen other shifts regarding HIV patients and hospitalizations over the past decade.

"In our last study of the period 2000 to 2002, there was not a change in hospitalization rates — it plateaued," Yehia says.

"When you look at the whole picture of hospitalization of HIV patients, it went along in the 1980s, and then in the mid-1990s there was a big drop," he explains. "The rate decreased from the pre-HAART era to the post-HAART era."

Then hospitalization rates reached a plateau, so this latest shift of a new decline is interesting, he adds.

Advent of daily dosing

"We conjectured why there might have been a decrease in hospitalization rates," he says. "We believe it's mostly due to there being easier to take HIV medications, the advent of once-a-day dosing."

Also, some of the side effects are less troubling with the newer drugs, he adds.

"I think the once-a-day HAART regimens were developed, making HAART easier for providers to prescribe and easier for patients to take and tolerate," Yehia says. "And because of that I think more patients got on therapy and had higher CD4 counts, and lower viral loads."

And the result has been fewer hospital admissions, he adds.

"But this was conjecture," Yehia says. "The study was mostly to analyze who these people are who are hospitalized."

They found that women, patients 50 years or older, blacks, injection drug users (IDUs), and patients without private insurance had higher hospitalization rates than other groups.

"The sad part is that our findings are not unique," Yehia says. "In every study of hospitalization you look at over the last 10 to 15 years, you find women, blacks, and injection drug users have higher rates."

This is true after adjusting for CD4 counts and other factors, he adds.

"We controlled for private insurance because if you have Medicare or Medicaid, you're more likely to be hospitalized, and we know that," Yehia explains. "But even when we controlled for that, women, African Americans, and injection drug users tended to have higher inpatient stays."

The study defined injection drug users as people who had a history of drug use, as well as current users.

It's easier to understand why people older than age 50 would have more hospital inpatient admissions because of this group's tendency to have greater comorbidities, including diabetes and cardiovascular disease, Yehia says.

"The take-home message is we've continued to be on the right track," he says. "HIV is going from a disease managed in the hospital to one managed in outpatient settings."

There continue to be disparities in health care in terms of women, African Americans, and IDUs, so this aspect requires further study to see why these categories of patients are hospitalized more often, Yehia says.

"We need to see what the inpatient diagnoses are for these patients and whether these have changed over time," he adds. "I think they have changed, but we haven't done that research and don't have data on that yet."

Reference

  1. Yehia BR, Fleishman JA, Hicks PL, et al. Inpatient health services utilization among HIV-infected adult patients in care, 2002-2007. JAIDS. 2009. Epub ahead of print.