High standards of care associated with reduced mortality risk of patients with HIV

Quality of care (QOC) in the first twelve months after entering HIV care is associated with longer-term mortality risk, investigators from the US Department of Veterans Affairs report in the online edition of Clinical Infectious Diseases. Patients who received at least 80% of recommended quality indicators (QIs) were 25% less likely to die during follow-up when compared to patients who received less than 80% of QIs. Good outcomes were observed in patients with drug or alcohol problems who received high levels of care.

“The current study finds that HIV-infected patients who receive high QOC experience improved mortality,” comment the authors. “High quality care provided by healthcare systems and providers may translate into decreased mortality for their patients.”

But good quality of care was unable to overcome mortality deficits associated with disease severity and co-morbid conditions.

Moreover, the author of an accompanying editorial suggests that quality of care indicators may need to change in order to keep pace with the ever-evolving medical needs associated with HIV infection.

Healthcare providers in the US are encouraged to track and report on quality of care measures. Although quality of care indicators for HIV infection are well established, the relationship between care indicators and subsequent mortality risk has not been well described. Importantly, it is not known if good quality of care can overcome the higher mortality risk observed in HIV-infected patients with drug and/or alcohol problems.

To answer these questions, investigations from the Veterans Ageing Cohort Study designed a study comparing mortality risk in HIV-positive patients according to the quality of care provided in the first twelve months after entering HIV care.

Patients who entered care between 2002 and 2008 were recruited to the study. Nine quality of care indicators were assessed:

• Receipt of antiretroviral therapy.
• PCP prophylaxis if warranted by low CD4 count.
• MAC prophylaxis if warranted by low CD4 count.
• Pneumococcal vaccination.
• Annual influenza vaccination.
• Regular screening for high blood lipids.
• Ongoing monitoring for hepatitis C virus (HCV) co-infection.
• Appropriate HIV clinic visits.
• CD4 count monitoring.

Data were also gathered on drug and alcohol use and co-morbid conditions. Patients were followed until 2014.

The investigators compared mortality risk between individuals who received 80% or more of quality of care indicators in the first twelve months of care and individuals who did not receive this standard of care.

A total of 3038 patients were recruited to the study. Most were male (98%) and black (67%). Average age at enrollment was 49 years. Alcohol abuse was present in 28% of patients and 26% reported substance use; 11% reported both drug and alcohol problems.

Patients were followed for a mean of eight years. There were 902 deaths (30% of cohort) during 24805 person-years of follow-up.

Approximately 70% of patients received 80% or more of care indicators in the first year.

Overall, receiving 80% or more of recommended care indicators was associated with a 25% reduction in mortality risk compared to lower standards of care (age-adjusted hazard ratio, 0.75; 95% CI, 0.65-0.86). The association between higher quality care and lower mortality risk was irrespective of drug or alcohol abuse. However, quality of care was unable to overcome the enhanced mortality risk associated with disease severity (age-adjusted hazard ratio, 1.18; 95% CI, 1.15-1.21).  

“The 2010 U.S. National HIV/AIDS Strategy identifies improving the QOC [quality of care] for persons living with HIV as a national priority,” conclude the authors. “The current study suggests that this policy may further improve survival among HIV-infected patients who engage in care, but that increased adherence to quality of care measure may not be sufficient for improving mortality without addressing underlying conditions.”

The accompanying editorial describes the lower mortality associated with good quality care soon after entering HIV care as “laudable.” But the author notes that the results “do not offer an indication of sustained quality care.” Moreover, because HIV has become a chronic, life-long condition, for most patients it is no longer appropriate to monitor outcomes based solely on care during the first year of follow-up. The author writes: “Our indicators of quality of care will have to change.”