HIV care coordination: comparative effectiveness, outcome determinants and costs

描述（由申请人提供）：艾滋病毒诊断率、与艾滋病毒护理的联系和保留、及时开始抗逆转录病毒治疗（ART）以及艾滋病毒感染者（PLWH）中病毒载量（VL）抑制方面的重大差距破坏了“治疗即预防”的潜在影响，并危及美国国家艾滋病毒/艾滋病战略（NHAS）目标的实现。对于几种有希望的干预策略的有效性，迫切需要更严格的证据，其中一些已经单独或联合实施。2009年底，纽约市健康和精神卫生部门（DOHMH）开始在28家瑞安·怀特资助的机构中实施一项全面的护理协调计划（CCP），目标是那些不理想护理级联结果的高风险患者。CCP干预措施将各种基于证据的方案要素结合成一揽子方案，包括病例管理、患者导航、直接观察治疗（DOT）、家庭/实地访问中的结构化健康促进，以及协助患者获得所需护理和相关服务的外联服务。这项回顾性队列研究由亨特学院CUNY公共卫生学院和NYCDOHMH的研究人员联合领导，目的是：1)通过比较CCP参与者与未接受CCP干预的HIV护理的类似PLWH的主要结局来评估CCP干预的有效性；2)在参加CCP的患者中，确定个体和项目层面的护理参与和VL抑制的决定因素，直至CCP入组后36个月；3)评估CCP相对于CCP以外的常规护理的成本效益（每质量调整生命年成本[QALY]），考虑下游成本节约以及由于VL抑制改善和HIV感染避免而带来的个人和公共卫生效益。我们期望拟议的研究能够产生急需的证据，这些证据与一种有前途的、可扩展的服务交付策略的有效性、结果决定因素和成本效益有关，最终使艾滋病毒护理计划进一步发展，实现最大可能的吸收和影响。

DESCRIPTION (provided by applicant): Significant gaps in HIV diagnosis rates, linkage to and retention in HIV care, timely antiretroviral therapy (ART) initiation, and viral load (VL) suppression among persons living with HIV (PLWH) undermine the potential impact of 'treatment as prevention' and jeopardize achievement of US National HIV/AIDS Strategy (NHAS) goals. There is a significant need for more rigorous evidence regarding the effectiveness of several promising intervention strategies, some of which are already being implemented alone or in combination. In late 2009, the NYC Department of Health and Mental Hygiene (DOHMH) began implementing a comprehensive Care Coordination Program (CCP) at 28 Ryan White-funded agencies, targeting patients at high risk for suboptimal care cascade outcomes. The CCP intervention combines various evidence-based programmatic elements into a package, including case management, patient navigation, directly observed therapy (DOT), structured health promotion in home/field visits, and outreach to assist patients in accessing needed care and related services. The purpose of this retrospective cohort study, led jointly by investigators from the CUNY School of Public Health at Hunter College and the NYCDOHMH, is to: 1) assess the effectiveness of the CCP intervention by comparing primary outcomes among CCP participants with those of similar PLWH in HIV care who do not receive the CCP intervention; 2) among those who enroll in CCP, identify individual and program-level determinants of care engagement and VL suppression up to 36 months following CCP enrollment; and 3) assess the cost-effectiveness (cost per quality-adjusted life year [QALY]) of the CCP relative to usual care outside the CCP, considering downstream cost-savings and individual and public health benefits due to improved VL suppression and HIV infections averted. We expect the proposed research to generate much- needed evidence related to the effectiveness, outcome determinants, and cost-effectiveness of a promising, scalable service delivery strategy, ultimately enabling HIV care programs to further evolve achieve the greatest possible uptake and impact.