HIV care coordination: comparative effectiveness, outcome determinants and costs

描述（由申请人提供）：在艾滋病毒诊断率、与艾滋病毒护理的联系和保留、及时启动抗逆转录病毒治疗（ART）以及艾滋病毒感染者（PLWH）病毒载量（VL）抑制方面存在的重大差距破坏了“以治疗为预防”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。非常需要更严格的证据来证明几项有希望的干预战略的有效性，其中一些战略已经单独或结合起来实施。2009年底，纽约市卫生和心理卫生部（DOHMH）开始在28个Ryan White资助的机构实施全面的护理协调计划（CCP），针对高风险患者进行次优护理级联结果。CCP干预措施将各种循证方案要素整合为一个一揽子计划，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帮助患者获得所需护理和相关服务的外联活动。这项回顾性队列研究的目的是：1）通过比较CCP参与者与未接受CCP干预的艾滋病护理中的类似PLWH的主要结局，评估CCP干预的有效性; 2）在参加CCP的人中，确定参加CCP后36个月内护理参与和VL抑制的个人和项目层面的决定因素;以及3）评估CCP相对于CCP以外的常规治疗的成本效益（每质量调整生命年的成本[QALY]），考虑下游成本节约以及由于改善VL抑制和避免HIV感染而带来的个人和公共健康益处。我们希望拟议的研究能够产生急需的证据，证明一个有前途的、可扩展的服务提供战略的有效性、结果决定因素和成本效益，最终使艾滋病毒护理计划能够进一步发展，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.