Use of antiretroviral therapy in older people with HIV during care transition

项目摘要 背景在美国，艾滋病毒感染者（PLWH）的数量正在迅速增长。一半的艾滋病毒携带者 2016年，50岁以上的人估计到2030年将达到70%。PLWH有大量的 合并症、多种药物和高住院率。护理设置之间的转换（例如，回家吧， 医院、急性期后护理和长期护理），这些都是老年人艾滋病病毒携带者必须接受的， 这些过渡所造成的护理问题是本提案的重点。以往的研究一般 老龄化人口显示，住院后药物问题很常见;大约一个 四分之一没有填写新的处方，14%的人经历了药物差异，几乎一半没有 住院后坚持服药。关于药物相关质量的数据有限 PLWH住院后的问题。在最近的一项研究中，只有64%的研究患者在护理 我们对医疗保险接受者的初步研究表明，大约三分之二的家庭使用ART。 在此期间，患有D部分（医疗保险药物覆盖范围）和HIV的NH居民的全国队列未接受ART 平均观察1年。本研究的目的是（1）确定 艾滋病病毒感染者从门诊状态向NH护理过渡的ART使用模式;（2）确定 与缺乏ART使用相关的患者水平特征和护理机构特征 在出院过渡后的NH停留期间。 方法.我们建议进行一项回顾性队列研究，包括所有医疗保险按服务收费的NH 2014年至2018年，全国？首先，我们将确定PLWH谁有一个急性住院，导致NH 入院我们将跟踪他们，检查出院后NH住院期间ART的使用情况，并跟踪他们 将时间回溯到入院前阶段，以确定他们是否作为门诊患者接受抗逆转录病毒治疗。我们将 进行多变量模型，以确定护理过渡后非ART使用的相关性。协变量 将包括个人水平的特征，如人口统计学，多种药物，合并症状态， 住院时间和诊断;以及护理设施一级的特征，如艾滋病毒浓度， 是否有艾滋病股和县一级的艾滋病毒流行率作为提供者艾滋病毒经验的代表。 预期结果和未来计划。我们希望观察到，在医院接受抗逆转录病毒治疗后， 放电过渡到NH。抗逆转录病毒疗法的使用是高质量艾滋病毒护理的一个关键因素，我们感到关切的是， 在NHS中，ART方案的下降是更广泛的护理质量问题的标志或指标。我们的研究将 明确质量改进干预措施的重点，以确保国家卫生机构中的艾滋病毒/艾滋病感染者（不存在 我们的方法也将用于进行类似的研究，以确保其他 慢性病的药物治疗在复杂的护理过渡期间适当地继续。

Project Summary Background. The number of older people living with HIV (PLWH) in the U.S. is growing rapidly. Half of PLWH in 2016 were over 50 years of age, with an estimate of 70% by 2030. PLWH have high numbers of comorbidities, polypharmacy and high hospitalization rates. The transitions between care settings (e.g., home, hospital, post-acute care, and long-term care) that necessarily occur for PLWH who are aging – and the quality of care problems that these transitions create – are the focus of this proposal. Previous studies in the general aging population show that problems with medications are common after a hospitalization; approximately one fourth did not fill new prescriptions,14% experienced medication discrepancies and almost half were not adherent to medications following hospitalizations. There is limited data about medication-related quality problems following hospitalization for PLWH. In a recent study, only 64% of the study patients in the nursing homes (NHs) used ART. Our preliminary work with Medicare recipients has shown that about two thirds of a national cohort of NH residents with Part D (Medicare drug coverage) and HIV did not receive an ART during an average of 1 years of observation in NHs. The purposes of this proposed research are to (1) determine patterns of ART use in PLWH who made the care transition from outpatient status to NH care; and (2) identify patient level characteristics and nursing facility characteristics that are associated with the lack of ART use during NH stays following hospital discharge transitions. Methods. We propose to conduct a retrospective cohort study including all Medicare fee-for-service NH residents (2014-2018) nationally. First, we will identify PLWH who had an acute hospitalization that led to a NH admission. We will follow them to examine ART use during post-hospital discharge NH stays, and follow them backward in time to the prehospital period to determine whether they were on ART as outpatients. We will conduct multivariable models to determine correlates of non-ART use following the care transition. Covariates will include individual level characteristics, such as demographics, polypharmacy, comorbidity status, hospitalization length of stay and diagnosis; and nursing facility level characteristics such as HIV concentration, the availability of an AIDS unit and county level HIV prevalence as a proxy of provider HIV experience. Expected findings and future plans. We expect to observe that a reduction in ART use following the hospital discharge transition to NHs. ART use is a critical element of high-quality HIV care, and we are concerned that dropping of an ART regimen at NHs is a marker or indicator of broader quality of care problems. Our study will identify a clear focus for quality improvement interventions to ensure that PLWH in NHs (absent contraindications) are using ART. Our methods will also be used to conduct similar studies to ensure that other medications for chronic conditions are appropriately continued through complex care transitions.