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

项目摘要 背景资料。美国老年艾滋病毒携带者(PLWH)的数量正在迅速增长。PLWH的一半 2016年超过50岁，预计到2030年将达到70%。PLWH有大量的 合并症、多药并存和高住院率。护理设置之间的转换(例如，家， 医院、急诊后护理和长期护理)，这对于正在老龄化的PLWH来说是必要的-以及质量 这些过渡造成的护理问题--是这项提案的重点。前人研究综述 人口老龄化表明，住院后用药问题很常见；大约1 4%的人没有开新处方，14%的人出现了用药差异，近一半的人没有 住院后坚持服药。有关药物相关质量的数据有限 因PLWH住院后出现的问题。在最近的一项研究中，只有%的研究患者参与了护理 英国国民健康保险制度(NHS)使用艺术品。我们对联邦医疗保险接受者的初步研究表明，大约三分之二的 拥有D部分(医疗保险药物覆盖范围)和艾滋病毒的全国NH居民队列在 在NHS的平均观察时间为1年。这项拟议研究的目的是(1)确定 在PLWH中从门诊过渡到NH护理的ART使用模式；以及(2)确定 与缺乏抗逆转录病毒药物使用相关的患者水平特征和护理设施特征 在出院过渡后的NH期间。 方法：研究方法。我们建议进行一项包括所有医疗保险服务收费的回溯性队列研究 全国居民(2014-2018年)。首先，我们将确定PLWH曾因急性住院导致NH 入场。我们将跟随他们检查出院后NH住院期间的ART使用情况，并遵循他们 时间倒退到院前阶段，以确定他们是否作为门诊患者接受抗逆转录病毒治疗。我们会 进行多变量模型以确定护理过渡后非抗逆转录病毒药物使用的相关性。协变量 将包括个人层面的特征，如人口统计、多药联用、合并症状况、 住院时间和诊断；护理设施水平特征，如艾滋病毒浓度， 艾滋病单位和县一级艾滋病毒流行率作为提供者艾滋病毒经验的替代。 预期的发现和未来的计划。我们希望在医院之后观察到抗逆转录病毒药物使用的减少 退役过渡到国民健康保险制度。抗逆转录病毒药物的使用是高质量艾滋病毒护理的关键因素，我们感到关切的是 在NHS放弃ART方案是更广泛的护理质量问题的标志或指标。我们的研究将 确定质量改进干预措施的明确重点，以确保国民健康服务体系中的公共卫生部门(不存在 禁忌症)正在使用抗逆转录病毒治疗。我们的方法也将用于进行类似的研究，以确保其他 针对慢性病的药物在复杂的护理过渡期间适当地继续进行。

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.