People living with HIV who don’t receive early intervention and primary care end up with a disproportionate share of health care costs, according to a new study that examined barriers to care and costs at a Dublin hospital.
Early intervention and primary care are crucial for managing HIV. Not receiving this care can lead to health complications and costly hospital visits for people infected with HIV, a new study found.
The study, published in Open Forum Infectious Diseases, analyzed the health records of 2063 people infected with HIV who received care at St. James’s Hospital in Dublin, Ireland, from October 2014 to October 2015.
“A small number of people living with HIV (PLWHIV) with mental health, addiction and social challenges (eg homelessness) don’t engage in outpatient HIV care and end up really sick and needing a lot of expensive hospital care,” Clíona Ní Cheallaigh, MB, MRCP, PhD, associate professor, Department of Clinical Medicine, Trinity College Dublin and consultant physician at St. James's Hospital, told Contagion®. “We could potentially save a lot of money by helping these people take their ART and maintain their health.”
Investigators found that 22 of 2063 patients had cumulative hospital stays of longer than 30 days during the study period. These high-cost, high-need users logged 99 emergency department visits and 1581 inpatient bed days, costing the hospital about $1 million during the study period. For 18 of those patients, the requirements that brought them to the hospital were potentially preventable, including 2 who had a late diagnosis of HIV and 16 who had advanced HIV.
“The amount of money (nearly 1 million euro on just 1 year’s worth of hospital care) was much more than we expected,” Ní Cheallaigh told Contagion®. “This money could potentially have been used more effectively in preventing these people becoming sick—ie by providing them with housing, social supports and addiction care.”
In Ireland, HIV care and antiretroviral drugs are provided free of charge at university teaching hospitals like St. James’s, with primary care provided by general practitioners working as independent contractors. General practitioner care is provided free for individuals with low income.
Barriers to relatively inexpensive primary care, including addiction, psychiatric disease and homelessness, affected 14 of 16 patients in the study who were not successfully engaged in care.
“It’s important to look at how well everyone can use healthcare systems - some people may find it challenging and may end up with a lot of potentially preventable illness (and costs),” Ní Cheallaigh told Contagion®.
During the study period, 208 of 2063 patients had one or more unscheduled inpatient admissions. The 22 who had more than 30 days of cumulative hospital stays accounted for 1581 of 3380 HIV-related bed days (47%). Patients who had not been successfully engaged in HIV care showed consequences including organ failure, cancer and infection.
“We hope to look at alternative models of care (eg assertive outreach models of integrated health and social care) to see if these work better at keeping this type of patient healthier,” Ní Cheallaigh told Contagion®.
Recent efforts to combat HIV have focused on early intervention and retention in care. In the United States, it is estimated that 85% of people living with HIV have been diagnosed, 62% have received medical care, and 48% have been retained in care. A recent study examined rapid initiation of antiretroviral therapy, finding that starting ART on the day of a diagnosis or at the first appointment is safe, well tolerated, leads to earlier viral suppression, and may increase retention in care.
Another study looked at the benefits of linking incarcerated people with HIV care upon release from jail. These patients often have barriers to care such as mental illness, substance abuse and homelessness. Implementing programs with transitional care coordinators responsible for patient engagement and education could reengage individuals lost to care and link diagnosed people to treatment.