Quality of care
(QOC) in the first twelve months after entering HIV care is associated with
longer-term mortality risk, investigators from the US Department of Veterans
Affairs report in the online edition of Clinical
Infectious Diseases. Patients who received at least 80% of recommended
quality indicators (QIs) were 25% less likely to die during follow-up when
compared to patients who received less than 80% of QIs. Good outcomes were
observed in patients with drug or alcohol problems who received high levels of
“The current study
finds that HIV-infected patients who receive high QOC experience improved
mortality,” comment the authors. “High quality care provided by healthcare
systems and providers may translate into decreased mortality for their
But good quality
of care was unable to overcome mortality deficits associated with disease
severity and co-morbid conditions.
author of an accompanying editorial suggests that quality of care indicators
may need to change in order to keep pace with the ever-evolving medical needs
associated with HIV infection.
providers in the US are encouraged to track and report on quality of care
measures. Although quality of care indicators for HIV infection are well established, the relationship between care indicators and subsequent mortality risk
has not been well described. Importantly, it is not known if good quality of
care can overcome the higher mortality risk observed in HIV-infected patients
with drug and/or alcohol problems.
To answer these
questions, investigations from the Veterans Ageing Cohort Study designed a
study comparing mortality risk in HIV-positive patients according to the
quality of care provided in the first twelve months after entering HIV care.
entered care between 2002 and 2008 were recruited to the study. Nine quality of
care indicators were assessed:
- Receipt of antiretroviral
- PCP prophylaxis if warranted by
low CD4 count.
- MAC prophylaxis if warranted by
low CD4 count.
- Pneumococcal vaccination.
- Annual influenza vaccination.
- Regular screening for high
- Ongoing monitoring for
hepatitis C virus (HCV) co-infection.
- Appropriate HIV clinic visits.
- CD4 count monitoring.
Data were also gathered
on drug and alcohol use and co-morbid conditions. Patients
were followed until 2014.
compared mortality risk between individuals who received 80% or more of quality
of care indicators in the first twelve months of care and individuals who did
not receive this standard of care.
A total of 3038
patients were recruited to the study. Most were male (98%) and black (67%).
Average age at enrollment was 49 years. Alcohol abuse was present in 28% of
patients and 26% reported substance use; 11% reported both drug and alcohol
followed for a mean of eight years. There were 902 deaths (30% of cohort)
during 24805 person-years of follow-up.
of patients received 80% or more of care indicators in the first year.
80% or more of recommended care indicators was associated with a 25% reduction
in mortality risk compared to lower standards of care (age-adjusted hazard
ratio, 0.75; 95% CI, 0.65-0.86). The association between higher quality care and lower mortality risk was irrespective of drug or alcohol abuse. However,
quality of care was unable to overcome the enhanced mortality risk associated
with disease severity (age-adjusted hazard ratio, 1.18; 95% CI, 1.15-1.21).
“The 2010 U.S.
National HIV/AIDS Strategy identifies improving the QOC [quality of care] for persons living with
HIV as a national priority,” conclude the authors. “The current study suggests
that this policy may further improve survival among HIV-infected patients who
engage in care, but that increased adherence to quality of care measure may not
be sufficient for improving mortality without addressing underlying
editorial describes the lower mortality associated with good quality care soon after
entering HIV care as “laudable.” But the author notes that the results “do not
offer an indication of sustained quality care.” Moreover, because HIV has
become a chronic, life-long condition, for most patients it is no longer
appropriate to monitor outcomes based solely on care during the first year of
follow-up. The author writes: “Our indicators of quality of care will have to