The Incidence, Prevalence and Mortality Rates of Black and White Persons with HIV in the United States in 2019.

INTRODUCTION: This study examines the experience of non-Hispanic Black Americans (hereinafter referred to as Black persons) and non-Hispanic White Americans (hereinafter referred to as White persons) with regard to the incidence (i.e., number of persons diagnosed with HIV), prevalence (i.e., number of persons living with HIV), and mortality rates of persons with HIV in the United States in 2019. With regard to mortality rates, this study examines the mortality rate of all Black persons and White persons with HIV in 2019 as well as the mortality rate of hospitalized Black persons and White persons with HIV in 2019. METHODS: Data on the racial characteristics of all persons in the United States in 2019 were obtained from the United States Census Bureau, and data on the racial characteristics of all persons with HIV in the United States were obtained from HIV Surveillance Reports produced by the Centers for Disease Control and Prevention (CDC). In addition, data on all hospital patients in seven states (California, Florida, Michigan, New Jersey, New York, South Carolina and Wisconsin) in 2019 were obtained from the Agency for Healthcare Research and Quality (AHRQ) Hospital Cost and Utilization Project (HCUP) State Inpatient Database (SID). These seven states included 44 percent of all persons living with HIV in the United States in 2019. RESULTS: This study found that Black persons were more likely to be diagnosed with HIV, live with HIV, and die with HIV than White persons in the United States. This is illustrated by the fact that in 2019 Black persons comprised 13.4 percent of the population, yet they comprised 42.1 percent of persons diagnosed with HIV, 40.4 percent of persons living with HIV, and 42.9 percent of persons who died with HIV. By comparison, in 2019 White persons comprised 76.3 percent of the population, yet they comprised 24.8 percent of persons diagnosed with HIV, 29.1 percent of persons living with HIV, and 31.8 percent of persons who died with HIV. Nevertheless, this study did not find a statistically significant difference between the in-hospital mortality rates of Black and White persons in seven states in 2019. CONCLUSIONS: The burden of HIV was considerably greater on Black persons than White persons in the United States in 2019.

Hospital Use by Persons With HIV in the 21st Century: A 5-State Study.

OBJECTIVE: The purpose of this study is to determine whether reductions in hospital utilization observed immediately after the availability of highly active antiretroviral therapy (between 1995 and 2000) have persisted into the 21st century. DATA SOURCES: Data on all human immunodeficiency virus (HIV)-related hospital admissions in 5 states (California, Florida, New Jersey, New York, and South Carolina) in 2000, 2005, 2010, and 2013 were obtained from the State Inpatient Database, which is administered by the Agency for Healthcare Research and Quality. In addition, data on the number of persons living with HIV were obtained from the Centers for Disease Control and Prevention and from the California Department of Public Health. STUDY DESIGN: This study compares the average number of hospitalizations per person living with HIV in each of the 5 states as well as the average cost for hospital care per person with HIV in 2000, 2005, 2010, and 2013. RESULTS: The total number of hospitalizations by persons with HIV in the 5 study states fell by one third between 2000 and 2013 even though the number of persons living with HIV increased by >50%. CONCLUSIONS: Persons with HIV disease were 64% less likely to be hospitalized in 2013 than they were in 2000. In addition, the probability of a person with HIV being hospitalized fell 44% between 2000 and 2010 and 29% between 2010 and 2013.

In Four ACA Expansion States, The Percentage Of Uninsured Hospitalizations For People With HIV Declined, 2012-14.

This study examines the influence of the Affordable Care Act's optional state Medicaid expansion on insurance coverage and health outcomes for hospitalized patients with HIV. I used data from the State Inpatient Databases of the Healthcare Cost and Utilization Project for all hospitalizations of patients with HIV from 2012 through the first six months of 2014 in four states that expanded their Medicaid programs and two states that did not. I found that the percentage of hospitalizations of uninsured people with HIV in the four expansion states fell from 13.7 percent to 5.5 percent in the study period, while the percentage in the two nonexpanding states increased from 14.5 percent to 15.7 percent. I also found that hospitalized patients with HIV who did not have insurance were 40 percent more likely to die during their hospital stays than comparable patients with insurance.

Assessing the cost effectiveness of pre-exposure prophylaxis for HIV prevention in the US.

About 50,000 people are infected with HIV in the US each year and this number has remained virtually the same for the past decade. Yet, in the last few years, evidence from several multinational randomized clinical trials has shown that the provision of antiretroviral drug to uninfected persons (i.e. pre-exposure prophylaxis) reduces the incidence of HIV by about 50 %. However, evidence from cost-effectiveness studies conducted in the US yield widely varying estimates of the cost per quality-adjusted life-year (QALY) gained, and this variation reflects the substantial uncertainty surrounding the determinants of HIV transmission (e.g. adherence rates to prophylactic medications, the average number of sexual partners, the number and types of sexual acts, the viral load of infected partners, and the proportion of contacts where condoms are used), as well as different approaches to translating a reduction in HIV cases into an estimate of the increase in the number of QALYs.

Contemporary costs of HIV healthcare in the HAART era.

BACKGROUND: The delivery of HIV healthcare historically has been expensive. The most recent national data regarding HIV healthcare costs were from 1996-1998. We provide updated estimates of expenditures for HIV management. METHODS: We performed a cross-sectional review of medical records at 10 sites in the HIV Research Network, a consortium of high-volume HIV care providers across the United States. We assessed inpatient days, outpatient visits, and prescribed antiretroviral and opportunistic illness prophylaxis medications for 14 691 adult HIV-infected patients in primary HIV care in 2006. We estimated total care expenditures, stratified by the median CD4 cell count obtained in 2006 (≤50, 51-200, 201-350, 351-500, >500 cells/µl). Per-unit costs of care were based on Healthcare Cost and Utilization Project (HCUP) data for inpatient care, discounted average wholesale prices for medications, and Medicare physician fees for outpatient care. RESULTS: Averaging over all CD4 strata, the mean annual total expenditures per person for HIV care in 2006 in three sites was US $19 912, with an interquartile range from US $11 045 to 22 626. Average annual per-person expenditures for care were greatest for those with CD4 cell counts 50 cell/µl or less (US $40 678) and lowest for those with CD4 cell counts more than 500 cells/µl (US $16 614). The majority of costs were attributable to medications, except for those with CD4 cell counts 50 cells/µl or less, for whom inpatient costs were highest. CONCLUSION: HIV healthcare in the United States continues to be expensive, with the majority of expenditures attributable to medications. With improved HIV survival, costs may increase and should be monitored in the future.

The cost and incidence of prescribing errors among privately insured HIV patients.

BACKGROUND: With the rapid growth in the volume of HIV-related studies that address drug interactions, appropriate medication regimens, and when and how to alter drug regimens, it is challenging for physicians to stay informed. Physicians require knowledge about all drugs taken by HIV patients in order to assess accurately the benefits and risks of various drug combinations. OBJECTIVE: To examine the cost and frequency of antiretroviral prescribing errors among a sample of privately insured patients with HIV disease. METHODS: Data were obtained from the MarketScan Commercial Claims and Encounter Database created by the Medstat Group Inc. The MarketScan database contains claims data for inpatient care, outpatient care, physician services and prescription drugs in benefit plans sponsored by >50 large employers in the US. This study compared data from the 1999-2000 MarketScan database with those from the 2005 MarketScan database. The 2005 MarketScan database includes 12,226 HIV enrollees who received antiretroviral drugs. This study compared the claims experience of HIV patients who filled a prescription for a drug combination that is not recommended by the US Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents with the claims experience of patients who did not receive such a prescription. RESULTS: In the 1999-2000 database the most common inappropriate drug combination involved the co-administration of a protease inhibitor (PI) and the lipid-lowering drug simvastatin, and 1% of patients experienced this type of error. In the 2005 database, only 0.4% of patients (46 of 12,226) experienced an inappropriate combination of simvastatin and a PI while 5.3% of patients (644 of 12,226) received atazanavir and tenofovir without ritonavir (referred to herein as 'boosting errors'). Patients who experienced a boosting error incurred higher annual costs than patients who took ritonavir along with tenofovir and atazanavir ($US 20,927 vs $US 16,704). Because atazanavir was approved by the US FDA in June 2003, medication errors involving atazanavir were not relevant in 1999 and 2000. Overall, it was found that HIV patients were three times as likely to experience an inappropriate drug combination in 2005 than they were in either 1999 or 2000 (5.9% vs 1.9%), and that this increase is attributable to boosting errors. In addition, the prevalence rate of HIV in the 2005 MarketScan database was almost triple that in the 1999 MarketScan database (0.14% vs 0.05%). CONCLUSION: This study indicates that those who provide care to HIV patients must be vigilant in their efforts to provide patients with a drug therapy regimen that minimizes the chance of an adverse reaction and maximizes the potential to control viral replication.

The effect of certificate-of-need laws on hospital beds and healthcare expenditures: an empirical analysis.

OBJECTIVE: To estimate the effect of certificate-of-need legislation on hospital bed supply and healthcare expenditures. STUDY DESIGN: This study uses state data on several variables, including healthcare expenditures, hospital bed supply, and the existence of a certificate-of-need program, from 4 periods (1985, 1990, 1995, and 2000). METHODS: We estimate 2 multivariate regression equations. In the first equation, hospital bed supply is the dependent variable, and certificate of need is included as an independent variable. In the second equation, healthcare expenditures is the dependent variable, and hospital bed supply and certificate of need are included as independent variables. RESULTS: Certificate-of-need laws have reduced the number of hospital beds by about 10% and have reduced healthcare expenditures by almost 2%. Certificate-of-need programs did not have a direct effect on healthcare expenditures. CONCLUSION: Certificate-of-need programs have limited the growth in the supply of hospital beds, and this has led to a slight reduction in the growth of healthcare expenditures.

The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients.

OBJECTIVE: To estimate the effect of medical errors on medical expenditures, death, readmissions, and outpatient care within 90 days after surgery. DATA SOURCES: 2001-2002 MarketScan insurance claims for 5.6 million enrollees. STUDY DESIGN: The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were used to identify 14 PSIs among 161,004 surgeries. We used propensity score matching and multivariate regression analyses to predict expenditures and outcomes attributable to the 14 PSIs. PRINCIPAL FINDINGS: Excess 90-day expenditures likely attributable to PSIs ranged from $646 for technical problems (accidental laceration, pneumothorax, etc.) to $28,218 for acute respiratory failure, with up to 20 percent of these costs incurred postdischarge. With a third of all 90-day deaths occurring postdischarge, the excess death rate associated with PSIs ranged from 0 to 7 percent. The excess 90-day readmission rate associated with PSIs ranged from 0 to 8 percent. Overall, 11 percent of all deaths, 2 percent of readmissions, and 2 percent of expenditures were likely due to these 14 PSIs. CONCLUSIONS: The effects of medical errors continue long after the patient leaves the hospital. Medical error studies that focus only on the inpatient stay can underestimate the impact of patient safety events by up to 20-30 percent.

The changing pattern of hospital care for persons living with HIV: 2000 through 2004.

OBJECTIVE: To compare inpatient utilization and costs by persons living with HIV in 2000 with inpatient utilization and costs in 2004. DATA SOURCES: Data on 91,343 hospital discharge abstracts representing all HIV-related admissions in 6 states (California, Florida, New Jersey, New York, South Carolina, and Washington state) in 2000 and data from 72,829 hospital discharge abstracts representing all HIV-related admissions in the same states in 2004 are used. These data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, and they were combined with data on the number of persons living with HIV that were obtained from the Centers for Disease Control and Prevention and 2 state departments of health. STUDY DESIGN: This study compares the hospital care received by persons living with HIV in 6 states in calendar year 2000 with the hospital care received by persons living with HIV in calendar year 2004 in the same 6 states. This study also compares population-based measures of hospital utilization (ie, to measure the average utilization of hospital care per person living with HIV in each state) across the 6 states. RESULTS: This study found that the average age of a hospitalized patient with HIV rose from 41 to 44 years and that the average number of diagnoses rose from 6.0 to 7.4. Moreover, it was found that the average number of admissions per person living with HIV fell 39% and that the percentages of female and black patients with HIV remained the same. CONCLUSIONS: Hospitalized patients living with HIV are getting older and sicker, although the average number of admissions per person living with HIV continues to fall.

The impact of state laws limiting malpractice damage awards on health care expenditures.

Twenty-eight states have laws that limit payments in malpractice cases, and several studies indicate that these laws reduce the frequency and severity of malpractice claims and lower premiums. Moreover, proponents believe that such laws reduce health care expenditures by reducing the practice of defensive medicine. However, there is a dearth of empirical evidence about the impact of these laws on the cost of health care. We used multivariate models and relatively recent data to estimate the impact of state tort reform laws that directly limit malpractice damage payments on health care expenditures. Estimates from these models suggest that laws limiting malpractice payments lower state health care expenditures by between 3% and 4%.

Economic models of antiretroviral therapy: searching for the optimal strategy.

The diffusion of protease inhibitors and non-nucleoside reverse transcriptase inhibitors in the US in 1996 and 1997 reduced the number of deaths attributable to HIV disease and changed the way we think about the illness. Today, HIV disease may be deemed a fairly expensive chronic condition rather than an intolerably expensive fatal illness. Although most studies have found that patients receiving new drug therapies are hospitalised less frequently than patients who received early drug therapies, it is unclear whether the diffusion of new drug therapies has increased or decreased the annual cost of care. However, it is evident that the diffusion of new drug therapies has increased the lifetime cost of care. Analysts rely on models to simulate the course and cost of HIV disease. This study reviews the evolution of these models, paying particular attention to how these models estimate the cost of care. The primary findings of this review are that the economic data used in these models are often too imprecise to accurately identify the cost of each disease stage and are almost always outdated. Moreover, it was found that estimates of drug costs in these models may not accurately reflect actual expenditures.

Inappropriate drug combinations among privately insured patients with HIV disease.

OBJECTIVE: The objective of this study was to examine inappropriate drug combinations among privately insured patients with HIV disease. DATA: Data were obtained from the MarketScan Commercial Claims and Encounter Database for the years 1999 and 2000. METHODS: Each of the 2110 person-years of data examined in this study represents the claims experience of an enrollee with HIV disease who filled an antiretroviral medication prescription in either 1999 or 2000 for a protease inhibitor or nonnucleoside reverse transcription inhibitor. This study compares the claims experience of patients with HIV who filled a prescription for an inappropriate drug combination as specified in guidelines jointly issued by the U.S. Department of Health and Human Services and the Henry J. Kaiser Family Foundation with the claims experience of patients who did not. RESULTS: An inappropriate drug combination was found in approximately 2% of the person-years of data, and persons who experienced an inappropriate drug combination had higher claims costs. One half of all of the inappropriate drug combinations involved a single lipid-lowering agent (simvastatin). Protease inhibitors decrease the activity of the enzyme that metabolizes simvastatin, and high concentrations of simvastatin have been associated with muscle damage. We found that patients who received protease inhibitors and simvastatin were more likely to experience muscle damage. CONCLUSION: Persons with HIV have compromised immune systems and often take many medications. Thus, the risk and consequences of medication errors are severe, and both providers and patients should carefully monitor drug regimens to ensure that they are both safe and efficacious.

Have state caps on malpractice awards increased the supply of physicians?

Twenty-seven states have laws that cap payments for noneconomic damages in malpractice cases. In this study we examined whether these laws have increased the supply of physicians, using county-level data from all fifty states from 1985 to 2000. Counties in states with a cap had 2.2 percent more physicians per capita because of the cap, and rural counties in states with a cap had 3.2 percent more physicians per capita. Rural counties in states with a dollar 250,000 cap had 5.4 percent more obstetrician-gynecologists and 5.5 percent more surgical specialists per capita than did rural counties in states with a cap above dollar 250,000.

Health plan liability and ERISA: the expanding scope of state legislation.

The federal Employee Retirement Income Security Act of 1974 (ERISA) supersedes state laws as they relate to employer-based health care plans. Thus, cases brought under ERISA are heard in federal courts. We examined the intent, scope, and impact of recent laws passed in 10 states attempting to expand the legal rights of health plan enrollees to sue their plans. In June 2004, the US Supreme Court ruled that state-law causes of action brought under the Texas Health Care Liability Act involving coverage decisions by Aetna Health Inc and CIGNA Health Care of Texas were preempted by ERISA. The full implications of this decision are not evident at present.

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001.

BACKGROUND: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization. METHODS: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART. RESULTS: In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART. CONCLUSIONS: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).

Antiretroviral therapy and health care utilization: a study of privately insured men and women with HIV disease.

OBJECTIVE: To compare the use of antiretroviral therapy and other health care resources by women and men with HIV disease who are privately insured. DATA SOURCES: Data were obtained from the MarketScan Commercial Claims and Encounter Database produced by the Medstat Group, Inc., of Ann Arbor, Michigan. This database includes eligibility files as well as claims data for inpatient care, outpatient care, physician services, and prescription drugs for enrollees in employer-sponsored benefit plans for 24 large employers around the nation. STUDY DESIGN: Examine utilization by 2,026 privately insured persons (1,494 men and 532 women) with HIV disease in calendar year 2000 under the age of 65. PRINCIPAL FINDINGS: Using a simple comparison, we found that 71 percent of men (68.7 to 73.3 percent is 95 percent confidence interval) and 39 percent of women (35.1 to 43.5 percent is 95 percent confidence interval) with HIV disease received antiretroviral therapy. We also found that the average annual drug cost was $9,037 for a man ($8,372 to $9,702 is 95 percent confidence interval) and $3,893 for a woman ($3,476 to $4,490 is 95 percent confidence interval). Furthermore, we found that the out-of-pocket expenses comprised 10 percent of total expenses for men ($1,617 out of $16,405) and 4 percent for women ($405 out of $10,397). CONCLUSION: There are major differences in the utilization and cost of health care between privately insured men and women with HIV disease.

HIV patients in the HCUP database: a study of hospital utilization and costs.

This study examines the utilization of hospital care by HIV patients in all hospitals in eight states (California, Colorado, Florida, Kansas, New Jersey, New York, Pennsylvania, and South Carolina), and examines the cost of hospital care for HIV patients in six of these states (California, Colorado, Kansas, New Jersey, New York, and South Carolina). The eight states in the sample account for more than 52% of all persons living with AIDS in the United States; the six states account for 39%. The unit of observation in both studies is a hospital admission by a patient with HIV. Hospital data were obtained from the Healthcare Cost and Utilization Project (HCUP), State Inpatient Database (SID), which is maintained by the Agency for Healthcare Research and Quality (AHRQ). The HCUP contains hospital discharge data and is a federal/state/industry partnership to build a multistate health care data system. Using multivariate analytic techniques and data from 2000, results indicate that cost and length of a hospital stay vary significantly across states after accounting for a patient's gender, insurance type, race, age, and number of diagnoses, as well as the teaching status and ownership category of the hospital.

Cost and Financing of Care for Persons With HIV Disease: An Overview.

This article explores the impact of new combination drug therapies on the cost and financing of human immunodeficiency virus (HIV) disease. Evidence indicates that the proportion of costs attributable to drugs has increased significantly since the diffusion of new combination drug therapies, and that the proportion of costs attributable to hospital inpatient care has decreased. The absence of timely data is the major difficulty in analyzing the impact of recent changes. Only two studies have examined costs since the diffusion of new combination drug therapies, and there are no recent studies of the insurance status of persons with HIV disease.