Impact of alpha 1-adrenergic antagonist use for benign prostatic hypertrophy on outcomes in patients with heart failure.

Previous clinical trials have shown that alpha(1)-adrenergic antagonists are not effective in subjects with heart failure (HF) and might increase HF rates when used for hypertension. However, alpha(1)-adrenergic antagonists may be prescribed to subjects with HF who have symptomatic benign prostatic hyperplasia. We sought to determine any association between alpha(1)-adrenergic antagonist use, commonly prescribed for benign prostatic hyperplasia, and the clinical outcomes of subjects with HF receiving contemporary therapy. An existing database of 388 subjects with decompensated HF admissions from 2002 to 2004 at the Veterans Affairs Hospital was analyzed according to the use of alpha(1)-adrenergic antagonists at discharge. Covariate-adjusted Cox proportional hazard models were used to examine any association with future admissions for decompensated HF and total mortality. Alpha-1-adrenergic antagonist therapy was prescribed in 25% of our HF population, predominantly for benign prostatic hyperplasia, and was not associated with significant increases in the combined risk of all-cause mortality and rehospitalization for HF (hazard ratio 1.24, 95% confidence interval 0.93 to 1.65, p = 0.14), HF hospitalization (hazard ratio 1.20, 95% confidence interval 0.85 to 1.70, p = 0.31), or all-cause mortality (hazard ratio 1.10, 95% confidence interval 0.78 to 1.56, p = 0.57). In patients not receiving beta-blocker therapy, alpha(1)-adrenergic antagonist therapy was significantly associated with increased HF hospitalizations (hazard ratio 1.94, 95% confidence interval 1.14 to 3.32, p = 0.015). In conclusion, in patients with chronic HF, the use of alpha(1)-adrenergic antagonists was significantly associated with more HF hospitalizations when prescribed without concomitant beta blockade. Thus, background beta-blocker therapy appears to be protective against the potential harmful effects of alpha(1)-adrenergic antagonist therapy in patients with HF.

Reduction in BNP levels with treatment of decompensated heart failure and future clinical events.

BACKGROUND: Brain natriuretic peptide (BNP) levels correlate with outcomes in patients with heart failure (HF). We sought to compare the relationship between absolute and relative changes in BNP with future clinical events, and whether serial BNP measurements add prognostic information in patients treated for decompensated HF. METHODS AND RESULTS: In 203 patients treated for HF, increasing tertiles of BNP levels after treatment had a hazard ratio of 1.4 (1.1-1.7, P < .01) and increasing tertiles of percent reduction in BNP, had a hazard ratio of 0.7 (0.6-0.9, P = .005), respectively, for the combined end point of total mortality or readmission for HF. Higher baseline BNP levels did not decrease to lower BNP levels as often as lower BNP levels (P < .001). Follow-up BNP performed better in a model, incorporating age, ejection fraction, prior HF hospitalization, New York Heart Association Class, race, use of beta-blockers and renin-angiotensin axis inhibitors and renal insufficiency, than did baseline BNP or percent reduction in BNP. More BNP measurements other than the follow-up BNP did not improve the fit of the model further. CONCLUSIONS: These results suggest that both lower absolute BNP levels and greater percentage reduction in BNP with treatment of decompensated HF are associated with better event-free survival. Advocating a threshold BNP to which patients should be treated may not be possible given that high BNP levels tend not to decrease to levels associated with better outcomes during the short period of treatment. More BNP measurements do not add prognostic information beyond that provided by a single BNP level after treatment.

A randomized trial of self-management and psychoeducational group therapies for comorbid chronic posttraumatic stress disorder and depressive disorder.

The authors randomized 101 male veterans with chronic combat-related posttraumatic stress disorder (PTSD) and depressive disorder to an evidence-based depression treatment (self-management therapy; n = 51) or active-control therapy (n = 50). Main outcome measures for efficacy, using intention-to-treat analyses, were subjective and objective PTSD and depression scales at pretest, posttest, and 3-, 6-, and 12-month follow-up. Other measures included treatment compliance, satisfaction, treatment-targeted constructs, functioning, service utilization, and costs. Self-management therapy's modestly greater improvement on depression symptoms at treatment completion disappeared on follow-up. No other differences on symptoms or functioning appeared, although psychiatric outpatient utilization and overall outpatient costs were lower with self-management therapy. Despite success in other depressed populations, self-management therapy produced no clinically significant effect in depression with chronic PTSD.

Unsupervised walking therapy and atherosclerotic risk-factor management for patients with peripheral arterial disease: a pilot trial.

BACKGROUND: Although only a small percentage of patients with peripheral arterial disease (PAD) have claudication, many more suffer from atypical leg symptoms. PURPOSE: This pilot trial evaluated a risk-factor modification program to improve walking ability in patients with PAD and leg symptoms other than intermittent claudication. METHODS: Patients 18 years or older with an ankle-brachial index (ABI) of 0.50 to 0.89 completed a baseline assessment of current walking ability, physical activity level, health-related quality of life, glycosylated hemoglobin values, and fasting lipid profiles. Patients were randomized to usual care (control group) versus usual care plus an educational intervention on risk-factor management (intervention group). We compared functional outcomes between and within groups using the Student's t test and control and intervention group outcomes at 12 weeks using analysis of covariance with the baseline value as the covariate. RESULTS: We randomized 50 patients into two treatment arms. There was no difference in the mean age of patients in each group. At baseline, mean ABI for the control versus the intervention group was 0.72 (SD = 0.10) and 0.75 (SD = 0.10), respectively, and mean stair-climbing values did not differ between groups. At 12 weeks, mean stair-climbing values were 40.2 (SD = 30.2) for the control and 61.2 (SD = 32.8) for the intervention group. The difference in adjusted mean walking distance between groups at 12 weeks was not significant. Analysis of covariance associated assignment to the intervention versus the control arm with a significant increase at 12 weeks in the ABI (p = .008) and stair-climbing ability (p = .02). CONCLUSIONS: Patients in the intervention group improved objective measures of blood flow and reported stair-climbing ability.

A practical screening tool for anxiety and depression in patients with chronic breathing disorders.

Obstructive lung diseases are associated with high rates of depression and anxiety, yet many patients are never screened or treated. This study evaluated the five-question Depression and Anxiety modules of the Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Questionnaire as a telephone screen in 1,632 patients with chronic breathing disorders at a Veterans Affairs Medical Center in Houston, TX. Subsequent testing of 828 patients with the Beck Depression Inventory-II and the Beck Anxiety Inventory showed that the sensitivity and specificity, respectively, of the Depression and Anxiety modules of the PRIME-MD Patient Questionnaire screening were 94.6% and 49.5% (Depression); 93.7% and 32.2% (Anxiety); and 97.7%, and 36.0% (combined screen), with an overall accuracy of 80.7%. In such populations, these two modules of the PRIME-MD Patient Questionnaire may be a useful screening tool.

Racial/ethnic differences in preferences for total knee replacement surgery.

OBJECTIVES: To determine whether there are ethnic differences in preferences for surgery vs. medical treatment of knee osteoarthritis (OA). STUDY DESIGN AND SETTING: Cross-sectional in-person interviews using conjoint analysis methodology, a technique often used in marketing, involved individuals making choices between alternative hypothetical scenarios for medical or surgical treatment of knee OA. One hundred ninety-three individuals over the age of 20 were recruited through random digit dialing in Harris County, TX, and 198 individuals with knee OA were recruited from a large outpatient health care provider in Houston, TX. RESULTS: African Americans were significantly less likely to chose surgery than whites (odds ratio 0.63 [0.42, 0.93]). Women and older individuals were also less likely to choose surgery (0.69 [0.51, 0.94], 0.98 [0.97, 0.99]). Larger reductions in negative symptoms with surgery significantly increased the likelihood of choosing surgery. There was no difference between the public and patients, and no effect of income level. CONCLUSIONS: Disparities in knee replacement rates among ethnic groups may be partly due to differences in preferences for surgery. Conjoint analysis was shown to be a feasible methodology for collecting preferences in health research. This methodology has great promise in contributing to our knowledge of drivers of health care decision making in individuals.

Racial differences in doctors' information-giving and patients' participation.

BACKGROUND: Whether doctor-patient communication differs by race was investigated in patients with pulmonary nodules or lung cancer. METHODS: Eligible patients (n = 137) had pulmonary nodules or lung cancer and were seen in thoracic surgery or oncology clinics for initial treatment recommendations at a large southern Veterans Affairs Medical Center from 2001-2004. Doctor-patient consultations were audiotaped. Audiotapes were transcribed, unitized into utterances, and utterances were coded as doctors' information-giving or patients' and companions' active participation (asking questions, expressing concerns, and making assertions). Data were compared by patient race and doctor-patient racial concordance using t-tests or chi-square tests as appropriate. Mixed linear regression was used to determine the independent predictors of doctor's information-giving after controlling for clustering of patients by doctor. RESULTS: Patient age, gender, marital status, clinical site, and health status were similar by race (P > .20), but black patients were somewhat less likely to have education beyond high school and to bring a companion to the visit (P = .06) than white patients. Black patients and their companions received significantly less information from doctors (49.3 vs. 87.3 mean utterances; P < .001) and produced significantly fewer active participation utterances (21.4 vs. 37.2; P < .001) than white patients. In mixed regression analyses, after adjusting for patients' and companions' participation, clustering by doctor, and other factors, race no longer predicted information-giving (P = .54). Patients in racially discordant interactions received significantly less information and were significantly less active participants (P < .001) when compared with patients in racially concordant interactions, and after controlling for patients' participation and other factors using mixed regression, racial discordance did not predict information-giving. CONCLUSIONS: The results indicate a pattern of communication that may perpetuate patient passivity and limited information exchange where black patients and patients in discordant interactions do less to prompt doctors for information and doctors in turn provide less information to these patients.

Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression.

The authors examined 179 veterans with chronic obstructive pulmonary disease (COPD) to determine the relative contribution of clinical depression and/or anxiety (Beck Depression and Beck Anxiety Inventories) to their quality of life (Chronic Respiratory Questionnaire and Medical Outcomes Survey Short Form). Multiple-regression procedures found that both depression and anxiety were significantly related to negative quality-of-life outcomes (anxiety with both mental and physical health quality-of-life outcomes, and depression primarily with mental health). When comorbid with COPD, mental health symptoms of depression and anxiety are some of the most salient factors associated with quality-of-life outcomes.

Racial differences in trust and lung cancer patients' perceptions of physician communication.

PURPOSE: Black patients report lower trust in physicians than white patients, but this difference is poorly studied. We examined whether racial differences in patient trust are associated with physician-patient communication about lung cancer treatment. PATIENTS AND METHODS: Data were obtained for 103 patients (22% black and 78% white) visiting thoracic surgery or oncology clinics in a large Southern Veterans Affairs hospital for initial treatment recommendation for suspicious pulmonary nodules or lung cancer. Questionnaires were used to determine patients' perceptions of the quality of the physicians' communication and were used to assess patients' previsit and postvisit trust in physician and trust in health care system. Patients responded on a 10-point scale. RESULTS: Previsit trust in physician was statistically similar in black and white patients (mean score, 8.2 v 8.3, respectively; P = .80), but black patients had lower postvisit trust in physician than white patients (8.0 v 9.3, respectively; P = .02). Black patients, compared with white patients, judged the physicians' communication as less informative (7.3 v 8.5, respectively; P = .03), less supportive (8.1 v 9.3, respectively; P = .03), and less partnering (6.4 v 8.2, respectively; P = .001). In mixed linear regression analysis, controlling for clustering of patients by physician, patients' perceptions of physicians' communication were statistically significant (P < .005) predictors of postvisit trust, although patient race, previsit trust, and patient and visit characteristics were not significant (P > .05) predictors. CONCLUSION: Perceptions that physician communication was less supportive, less partnering, and less informative accounted for black patients' lower trust in physicians. Our findings raise concern that black patients may have lower trust in their physicians in part because of poorer physician-patient communication.

The utility of somatic symptoms as indicators of depression and anxiety in military veterans with chronic obstructive pulmonary disease.

The interrelationship between medical illnesses and psychological distress has received increasing attention in the last several years. Partly at issue is the best way to diagnose mental health problems such as depression and anxiety in medical populations. Specifically, are somatic symptoms a valid indicator of depression and anxiety in a medical population? Furthermore, do anxiety and depression remain as distinct constructs for this population, or do they combine to represent general distress? We examine these issues using confirmatory factor analysis in a sample of 202 military veterans with chronic obstructive pulmonary disease. Results indicate best fit for a model of depression and anxiety for which the constructs remained separate rather than as combined indicators of general distress. Furthermore, in this model, somatic symptoms are retained as valid indicators of psychological distress for this sample.

Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review.

OBJECTIVE: Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. METHOD: This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. RESULTS: Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. CONCLUSION: Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed.

Valuation of arthritis health states across ethnic groups and between patients and community members.

OBJECTIVE: We sought to examine differences in valuation of health by individuals from different ethnic backgrounds and between patients and community members. RESEARCH DESIGN: We surveyed 193 community members identified by random-digit dialing (ie, 64 white, 65 black, and 64 Hispanic) and 198 patients with osteoarthritis (OA), 66 per ethnic group, drawn sequentially from clinic lists of an outpatient institution. MEASURES: Participants were interviewed and asked to rate 2 scenarios describing arthritis (mild and severe) using visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO). Differences were adjusted for cohort, age, gender, and education. RESULTS: Members of the public had higher preference scores for the 2 health states than patients (SG severe state: 0.77 public, 0.66 patients; SG mild state: 0.90 public, 0.84 patients). The difference score between the mild and severe states was smaller for black than white subjects (P < 0.001) by SG and TTO. Scores for Hispanics and whites did not differ. Preference scores increased with age (SG, TTO). CONCLUSIONS: Significant differences were observed in the valuation of health between members of the public and patients, among ethnic groups, and in relation to educational status and age, with the difference between utilities of health states being a more efficient measure of preference than the utility of a single state. Utilities elicited through valuation of hypothetical health scenarios are dependent on sociodemographic traits, experience of disease, and method used. These findings suggest that utilities cannot be used interchangeably across populations, with implications for economic analyses.

Physician-patient communication following invasive procedures: an analysis of post-angiogram consultations.

Although rarely studied, physician-patient interactions immediately following diagnostic tests are significant medical events because during these encounters the physician and patient often make decisions about major and sometimes invasive treatment. This investigation analyzed patterns of physician-patient communication following coronary angiography with particular attention to behaviors important to decision-making: physician information-giving, physician use of partnership-building, and active forms of patient participation (e.g., asking questions, being assertive, expressing concerns). We were particularly interested in effects related to the patient's race in light of documented evidence of racial disparities in cardiac care and outcomes. From audiotape recordings, 93 physician-patient interactions after coronary angiogram in a catheterization laboratory in a large US Veterans Affairs Medical Center were coded to measure the frequency of physicians' information-giving and partnership-building and the frequency of active patient participation. We also stratified these behaviors according to whether the behavior was prompted (e.g., physician information in response to a patient's question; a patient's opinion solicited by the doctor) or self-initiated. Several findings were noteworthy. First, these interactions were very brief and dominated by the physician. Second, although physician information-giving increased with more active patient participation, which in turn was correlated with physicians' use of partnership-building, proportionally little of the physicians' information (8%) and active patient participation (9%) was directly prompted by the other interactant. Finally, there was a tendency for physicians to self-initiate less information giving to black patients and for black patients to self-initiate less active participation than white patients. Although these differences were attenuated when other variables (e.g., the physician's training, disease severity) were included in the analysis, the pattern suggests a potential cycle of passivity where certain patients tend to receive fewer informational resources and these patients in turn do less to prompt the doctor for more.

Comorbid psychosocial symptoms and quality of life in patients with dementia.

OBJECTIVE: The authors examined the association between treatable comorbid psychosocial symptoms and quality of life (QOL) in patients with dementia. In an effort to develop a more comprehensive understanding of this relationship, this study included both patient reports of their QOL and caregiver reports of patient QOL. METHODS: Eighty-nine dyads, consisting of a community-residing veteran with dementia and his family caregiver, were interviewed once to determine the correlation between patient QOL and depression, functional disability, pain, and agitation. RESULTS: Higher patient-rated QOL was significantly associated with lower patient depression. Higher caregiver-rated patient QOL was associated with lower caregiver depression and higher patient functional status. Agitation was not related to patient-rated or caregiver-rated patient QOL. CONCLUSIONS: Authors discuss the psychometric and conceptual implications of possible differences between self- and other-ratings of QOL, and treatment implications for caregiver-education interventions.

Ethnic variation in knee replacement: patient preferences or uninformed disparity?

BACKGROUND: Despite the efficacy and cost-effectiveness of total knee replacement (TKR), minority patients with knee osteoarthritis (OA) are half as likely as their white counterparts to undergo this procedure. Patient preferences may play a large role in the variations in utilization of TKR. We evaluated the preferences and beliefs of patients with knee OA from diverse ethnic backgrounds in relation to TKR. METHODS: The 198 patients with knee OA surveyed were of different ethnicities. Patients were asked about physician recommendations of TKR and whether they had considered having the procedure, their perceptions about the benefits and risks of TKR, their expectations if they were to undergo the procedure, and their trust in physicians and the health system. Bivariate and multivariate analyses were performed. RESULTS: A physician had discussed TKR with 27% of African Americans, 15% of whites, and 11% of Hispanics (P = .04). White patients were more likely than minority patients to have considered undergoing TKR (P = .04), more likely to consider TKR if their OA worsened and the procedure were recommended by their physician (P = .002), and more likely to consider TKR as a beneficial procedure (P = .02). Ethnic differences in preferences remained after controlling for severity of OA. CONCLUSIONS: Ethnic minority patients with knee OA are less likely to consider TKR. In our study, these differences were not related to physician recommendation biases. The ethnic variation in preferences was associated with differences in perception of benefit, lack of personal experiences with TKR, and trust.

Surprisingly high prevalence of anxiety and depression in chronic breathing disorders.

STUDY OBJECTIVES: The objectives of this study were to assess the prevalence, screening, and recognition of depression and anxiety in persons with chronic breathing disorders, including COPD. DESIGN: Cross-sectional study. SETTING: The Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC). PARTICIPANTS: A large sample of 1,334 persons with chronic breathing disorder diagnoses who received care at the MEDVAMC. MEASUREMENTS: The prevalence of anxiety and depression was measured in a large sample of persons with a chronic breathing disorder diagnosis who received care at the MEDVAMC, using the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questions. The positive predictive value of the PRIME-MD questions was then determined. The prevalence of anxiety and depressive diagnoses in patients determined to have COPD was then measured, using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). RESULTS: Of patients screened with the PRIME-MD, 80% screened positive for depression, anxiety, or both. The predictive value of a positive phone screen for either depression or anxiety was estimated to be 80%. In the subsample of patients who had COPD and received a diagnosis using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Of those patients, only 31% were receiving treatment for depression and/or anxiety. CONCLUSIONS: It is troubling that a mere 31% of COPD patients with depression or anxiety are being treated, particularly given their high prevalence in this population. Practical screening instruments may help increase the recognition of anxiety and depression in medical patients, as suggested by the excellent positive predictive value of the PRIME-MD in our study.

Survival in hepatitis C and HIV co-infection: a cohort study of hospitalized veterans.

BACKGROUND & AIMS: Previous studies reported increased morbidity and mortality related to liver disease among human immunodeficiency virus (HIV)-infected patients with hepatitis C co-infection. However, the long-term effect of hepatitis C virus (HCV) co-infection on the mortality of HIV-infected patients remains unclear. METHODS: By using national Veterans Affairs (VA) databases, we performed a retrospective cohort study of HIV patients hospitalized between October 1991 and September 2000. Mortality rates and hazard rate ratios (HRRs) for mortality were calculated for the entire cohort as well as after excluding patients with pre-existing liver disease, with follow-up through September 2001 after discharge. Multivariable adjustment for differences in demographics, comorbidities, and HIV disease severity was performed. Separate analyses were performed for patients identified during the highly active antiretroviral therapy (HAART) era. RESULTS: We identified 18,081 patients, of whom 5320 patients had dual HCV/HIV infection and 12,761 patients had HIV monoinfection. The number of deaths per 100 patient-years was 7.33 in the dual infection group and 14.13 in the HIV monoinfection group during 22,054 and 40,655 person-years of follow-up, respectively. The mortality rate ratio between HCV/HIV dual infection and HIV monoinfection was .53. In Cox multiple regression, the dual HCV/HIV infection group had an adjusted HRR for mortality of .55 compared with the HIV monoinfection group (95% CI, .51-.58, P < .0001), after controlling for age, race, sex, year of diagnosis, and HIV disease severity. These findings persisted in several sensitivity analyses. However, in the HAART era, if patients with liver disease at baseline were excluded, the HRR for mortality was .83 (95% CI, .73-.94, P = .003). CONCLUSIONS: Co-infection with hepatitis C is associated with a significant decrease in the mortality of HIV-infected patients. However, this effect was less pronounced during the HAART era.

Hepatitis C coinfection increases the risk of fulminant hepatic failure in patients with HIV in the HAART era.

BACKGROUND/AIMS: It is uncertain if patients coinfected with hepatitis C and HIV are more likely to suffer fulminant hepatic failure (FHF) when compared to patients with HIV-only. METHODS: We conducted a retrospective cohort study using national administrative databases from the Department of Veterans Affairs in patients hospitalized for the first time with HIV and/or hepatitis C between 10/1991 and 9/2000. Fulminant hepatic failure was defined as occurring after the index hospitalization through 9/2001 in the absence of pre-existing liver disease. We calculated incidence rates, Kaplan Meier cumulative incidence curves, and Cox proportional hazards ratios while adjusting for demographics and other potential confounders. RESULTS: We identified 11,678 patients with HIV-only and 4761 patients with coinfection. There were 92 cases of fulminant hepatic failure yielding an incidence rate of 1.1/1000 person-years and 2.5/1000 person-years in the HIV-only and coinfected groups. The cumulative incidence of fulminant hepatic failure in the coinfected group was higher than in the HIV-only group (P<0.0001). The risk of fulminant hepatic failure in patients with coinfection compared to HIV-only during the HAART era was several folds higher than that during the pre-HAART era. CONCLUSIONS: HAART and hepatitis C coinfection appeared to act synergistically in HIV-infected patients to increase the risk of fulminant hepatic failure, a rare but often fatal disease.

The effect of HIV coinfection on the risk of cirrhosis and hepatocellular carcinoma in U.S. veterans with hepatitis C.

OBJECTIVES: This study was conducted to determine whether HIV coinfection increases the risk of cirrhosis in HCV-infected patients in the HAART and pre-HAART eras. Further, the risk of hepatocellular carcinoma was also examined. METHODS: This retrospective cohort study was conducted among HCV-infected veterans who were seen at one of the 172 Veterans Health Administration hospitals between October 1, 1991 and September 30, 2000. Patients with prerecorded advanced liver disease were excluded. Incidence rates, cumulative incidence, and Cox proportional hazard ratios were calculated. RESULTS: There were 26,641 patients with HCV-only and 4,761 patients with HCV-HIV coinfection. The unadjusted incidence rate of cirrhosis was lower in patients with coinfection than HCV-only (p < 0.01). After controlling for demographics and confounders (including alcoholism and chronic hepatitis B), coinfection was not significantly associated with cirrhosis. However, there was an increased risk of cirrhosis in patients with coinfection compared to HCV-only during the pre-HAART era (before October 1, 1996) (hazard ratio = 1.48, 1.06-2.07, p= 0.02), but not among patients who entered the cohort during the HAART era. The unadjusted incidence rate of hepatocellular carcinoma in patients with coinfection and HCV-only was 1.3 and 2/1,000 person-years, respectively (p= 0.04). In the multivariate model, coinfection was not associated with hepatocellular carcinoma (hazard ratio = 0.84, p= 0.40). CONCLUSIONS: Coinfection was a significant risk factor for cirrhosis only during the pre-HAART era and was not associated with hepatocellular carcinoma, irrespective of time period.

Cirrhosis and hepatocellular carcinoma in HIV-infected veterans with and without the hepatitis C virus: a cohort study, 1992-2001.

BACKGROUND: Because they develop slowly and infrequently, the incidence and relative risk of cirrhosis and hepatocellular carcinoma (HCC) in patients with the human immunodeficiency virus (HIV) only and in patients coinfected with the hepatitis C virus (HCV) are not known. METHODS: By using national Veterans Health Administration administrative databases, we conducted a retrospective cohort study. Excluding patients with preexisting liver disease, 11,678 HIV-only and 4761 coinfected patients hospitalized between October 1, 1991, and September 30, 2000, were included. Incidence rates and adjusted hazard ratios (HRs) for nonalcoholic cirrhosis and HCC after discharge were calculated through September 30, 2001. RESULTS: The incidence rates of cirrhosis in the HIV-only and coinfected groups were 1.47 and 15.88 per 1000 person-years, respectively. In a Cox multivariate proportional hazards regression model, coinfected patients had an adjusted HR for cirrhosis of 9.24 compared with HIV-only patients (95% confidence interval, 6.92-12.33; P<.001). The incidence rates of HCC in the HIV-only and coinfected groups were 0.20 and 1.32 per 1000 person-years, respectively. In a Cox multivariate proportional hazards regression model, coinfected patients had an adjusted HR for HCC of 5.35 compared with HIV-only patients (95% confidence interval, 2.34-12.20; P<.001). Among patients identified during the highly active antiretroviral therapy era, the HR for cirrhosis was 19.06 (95% confidence interval, 10.14-35.85; P<.001), while the HR for HCC was 5.07 (95% confidence interval, 1.72-14.99; P = .003). CONCLUSIONS: To our knowledge, this study is the largest longitudinal study to examine the incidence of nonalcoholic cirrhosis and HCC in HIV-only and HCV-coinfected patients. Hepatitis C virus coinfection dramatically promotes the development of HCC (5-fold) and of cirrhosis (10- to 20-fold), and is especially associated with cirrhosis in the highly active antiretroviral therapy era. Treatment of HCV in HIV-infected patients, while often unsuccessful, should be considered.