Benchmarking HIV health care: from individual patient care to health care evaluation. An example from the EuroSIDA study

Daria N Podlekareva, Joanne Reekie, Amanda Mocroft, Marcelo Losso, Aza G Rakhmanova, Elzbieta Bakowska, Igor A Karpov, Jeffrey V Lazarus, Jose Gatell, Jens D Lundgren, Ole Kirk, EuroSIDA study in EuroCoord, Daria N Podlekareva, Joanne Reekie, Amanda Mocroft, Marcelo Losso, Aza G Rakhmanova, Elzbieta Bakowska, Igor A Karpov, Jeffrey V Lazarus, Jose Gatell, Jens D Lundgren, Ole Kirk, EuroSIDA study in EuroCoord

Abstract

Background: State-of-the-art care involving the utilisation of multiple health care interventions is the basis for an optimal long-term clinical prognosis for HIV-patients. We evaluated health care for HIV patients based on four key indicators.

Methods: Four indicators of health care were assessed: Compliance with current guidelines on initiation of: 1) combination antiretroviral therapy (cART); 2) chemoprophylaxis; 3) frequency of laboratory monitoring; and 4) virological response to cART (proportion of patients with HIV-RNA < 500copies/ml for >90% of time on cART).

Results: 7097 EuroSIDA patients were included from Northern (n = 923), Southern (n = 1059), West Central (n = 1290) East Central (n = 1366), Eastern (n = 1964) Europe, and Argentina (n = 495). Patients in Eastern Europe with a CD4 < 200cells/mm(3) were less likely to initiate cART and Pneumocystis jiroveci-chemoprophylaxis compared to patients from all other regions, and less frequently had a laboratory assessment of their disease status. The proportion of patients with virological response was highest in Northern, 89% vs. 84%, 78%, 78%, 61%, 55% in West Central, Southern, East Central Europe, Argentina and Eastern Europe, respectively (p < 0.0001). Compared to Northern, patients from other regions had significantly lower odds of virological response; the difference was most pronounced for Eastern Europe and Argentina (adjusted OR 0.16 [95%CI 0.11-0.23, p < 0.0001]; 0.20[0.14-0.28, p < 0.0001] respectively).

Conclusions: This assessment of HIV health care utilization revealed pronounced regional differences in adherence to guidelines and can help to identify gaps and direct target interventions. It may serve as a tool for the assessment and benchmarking of the clinical management of HIV patients in any setting worldwide.

Figures

Figure 1
Figure 1
Inclusion criteria for EuroSIDA patients in the analysis of four different Health Care Interventions (HCI). cART, combination antiretroviral therapy; baseline = date of enrolment into the EuroSIDA study. Patients for each HCI were selected from 7,366 patients based on the inclusion criteria explained below. HCI 1: all patients who ever started cART (either prior to or after baseline) were included (5859 patients, 4586 on cart at baseline, 1273 start cart after baseline). HCI 2: all EuroSIDA patients, enrolled after 2001 and with a minimum of one follow-up visit (7097). HCI 3: the off cART group included patients who were off cART at baseline and subsequently have not started cART. If patients started cART, they were censored at the time of starting cART. The on cART group included patients who were on cART at baseline or started cART during follow-up (5859 on cart group and 2511 in the off cART group). HCI 4: patients who were on cART for at least 4 consecutive months and had their CD4-cell count and HIV-RNA measured whilst on cART. The first 4 months after each start/change of cART were excluded to ensure that periods when viral suppression would not be expected were not included in the measure of HCI [14]. Follow-up was censored if a patient had not had a HIV-RNA measurement for >6 months and continued from the next available HIV-RNA measurement (5277).
Figure 2
Figure 2
Proportion of EuroSIDA patients starting cART at various CD4-cell strata and presence of AIDS diagnosis according to the region of residence and calendar year. SE, Southern Europe: Greece, Israel, Italy, Portugal, Spain; WCE, West Central Europe: Austria, Belgium, France, South Germany, Luxembourg, Switzerland; NE, Northern Europe: Denmark, Finland, North Germany, Ireland, the Netherlands, Norway, Sweden, the United Kingdom; ECE, East Central Europe: Bulgaria, Croatia, the Czech Republic, Hungary, Poland, Romania, Serbia and Slovakia; EE, Eastern Europe: Belarus, Estonia, Latvia, Lithuania, the Russian Federation and the Ukraine.
Figure 3
Figure 3
Proportion of CD4-cell measurements < 200 cells/mm3where patients were receiving prophylaxis for Pneumocystis jiroveci pneumonia (PCP) and had not had PCP diagnosis. SE, Southern Europe: Greece, Israel, Italy, Portugal, Spain; WCE, West Central Europe: Austria, Belgium, France, South Germany, Luxembourg, Switzerland; NE, Northern Europe: Denmark, Finland, North Germany, Ireland, the Netherlands, Norway, Sweden, the United Kingdom; ECE, East Central Europe: Bulgaria, Croatia, the Czech Republic, Hungary, Poland, Romania, Serbia and Slovakia; EE, Eastern Europe: Belarus, Estonia, Latvia, Lithuania, the Russian Federation and the Ukraine; AR, Argentina. cART, combination antiretroviral therapy.
Figure 4
Figure 4
Frequency of CD4-cell count and HIV-RNA measurements among patients not receiving cART and those receiving cART in the EuroSIDA study. SE, Southern Europe: Greece, Israel, Italy, Portugal, Spain; WCE, West Central Europe: Austria, Belgium, France, South Germany, Luxembourg, Switzerland; NE, Northern Europe: Denmark, Finland, North Germany, Ireland, the Netherlands, Norway, Sweden, the United Kingdom; ECE, East Central Europe: Bulgaria, Croatia, the Czech Republic, Hungary, Poland, Romania, Serbia and Slovakia; EE, Eastern Europe: Belarus, Estonia, Latvia, Lithuania, the Russian Federation and the Ukraine; AR, Argentina. cART, combination antiretroviral therapy; HIV-RNA, viral load.
Figure 5
Figure 5
Odds Ratio (OR) of having suppressed HIV-RNA (<500 copies/ml) during more than 90% of time spent on cART. Multivariable model was also adjusted for: gender, age, race, risk factor for HIV acquisition, hepatitis B/C status, type of cART regimen, being ART naïve at initiation of cART, year of cART initiation, baseline CD4-cell count and HIV-RNA. SE, Southern Europe: Greece, Israel, Italy, Portugal, Spain; WCE, West Central Europe: Austria, Belgium, France, South Germany, Luxembourg, Switzerland; NE, Northern Europe: Denmark, Finland, North Germany, Ireland, the Netherlands, Norway, Sweden, the United Kingdom; ECE, East Central Europe: Bulgaria, Croatia, the Czech Republic, Hungary, Poland, Romania, Serbia and Slovakia; EE, Eastern Europe: Belarus, Estonia, Latvia, Lithuania, the Russian Federation and the Ukraine; AR, Argentina. cART, combination antiretroviral therapy; HIV-RNA, viral load.

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