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Background: Drug users rely heavily on emergency departments (EDs) for care. Medical and other services in outpatient drug treatment clinics may reduce demand for ED care.Objective: The objective of this study was to examine the association of services in drug treatment clinics with repeated ED use by clinic patients.Design: This study consisted of telephone interviews of directors of a stratified random sample of 125 New York state outpatient drug treatment clinics linked to Medicaid claims for patients with long-term (>or=6 months) treatment at these clinics.Patients: This study comprised a total of 8397 Medicare enrollees in surveyed clinics in 1996 to 1997.Measurements: The surveys addressed drug treatment; general medical, HIV, alcohol, and social support services; location of selected services; primary care, HIV specialty, and mental health provider staffing levels; accessibility; and academic affiliation. From Medicaid claims, we defined patient demographic, clinical, and healthcare variables. Logistic regression models examined associations of availability of onsite medical services with repeated (2 or more) ED visits in 1997, adjusted for patient characteristics and patient clustering in clinics.Results: Repeated ED visits occurred in 15% of the cohort and were less likely when medical services were all onsite versus more distant (12.9% vs 16.8%, P<0.001). An interaction showed that onsite medical care was associated with less ED use only in low-volume (Conclusions: Greater onsite medical care in low- and moderate-volume drug treatment clinics was associated with less repeated ED use. [ABSTRACT FROM AUTHOR]

Background: The complier average causal effect (CACE) analysis addresses noncompliance with intervention and missing end-point measures in randomized controlled trials., Objectives: To conduct a CACE analysis for the Peer Coach and Office Staff Support Trial examining the intervention's effect among "compliers," defined as subjects who would have received an effective dose of the intervention had it been offered, and to compare with an intention-to-treat analysis., Research Design and Subjects: A randomized controlled trial of 280 African American patients aged 40-75 with sustained uncontrolled hypertension from 2 general internal medicine practices., Measures: Change in 4-year coronary heart disease (CHD) risk (primary) and in systolic blood pressure (SBP) (secondary) from the baseline to the end of the 6-month intervention., Results: Of 136 intervention subjects, 68% were compliers who had significantly more end points measured (86% vs. 34% for CHD risk; 99% vs. 57% for SBP) and lower baseline CHD risk (5% vs. 7.5%) and SBP (139 vs. 144 mm Hg) compared with noncompliers. In the intention-to-treat analysis, the effect of offering the intervention was nonsignificant for 4-year CHD risk (P=0.08) but significant for SBP (P=0.003). CACE analyses showed that receipt of an effective dose of the intervention resulted in a 1% greater reduction in 4-year CHD risk (P<0.05) and at least 8.1 mm Hg greater reduction in SBP compared with compliers in the control group (P<0.05)., Conclusions: Among compliers, an effective dose of peer coach and office-based support resulted in significant reductions in 4-year CHD risk and SBP. More intensive interventions are likely to be required for noncompliers.

Objective: To examine the association of drug users' outpatient patterns of care with subsequent intensity of antiretroviral therapy (ART)., Materials and Methods: Annual types of ART in 8897 New York State Medicaid drug users who were prescribed ART for > or =6 months in 1996 or 1997 were determined. From pharmacy claims, intensity was classified from changes in annual type of ART in 1996 to 97 and 1997 to 98 as: optimal (ie, on or starting highly active ART [HAART]), acceptable (ie, on or starting 2+ non-HAART drugs), or suboptimal (ie, none, <6 months, one drug, or change from HAART to non-HAART). In both 1996 and 1997, outpatient pattern of care was defined including regular medical care, regular drug treatment, both, and neither and categories of visits for HIV-focused care. Predictors of adequate ART intensity were examined among the group with suboptimal or adequate intensity (model 1) and predictors of optimal ART intensity among the group with adequate or optimal intensity (model 2)., Results: The adjusted odds ratios (AOR) of acceptable ART intensity in model 1 were increased for those with HIV-focused care (AOR, 2.9; 95% CI, 2.6, 3.3 for 4+ visits 1.7; 95% CI, 1.5, 1.9 for 1-3 visits) or regular medical care (AOR, 1.2 [1.1, 1.4]. Adjusted odds ratios (AOR) of optimal intensity in model 2 were increased for those with regular substance abuse care with (AOR, 1.4 [1.2, 1.7]) or without (AOR, 1.2 [1.1, 1.4]) regular medical care whereas HIV-focused visits had no effect., Conclusion: Care from an HIV-focused provider was predictive of a drug user receiving at least adequate intensity of ART for more than 2 years whereas regular drug abuse treatment, especially with regular medical care, was associated with optimal intensity of ART.

Objectives: The objectives of this study were (1) to estimate the prevalence, bothersomeness, and variation of HIV-related symptoms in a nationally representative sample of HIV-infected adults receiving medical care and (2) to evaluate new aggregate measures of symptom frequency and bothersomeness., Methods: Beginning in January 1996, 76% of a multistage national probability sample of 4,042 HIV-infected adults receiving medical care were interviewed. Participants endorsed the presence and degree of bothersomeness of 14 HIV-related symptoms during the preceding 6 months. Sex-standardized symptom number and bothersomeness indices were constructed. After sampling weights were incorporated, symptom distributions were compared according to selected characteristics by analysis of variance and multiple linear regression modeling., Results: Prevalence of specific symptoms in the reference population was as follows: fever/night sweats, 51.1%; diarrhea, 51%; nausea/anorexia, 49.8%; dysesthesias, 48.9%; severe headache, 39.3%; weight loss, 37.1%; vaginal symptoms, 35.6% of women; sinus symptoms, 34.8%; eye trouble, 32.4%; cough/dyspnea, 30.4%; thrush, 27.3%; rash, 24.3%; oral pain, 24.1%; and Kaposi's sarcoma, 4%. Aggregate measures were reliable (Cronbach's alpha > or =0.75) and demonstrated construct validity when compared with other measures of disease severity. After adjustment for CD4 count, both symptom number and bothersomeness varied significantly (P <0.05) by teaching status of care setting, exposure/risk group, educational achievement, sex, annual income, employment, and insurance category. However, the magnitude of variation was small. Symptoms were greatest in women and injection drug users, as well as in persons with lower educational levels, lower income, and Medicare enrollment or those who were followed up at teaching hospitals., Conclusions: The prevalence and bothersomeness of HIV-related symptoms are substantial and vary by setting of care and patient characteristics.

The Severity Classification for AIDS Hospitalizations (SCAH) was applied to a longitudinal person-based data set of Maryland adult residents diagnosed with acquired immunodeficiency syndrome (AIDS) between 1983 and 1989 to predict long-term survival. In contrast to other AIDS severity measures, SCAH can be applied to administrative data bases for analyses of large populations. Although SCAH was created to predict inpatient mortality using cross-sectional hospital discharge data, the models used in this study show SCAH stage at first AIDS hospitalization to predict long-term survival in persons with AIDS, even after adjusting for sociodemographic and treatment variables. Additional models in the study show SCAH stage at first hospitalization has a strong association with inpatient length of stay and associated charges, making it useful for health care resource planning.

We examined patterns of ambulatory care in the year before diagnosis of acquired immune deficiency syndrome (AIDS) for 5,720 persons infected with human immunodeficiency virus (HIV) who were continuously enrolled in the New York State Medicaid program and diagnosed in 1984-90. For 3,175 persons followed > or = 6 months after AIDS, we also examined the change between the year before AIDS diagnosis and the 6 months afterward in the predominant provider who was seen most frequently and at least twice. Approximately 75% of the population had a predominant provider identified. Of this group, 43% of the patients had a generalist as their predominant provider before AIDS diagnosis, falling to only 25% after diagnosis. The proportion with an AIDS specialist predominant provider increased from 22% before AIDS diagnosis to 39% afterward (P < 0.001). Patients with a generalist predominant provider before AIDS diagnosis had higher odds of switching providers and of hospitalization after AIDS diagnosis than patients with an AIDS specialist predominant provider. If generalists are to be encouraged to manage patients with advanced HIV disease, a better understanding of factors contributing to these outcomes is needed.

The authors describe a new model for classifying hospitalized patients with acquired immunodeficiency syndrome (AIDS) according to their severity of illness. In the first phase of the project, a clinical model indicating the relative severity of AIDS complications was formulated, based on the clinical literature and expert opinion. In the second phase, the model was tested empirically using data on in-patient mortality of over 6,000 adult AIDS hospitalizations in New York State during 1985. The ordering of AIDS-related complications in the clinical model was revised to reflect a continuum of increasing likelihood of death in the hospital. The final classification system for AIDS hospitalizations has 20 substages, grouped into three stages, with in-patient mortality rates increasing from 6% to 60%. The system is automated and can be applied to different AIDS populations to analyze resource use and outcomes of hospital care.

This study uses the Severity Classification for AIDS Hospitalizations to examine and contrast the duration and costs of hospitalizations among 6,142 AIDS discharges from New York hospitals during 1985. Multivariate regression analyses of resource-use differences suggest that more severely ill AIDS patients have considerably longer stays and higher total charges, regardless of hospital type. Severity of illness alone accounts for most of the explained variation in hospital length of stay (LOS) and total charges. In contrast, other patient characteristics, such as gender, race, and reported drug use, are less important predictors of resource use. It was also found that public teaching hospitals serve somewhat more severely ill AIDS patients than those treated in private teaching hospitals. The study concludes that the AIDS severity classification facilitates interhospital comparisons of illness levels and variations in resource use.