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Although prior authorization (PA) for prescription medications is widely employed for cost-containment for third-party insurers, it is a frustrating aspect of outpatient clinical care that imposes uncompensated costs to medical providers. To characterize these costs, we monitored the PA-associated administrative and operational process at the University of Alabama at Birmingham 1917 HIV Clinic over a 2-year period. A total of 288 PAs were processed with a mean (± standard deviation [SD]) of days 3.1±5.8 delay in the patient's access to medication. A mean (±SD) of 26.8±18.4 min was spent by the nurse practitioner and 6.5±2.9 min was spent by a clerk per PA. Nearly three-quarters (73%) of PAs were approved, 18% were denied, and 10% were voided. The mean (±SD) pages of paperwork was 5.8±6.5. The overall cost was $41.60 per PA. Although evidence supports that PA reduces third-party expenditures, it significantly delays medication accessibility for patients and imposes high costs that negatively impact operating margins for health care providers. [ABSTRACT FROM AUTHOR]

Background. The applicability of clinical trial findings (efficacy) to the routine care setting (effectiveness) may be limited because of study eligibility criteria and volunteer bias. Although well-chronicled in many conditions, the efficacy versus effectiveness of antiretroviral therapy (ART) remains understudied. Methods. A retrospective study of the University of Alabama at Birmingham 1917 Clinic Cohort evaluated ART-naive patients who started ART from 1 January 2000 through 31 December 2006. Patients received ART through clinical trials or routine care. Multivariable logistic and linear regression models were fit to evaluate factors associated with virological failure (virological failure was defined as a viral load >50 copies/mL) and change from baseline CD4+ cell count 6 and 12 months after ART initiation. Sensitivity analyses evaluated the impact of missing data on outcomes. Results. Among 570 patients starting ART during the study period, 121 (21%) enrolled in clinical trials, and 449 (79%) received ART via routine care. ART receipt through routine care was not associated with viral failure at either 6 months (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.54-1.86) or 12 months (OR, 1.56; 95% CI, 0.80-3.05) in primary analyses. No statistically significant differences in CD4+ cell count responses at 6 and 12 months were observed. Conclusions. Although marked differences in efficacy versus effectiveness have been observed in the therapeutic outcomes of other conditions, our analyses found no evidence of such divergence among our patients who initiated antiretroviral therapy for human immunodeficiency virus infection. [ABSTRACT FROM AUTHOR]

Numerous antiretroviral therapy (ART) regimens are recommended for first-line and subsequent HIV care, but regimen selection for clinical use may not represent the full range of options. We hypothesized that despite an increase in available antiretrovirals, clinical trial data on regimen efficacy and fixed-dose combination options have lead to uniformity in initial ART. We evaluated regimen selection for ART-naïve patients at the University of Alabama at Birmingham (UAB) 1917 Clinic between January 2000 and December 2007. The annual number of unique initial regimens was quantified. Initial regimen variability was expressed as regimens per 100 patients. Subsequent ART regimens were characterized for complexity via regimen sequence trees detailing the first three generations of regimens for patients starting the two most common initial combinations. Four hundred eighty-two ART-naïve patients were treated with 39 unique initial regimens (8.0 regimens per 100 patients). Variability in initial regimen selection was highest in the first 6 years (14.9–24.4 regimens per 100 patients). A sharp decline was observed in 2006 (16.1 regimens per 100 patients) and 2007 (6.5 regimens per 100 patients). The most dramatic shift in drug selection involved an increase in emtricitabine plus tenofovir plus efavirenz, from 0% in 2003 to 85% in 2007. During the study period, 205 of 482 (43%) patients required a change in initial therapy. Of these, 156 of 205 (76%) had a unique sequence of regimens. A shift toward homogeneity of initial ART was observed (85% of patients received the same first-line regimen in 2007). In contrast, regimen sequencing beyond the first regimen remained complex. These shifts in ART prescribing patterns may have implications for collaborative HIV care. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the racial and ethnic differences in medical care access and appointments among human immunodeficiency virus (HIV) positive persons. Components that affect appointment nonadherence and missed outpatient visits were assessed at the University of Alabama in Birmingham, Alabama. Results indicate that African American patients were the common patients that do not adhere to medical appointments.

A retrospective cohort study evaluating the frequency of and factors related to clinical inertia in low-density lipoprotein (LDL) management was performed. Subjects were 90 patients that were not meeting National Cholesterol Education Program Adult Treatment Panel III LDL goals at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic between 1 August 2004 and 1 August 2005. Clinical inertia was observed in 44% of cases. Patients with higher baseline LDL levels were less likely to experience inertia, whereas women and those in the highest coronary heart disease risk category were more likely to be affected. [ABSTRACT FROM AUTHOR]

Background. Health care expenditures for persons infected with human immunodeficiency virus (HIV) in the United State determined on the basis of actual health care use have not been reported in the era of highly active antiretroviral therapy. Methods. Patients receiving primary care at the University of Alabama at Birmingham HIV clinic were included in the study. All encounters (except emergency room visits) that occurred within the University of Alabama at Birmingham Hospital System from 1 March 2000 to 1 March 2001 were analyzed. Medication expenditures were determined on the basis of 2001 average wholesale price. Hospitalization expenditures were determined on the basis of 2001 Medicare diagnostic related group reimbursement rates. Clinic expenditures were determined on the basis of 2001 Medicare current procedural terminology reimbursement rates. Results. Among the 635 patients, total annual expenditures for patients with CD4+ cell counts <50 cells/μL ($36,533 per patient) were 2.6-times greater than total annual expenditures for patients with CD4+ cell counts ⩾350 cells/μL ($13,885 per patient), primarily because of increased expenditures for nonantiretroviral medication and hospitalization. Expenditures for highly active antiretroviral therapy were relatively constant at ∼$10,500 per patient per year across CD4+ cell count strata. Outpatient expenditures were $1558 per patient per year; however, the clinic and physician component of these expenditures represented only $359 per patient per year, or 2% of annual expenses. Health care expenditures for patients with HIV infection increased substantially for those with more-advanced disease and were driven predominantly by medication costs (which accounted for 71%–84% of annual expenses). Conclusions. Physician reimbursements, even with 100% billing and collections, are inadequate to support the activities of most clinics providing HIV care. These findings have important implications for the continued support of HIV treatment programs in the United States. [ABSTRACT FROM AUTHOR]