Kushel M B, Colfax G, Ragland K, Heineman A, Palacio H, Bangsberg D R
Division of General Internal Medicine, San Francisco General Hospital Medical Center, University of California, San Francisco 94143-1372, USA.
Clin Infect Dis. 2006 Jul 15;43(2):234-42. doi: 10.1086/505212. Epub 2006 Jun 8.
Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection.
We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM in <or=25% of quarters in the study), moderate (>25% but <or=75%), or consistent (>75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count of >or=50% and geometric mean HIV load of <or=400 copies/mL).
In multivariate models, CM was not associated with increased primary care, emergency department use, or hospitalization. Moderate CM, compared with no or rare CM, was associated with an adjusted beta coefficient of 0.13 (95% confidence interval [CI], 0.02-0.25) for improved antiretroviral adherence. Consistent CM (adjusted odds ratio [AOR], 10.7; 95% CI, 2.3-49.6) and moderate CM (AOR, 6.5; 95% CI, 1.3-33.0) were both associated with >or=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load <400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization.
CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.
病例管理（CM）可为有复杂医疗需求的人群协调医疗服务。目前尚不清楚病例管理对于改善感染人类免疫缺陷病毒（HIV）的无家可归者和居住条件差的人的生物学指标是否有效。我们的目标是确定病例管理是否与感染HIV的无家可归者和居住条件差的人的急性医疗服务使用减少及生物学指标改善相关。
我们在加利福尼亚州旧金山的一个基于概率的社区样本中，对感染HIV的无家可归者和居住条件差的成年人群进行了一项前瞻性观察队列研究。主要自变量为病例管理，定义为无或很少（在研究的四分之一时间内接受任何病例管理的比例≤25%）、中等（>25%但≤75%）或持续（>75%）。因变量为3项自我报告的医疗服务使用指标（接受初级保健、急诊就诊和住院治疗以及抗逆转录病毒治疗依从性）和2项生物学指标（CD4(+)细胞计数增加≥50%以及HIV几何平均病毒载量≤400拷贝/毫升）。
在多变量模型中，病例管理与初级保健、急诊就诊或住院治疗的增加无关。与无或很少接受病例管理相比，中等程度的病例管理与抗逆转录病毒治疗依从性改善的调整后β系数为0.13（95%置信区间[CI]，0.02 - 0.25）相关。持续的病例管理（调整后的优势比[AOR]，10.7；95%CI，2.3 - 49.6）和中等程度的病例管理（AOR，6.5；95%CI，1.3 - 33.0）均与CD4(+)细胞计数改善≥50%相关。当模型中纳入抗逆转录病毒治疗依从性时，病例管理与HIV病毒载量<400拷贝/毫升无关。研究局限性包括缺乏随机分组。
病例管理可能是一种成功的方法，可提高感染HIV的无家可归者和居住条件差的成年人对抗逆转录病毒治疗的依从性以及改善生物学指标。
