Handford C D, Tynan A M, Rackal J M, Glazier R H
Cochrane Database Syst Rev. 2006 Jul 19;2006(3):CD004348. doi: 10.1002/14651858.CD004348.pub2.
Treating the world's 40.3 million persons currently infected with HIV/AIDS is an international responsibility that involves unprecedented organizational challenges. Key issues include whether care should be concentrated or decentralized, what type and mix of health workers are needed, and which interventions and mix of programs are best. High volume centres, case management and multi-disciplinary care have been shown to be effective for some chronic illnesses. Application of these findings to HIV/AIDS is less well understood.
Our objective was to evaluate the association between the setting and organization of care and outcomes for people living with HIV/AIDS.
Computerized searches from January 1, 1980 to December 31, 2002 of MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsychInfo, PsychLit, Social Sciences Abstracts, and Sociological Abstracts as well as searches of meeting abstracts and relevant journals and bibliographies in articles that met inclusion criteria. Searches included articles published in English and other languages.
Articles were considered for inclusion if they were observational or experimental studies with contemporaneous comparison groups of adults and/or children currently infected with HIV/AIDS that examined the impact of the setting and/or organization of care on outcomes of mortality, opportunistic infections, use of HAART and prophylaxis, quality of life, health care utilization, and costs for patient with HIV/AIDS.
Two authors independently screened abstracts to determine relevance. Full paper copies were reviewed against the inclusion criteria. The findings were extracted by both authors and compared. The 28 studies that met inclusion criteria were too disparate with respect to populations, interventions and outcomes to warrant meta-analysis.
Twenty-eight studies were included involving 39,776 study subjects. The studies indicated that case management strategies and higher hospital and ward volume of HIV-positive patients were associated with decreased mortality. Case management was also associated with increased receipt of ARVs. The results for multidisciplinary teams or multi-faceted treatment varied. None of the studies examined quality of life or immunological or virological outcomes. Healthcare utilization outcomes were mixed.
AUTHORS' CONCLUSIONS: Certain settings of care (i.e. high volume of HIV positive patients) and models of care (i.e. case management) may improve patient mortality and other outcomes. More detailed descriptions of care models, consistent definition of terms, and studies on innovative models suitable for developing countries are needed. There is not yet enough evidence to guide policy and clinical care in this area.
治疗全球目前感染艾滋病毒/艾滋病的4030万人是一项国际责任，这涉及前所未有的组织挑战。关键问题包括护理应集中还是分散，需要何种类型和组合的卫生工作者，以及哪些干预措施和项目组合是最佳的。高容量中心、病例管理和多学科护理已被证明对某些慢性病有效。将这些研究结果应用于艾滋病毒/艾滋病的情况尚不太清楚。
我们的目的是评估艾滋病毒/艾滋病患者护理的环境和组织与治疗结果之间的关联。
对1980年1月1日至2002年12月31日期间的MEDLINE、EMBASE、国际学位论文摘要数据库（DAI）、护理学与健康领域数据库（CINAHL）、健康之星数据库（HealthStar）、心理学文摘数据库（PsychInfo）、心理学文献数据库（PsychLit）、社会科学文摘数据库和社会学文摘数据库进行计算机检索，并检索会议摘要以及符合纳入标准的文章中的相关期刊和参考文献。检索包括以英语和其他语言发表的文章。
如果文章是观察性或实验性研究，有同时期的成人和/或儿童艾滋病毒/艾滋病感染对照人群，研究护理环境和/或组织对艾滋病毒/艾滋病患者死亡率、机会性感染、高效抗逆转录病毒治疗和预防措施的使用、生活质量、医疗保健利用情况及费用等结果的影响，则考虑纳入。
两位作者独立筛选摘要以确定相关性。根据纳入标准对全文进行审查。两位作者提取研究结果并进行比较。符合纳入标准的28项研究在人群、干预措施和结果方面差异太大，无法进行荟萃分析。
纳入28项研究，涉及39776名研究对象。研究表明，病例管理策略以及艾滋病毒阳性患者较高的医院和病房容量与死亡率降低相关。病例管理还与抗逆转录病毒药物的更多使用相关。多学科团队或多方面治疗的结果各不相同。没有研究考察生活质量或免疫或病毒学结果。医疗保健利用结果好坏参半。
某些护理环境（即艾滋病毒阳性患者数量多）和护理模式（即病例管理）可能改善患者死亡率和其他结果。需要对护理模式进行更详细的描述，对术语进行一致的定义，并开展适合发展中国家的创新模式研究。目前尚无足够证据指导该领域的政策和临床护理。
