aDepartment of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island bDepartment of Health Law, Policy, & Management, Boston University School of Public Health cInstitute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts dDepartment of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA.
AIDS. 2019 Nov 1;33(13):2081-2089. doi: 10.1097/QAD.0000000000002316.
While antiretroviral therapy (ART) is essential to patients with HIV, there is substantial variation in adherence nationally. We assess how provider and practice factors contribute to successful HIV ART adherence.
We used Medicaid Analytic Extract claims from 2008 to 2012. We attributed patients with HIV to the provider that provided the plurality of HIV-related services or primary care in a given year and assigned these providers to a medical practice based on the National Provider Identifier registry file. We fit successive linear hierarchical models with patient, provider, and practice characteristics to partition the variation in adherence driven by each factor. Our unit of analysis was the patient-year.
Fourteen US states with the highest HIV prevalence.
A total of 111 013 patient-years representing 60 496 Medicaid enrollees living with HIV attributed to 4930 providers and 1960 practices.
Percentage of year individual patients were adherent to an ART regimen.
Provider and practice random effects jointly explained 6.8% of variation in adherence with patient differences accounted for 45.2% of the variation. Patients seen by generalists and other specialists had a 1.6 [95% confidence interval (CI): 0.6-2.5] and 5.1 (95% CI: 4.1-6.1) percentage point greater adherence than those seen by infectious disease specialists (P < 0.001). Every additional year a patient saw the same provider was associated with a 6% increase in adherence (95% CI: 5.7-6.3).
There is substantial variation in ART adherence attributable to providers and practices and between provider specialties. To improve ART adherence for patients living with HIV, structural aspects of care should be considered.
抗逆转录病毒疗法（ART）对 HIV 患者至关重要，但全国范围内的依从率存在很大差异。我们评估了提供者和实践因素如何促成成功的 HIV ART 依从性。
我们使用了 2008 年至 2012 年的医疗补助分析提取索赔数据。我们将 HIV 患者归因于在特定年份提供多数 HIV 相关服务或初级保健的提供者，并根据国家提供者标识符注册文件将这些提供者分配到医疗实践中。我们拟合了具有患者、提供者和实践特征的连续线性分层模型，以划分每个因素驱动的依从性变化。我们的分析单位是患者年。
HIV 流行率最高的 14 个美国州。
共有 111013 个患者年，代表了 60496 名 Medicaid 参保的 HIV 感染者，归因于 4930 名提供者和 1960 个实践。
个体患者遵守 ART 方案的年百分比。
提供者和实践的随机效应共同解释了 6.8%的依从性变化，而患者差异则解释了 45.2%的变化。与传染病专家相比，全科医生和其他专科医生治疗的患者的依从性高出 1.6 个百分点（95%置信区间：0.6-2.5）和 5.1 个百分点（95%置信区间：4.1-6.1）（P<0.001）。患者与同一提供者就诊的每增加一年，其依从性增加 6%（95%置信区间：5.7-6.3）。
由于提供者和实践以及提供者专业之间的差异，ART 依从性存在很大差异。为了提高 HIV 感染者的 ART 依从性，应该考虑护理的结构方面。
