CATIE News

25 September 2018 

Vancouver researchers study short-term hospital readmission rates among HIV-positive people

  • B.C. researchers analyzed the hospital records of over 7,000 people living with HIV.
  • 13% of people with HIV were readmitted to hospital within 30 days of discharge.
  • Patients with a single healthcare provider were less likely to need readmission.

Studies have found that HIV-positive people who have been readmitted to a hospital within 30 days after having been discharged are at heightened risk for poorer health.

Researchers in Vancouver at the British Columbia Centre for Excellence in HIV/AIDS and local universities conducted a study to explore possible reasons that could explain why some HIV-positive people are at increased risk for hospital readmission in the short term. In reviewing the medical records of more than 7,000 HIV-positive people hospitalized between 1996 and 2015, researchers found that about 13% were readmitted to hospital within 30 days of having been discharged from an initial hospital visit.

In analysing many factors that could play a role in readmission, the researchers found that people who tended to visit the same healthcare provider for most of their medical care were less likely to need readmission to a hospital. The researchers stated: “Our findings support the adoption of interventions that seek to build patient-provider relationships in order to optimize outcomes for people living with HIV and enhance healthcare sustainability.”

Study details

Researchers combed through several databases to assess health-related information on HIV-positive patients who had to be rehospitalized within 30 days of discharge. The databases also provided some information on the healthcare sought in the year prior to hospitalization.

The researchers focused on 7,013 HIV-positive patients who had been hospitalized between April 1996 and March 2015. All people had been prescribed potent combination HIV treatment (ART) prior to hospitalization.

The average profile of participants upon entering the study was as follows:

  • age – 43 years
  • 80% men, 20% women
  • CD4+ cell count – almost half of participants had less than 350 cells/mm3
  • viral load – 126 copies/mL
  • about 41% of participants had a history of injecting street drugs

Results

Researchers found that 931 patients (13%) were readmitted to hospital within 30 days of being discharged. A total of 564 patients (8%) were readmitted for the same problem for which they initially sought hospitalization.

These percentages from B.C. are less than those seen in American healthcare settings, where one large study found hospital readmission rates within 30 days of discharge to be about 20% among HIV-positive people.  However, figures from the U.S. may not be readily comparable to Canada. Unlike the U.S., Canada has universal healthcare, and in B.C., in particular, patients do not have to pay when accessing essential medicines, including ART.

After taking into account many factors (including age, gender, history of injecting street drugs, viral load, CD4+ count, severity of co-existing illnesses, calendar year), researchers found that people who sought most of their medical care from one practitioner in the year prior to hospitalization were significantly less likely to be rehospitalized in the short term.

The main types of physicians from whom patients sought care in the year prior to hospitalization were as follows:

  • family doctors (general practitioners) – 73%
  • internal medicine specialists – 10%
  • psychiatrists – 5%

The main reasons for admission (and readmission) to a hospital were as follows (in decreasing order):

  • diseases and disorders of the intestinal tract
  • infections at several sites in the body
  • mental health conditions

For many people, readmission to a hospital is a stressful event. Hospitalizations are also expensive for the healthcare system. To reduce hospital readmission, the researchers made several recommendations affecting different aspects of healthcare services and delivery.

Improving the doctor-patient relationship

The researchers noted that many HIV-positive people continue to experience negative attitudes and behaviour—social stigma—from some other people because of their infection status or due to other factors such as “mental illness, homelessness or injection drug use.” This stigmatization can cause some HIV-positive people to mistrust the healthcare system and be reluctant “to seek and remain engaged in care.” The researchers stated that it is possible that some healthcare providers may have “inadvertently contributed” to the issue of patient mistrust. To address patient mistrust, the researchers suggested that healthcare providers receive training so that they can “deliver trauma-informed care in an effort to build trust and rapport with their patients.” They suggested that physician training and education should include how to foster “good communication and shared decision-making.” The researchers stated that a future study should examine the impact of physician training and education regarding these issues on hospital readmission rates.

The importance of family doctors

In the present study, nearly 75% of medical care in the year prior to hospital readmission was provided by family doctors. The researchers noted that for many HIV-positive people in the current era, HIV care has shifted from providing acute care to focusing on chronic health issues such as “cardiovascular or kidney disease.” Due to this shift, family doctors are well placed to provide the care that HIV-positive people need. The researchers further stated that family doctors are capable of “providing important psychosocial support and a person-centred approach [to care], thus increasing care quality.” They also stated that integrating HIV care into the practices of family doctors can “provide comprehensive care for [HIV-positive people] and decrease hospital admissions.” The researchers suggested monitoring hospital readmission rates for HIV-positive people in the future.

Healthcare systems

Based on their findings, the Vancouver researchers encouraged healthcare systems to move toward models of care delivery that promote the following:

  • coordinate patient care by primary care providers (family doctors, nurse practitioners)
  • integrate HIV care services into primary care
  • “widespread physician education programs”

For the future

Studies analysing information captured by databases (observational studies) are relatively inexpensive compared to large prospective clinical trials. Observational studies, no matter how large, cannot prove “cause and effect.” That is, observational studies such as the present one cannot prove that people who obtained most of their care from one healthcare provider (usually a family doctor)  are at reduced risk for short-term rehospitalization (should they require hospitalization). Given the austerity that currently holds sway over government and health-research spending, it is unlikely that a large prospective study will be done in the short term on hospital readmission among HIV-positive people. Thus, the analysis from Vancouver is timely and useful.

Another approach could be to work with a sub-group of patients and healthcare providers to conduct interviews with both parties to find out more about what the researchers termed the “emotional attachment” between doctor and patient and how this might affect health-seeking behaviour and rates of rehospitalization.

Finally, the present study only assessed whether or not patients had a history of using street drugs. Researchers were not able to assess whether patients were currently using street drugs. It is not clear if this difference in categories of drug use could have had an impact on the conclusions of the study.

Resources

British Columbia Centre for Excellence in HIV/AIDS

A shift over time in the HIV ward of one of Canada’s largest hospitalsCATIE News

High rates of mental health and addiction care use in OntarioCATIE News

Continuing care needed for HIV-positive people after hospitalization for mental health issuesCATIE News

Investigating where patients go when they leave HIV careCATIE News

—Sean R. Hosein

REFERENCES:

  1. Parent S, Barrios R, Nosyk B, et al. The impact of patient-provider attachment on hospital readmission among people living with HIV: a population-based study. Journal of Acquired Immune Deficiency Syndromes. 2018; in press.
  2. Berry SA, Fleishman JA, Moore RD, et al. Thirty-day hospital readmissions for adults with and without HIV infection. HIV Medicine. 2016 Mar;17(3):167-77.
  3. Bizune DJ, Kempker RR, Kagei M, et al. Treatment complexities among patients  with tuberculosis in a high HIV prevalence cohort in the United States. AIDS Research and Human Retroviruses. 2018; in press.
  4. Nijhawan AE, Kitchell E, Etherton SS, et al. Half of 30-day hospital readmissions among HIV-infected patients are potentially preventable. AIDS Patient Care STDS. 2015 Sep;29(9):465-73.
  5. Beach MC, Keruly J, Moore RD. Is the quality of the patient-provider relationship associated with better adherence and health outcomes for patients with HIV? Journal of General Internal Medicine. 2006 Jun;21(6):661-5.
  6. Beach MC, Duggan PS, Moore RD. Is patients' preferred involvement in health decisions related to outcomes for patients with HIV? Journal of General Internal Medicine. 2007 Aug;22(8):1119-24.