This application is submitted in response to PA-09-070, AHRQ Health Services Research Projects (R01). New therapies are increasing the life expectancy for patients with HIV and, in turn, the importance of the quality of the health care they receive. This study will assess the degree of association between successful clinical care by HIV treatment providers (reflected in adherence to recommended prevention and screening guidelines) and quality of care and outcomes for a sample of 4,000 HIV-infected Kaiser Permanente (KP) patients in the Northwest and California. Specific project aims include: 1. Develop new composite quality of care measures for use in the management of patients infected with HIV. 1a. Using KP electronic medical records and data systems, calculate the proportion of patient time covered by receipt of various recommended general preventive and HIV-specific services, relative to the time during which patients were coverage-eligible-the "Prevention Index-HIV" (PIH), quantifying adherence to established standards for recommended preventive health services. 1b. Calculate the degree to which patients with HIV are within established standards for various clinical measures relevant to HIV management-the "Disease Management Index-HIV" (DMIH). We will calculate a PIH and DMIH for multiple 12-month periods following initial HIV diagnosis. In addition to service-specific PIHs and DMIHs, our objective is to produce a summary PIH and DMIH for a representative set of services and measures considered important to the care of patients with HIV. 2. Examine the association of the quality of care measures from Aim 1 with clinical outcomes. 2a. Assess the temporal trend of the estimated service-specific and summary PIHs and DMIHs across years to evaluate the quality of care for patients with HIV, adjusting for secular trends in HIV care. 2b. Assess whether higher levels of the 12-month post-dx PIHs and DMIHs, predict use of the latest highly active anti-retroviral therapy regimens, adherence to and/or changes in such regimens, and changes in selected HIV-related outcomes. 3. Study the association of practice variation with the developed quality of care measures. 3a. Explore how different provider characteristics induce practice variation, and thus affect the PIH and DMIH. The study team of experienced health services researchers and HIV clinical experts will use KP's electronic medical record and data systems to explore and describe the association of general clinical care with outcomes. We expect our results to improve understanding of the influence of primary care practice characteristics on the quality of care and outcomes for patients with HIV.
Quality performance measures are being developed that reflect the spectrum of HIV care, including testing for and diagnosis of HIV disease, access to care and follow-up, appropriate use of antiretroviral therapy (ART) and opportunistic infection prevention, and outcome measures for patients prescribed ART. The results of this study will show where both general health prevention and HIV-related health prevention are deficient, and where more systematic interventions to improve health maintenance among HIV-infected patients are needed.