International Journal for Quality in Health Care 11:293-300 (1999)
© 1999 International Society for Quality in Health Care
The association between primary source of ambulatory care and access to a outcomes of treatment among AIDS patients
0 Department of Ambulatory Care, and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston, USA
1 Department of Medicine, Beth Israel Hospital, Boston, USA
2 The Heller School at Bradeis University, Waltham, USA
3 The Infectious Disease Unit, Department of Medicine, Massachusetts General Hospital, Boston, USA
Correspondence to TI McLaughlin, Department of' Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim, Health Care, 126 Brookline Avenue, Suite 200, Boston, MA 02215, USA. Tel: + 1 617 421 6865, Fax: + 1 617 859 8112. E-mail: tom_mclaughlin@HMS.harvard.edu
Objectives.To examine the relationships between having a primary source of ambulatory care (PSAC), access to AIDS treatment and prophylaxis for opportunistic infection, and hospital and mortality outcomes among heterosexual men and women with AIDS.
Methods.Using a linked AIDS registry-Medicaid database, 366 adults were identified (1989-1991) with at least 1 year of continuous Medicaid enrollment before AIDS diagnosis who suvived 2 weeks after diagnosis and with no antiretroviral use or Pneumocystis carinii pneumonia (PCP) prophylaxis during the pre-diagnosis year. Outcomes included times to zidovudine treatment, PCP prophylaxis, hospitalization and death following diagnosis. Multivariate proportional hazards models were used to estimate the effects of patients' PSAC status in the 12-month post-diagnosis period on outcomes, controlling for demographic and case-mix variables.
Results.Study criteria preferentially included females, non-whites and enrollees eligible on the basis of aid to families with dependent children. A total of 49% of the patients had no PSAC. Patients with a PSAC were more likely to have received zidovudine [relative risk (RR) = 1.75, 95% confidence interval (CI) = 1.2, 2.2] or PCP prophylaxis (RR = 2.22, 95% CI = 1.5,3.3). Regression models simultaneously examining association of the propensity to use zidovudine and PCP prophylaxis agents with death indicated that zidovudine-treated and PCB-prophylaxed patients were 64% and 51% less likely to die, respectively (RRdeath,zidovudine = 0.36, 95% CI = 0.2, 0.4; RRdeath,PCP prophylaxed = 0.49, 95% CI = 0.3, 0.8).
Conclusions.Patients' underuse of zidovudine and PCP prophylaxis was systematically associated with not having a PSAC. Lack of PSAC, in turn, predicted shorter survival but not increased hospitalization. Female gender, injecting drug use, non-white race and earlier diagnosis year also predicted poorer outcomes.
Keywords: primary source of care, AIDS, access to treatment, outcomes