Disparities in the Quality of Cardiovascular Care Between HIV-Infected Versus HIV-Uninfected Adults in the United States

A Cross-Sectional Study

Published in: Journal of the American Heart Association , Volume 6, Issue 11 (November 2017), e007107. doi: 10.1161/JAHA.117.007107

Posted on RAND.org on December 15, 2017

by Joseph A. Ladapo, Adam Richards, Cassandra M. DeWitt, Nina T. Harawa, Steven Shoptaw, William Cunningham, John N. Mafi

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Research Question

  1. Do physicians in the United States give comparable cardiovascular care to HIV-infected patients and those who are not infected?

Background

Cardiovascular disease is emerging as a major cause of morbidity and mortality among patients with HIV. We compared use of national guideline-recommended cardiovascular care during office visits among HIV-infected versus HIV-uninfected adults.

Methods and Results

We analyzed data from a nationally representative sample of HIV-infected and HIV-uninfected patients aged 40 to 79 years in the National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey, 2006 to 2013. The outcome was provision of guideline-recommended cardiovascular care. Logistic regressions with propensity score weighting adjusted for clinical and demographic factors. We identified 1631 visits by HIV-infected patients and 226 862 visits by HIV-uninfected patients with cardiovascular risk factors, representing [approximately equal to] 2.2 million and 602 million visits per year in the United States, respectively. The proportion of visits by HIV-infected versus HIV-uninfected adults with aspirin/antiplatelet therapy when patients met guideline-recommended criteria for primary prevention or had cardiovascular disease was 5.1% versus 13.8% (P=0.03); the proportion of visits with statin therapy when patients had diabetes mellitus, cardiovascular disease, or dyslipidemia was 23.6% versus 35.8% (P<0.01). There were no differences in antihypertensive medication therapy (53.4% versus 58.6%), diet/exercise counseling (14.9% versus 16.9%), or smoking cessation advice/pharmacotherapy (18.8% versus 22.4%) between HIV-infected versus HIV-uninfected patients, respectively.

Conclusions

Physicians generally underused guideline-recommended cardiovascular care and were less likely to prescribe aspirin and statins to HIV-infected patients at increased risk- findings that may partially explain higher rates of adverse cardiovascular events among patients with HIV. US policymakers and professional societies should focus on improving the quality of cardiovascular care that HIV-infected patients receive.

Key Findings

  • U.S. physicians underutilized cardiovascular care guidelines for their high-risk adult patients, including those infected with HIV.
  • In comparison to HIV-negative patients, physicians were less likely to prescribe aspirin and statins to HIV-infected adults.
  • The different rates of aspirin and statin prescriptions among the two groups suggest the need for efforts to improve cardiovascular care quality among HIV-infected adults.
  • Physicians did not differ in their provision of therapy for hypertension; smoking counseling and/or medication; or counseling about diet, exercise, or weight loss.

Recommendation

Changes to quality of care-related professional and practice-level guidelines and reimbursement policies are needed to reduce care disparities and adverse cardiovascular events among patients with HIV.

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