Efficacy of 25-OH Vitamin D3 prophylactic administration for reducing lameness in broilers grown on wire flooring

Bacterial chondronecrosis with osteomyelitis (BCO) is the most common cause of lameness in commercial broilers. Growing broilers on wire flooring provides an excellent experimental model for reproducibly triggering significant levels of lameness attributable to BCO. In the present study we evaluated the efficacy of adding HyD (25-OH vitamin D3) to the drinking water as a preventative/prophylactic treatment for lameness. Broiler chicks were reared on 5 x 10 ft flat wire floor panels within 6 environmental chambers. Three chambers were supplied with tap water (Control group) and the remaining chambers were supplied with HyD (HyD group: 0.06 mL HyD solution/L water; dosing based on the HyD Solution label to provide 33.9 μg 25-OHD3/L) from d 1 through 56. Feed was provided ad libitum and was formulated to meet or exceed minimum standards for all ingredients, including 5,500 IU vitamin D3/kg. Lameness initially was detected on d 28, and the cumulative incidence of lameness on d 56 was higher in the Control group than in the HyD group (34.7 vs. 22.7%, respectively; P = 0.03; Z-test of proportions; chambers pooled). The most prevalent diagnoses for lame birds were osteochondrosis and osteomyelitis (BCO) of the proximal femora (52%) and tibiae (79%), accompanied by minor incidences of tibial dyschondroplasia (0.33%), spondylolisthesis, or kinky back (0.67%), and twisted legs (1%). Broilers that survived to d 56 without developing lameness did not differ in BW when compared by group within a gender. The wire flooring model imposes a rigorous, sustained challenge that undoubtedly is much more severe than typically would be experienced by broilers under normal commercial conditions. Therefore the encouraging response to HyD supplementation in the present study supports the potential for 25-OH vitamin D3 to attenuate outbreaks of lameness caused by BCO in commercial broiler flocks.

Effect of vitamin D status improvement with 25-hydroxycholecalciferol on skeletal muscle growth characteristics and satellite cell activity in broiler chickens

Skeletal muscle satellite cells (SC) play a critical role in the hypertrophic growth of postnatal muscle. Increases in breast meat yield have been consistently observed in broiler chickens fed 25-hydroxycholecalciferol (25OHD3), but it is unclear whether this effect is mediated by SC. Thus, our objective was to determine the effect of vitamin D status improvement by replacing the majority of dietary vitamin D3 (D3) with 25OHD3 on SC activity and muscle growth characteristics in the pectoralis major (PM) and the biceps femoris (BF) muscles. Day-old, male Ross 708 broiler chickens (n = 150) were fed 1 of 2 corn and soybean meal-based diets for 49 d. The control diet (CTL) contained 5,000 IU D3 per kg of diet and the experimental diet (25OHD3) contained 2,240 IU D3 per kg of diet + 2,760 IU 25OHD3 per kg of diet. Ten birds per treatment were harvested every 7 d. Two hours before harvest, birds were injected intraperitoneally with 5'-bromo-2'deoxyuridine (BrdU) to label mitotically active cells. Blood was collected from each bird at harvest to measure circulating concentrations of 25OHD3, a marker of vitamin D status. The PM and BF muscles were weighed and processed for cryohistological determination of skeletal muscle fiber cross-sectional area, enumeration of Myf-5+ and Pax7+ SC, and mitotically active (BrdU+) SC using immunofluorescence microscopy. Circulating 25OHD3 concentrations were greater in 25OHD3-fed birds on d 7, 14, 21, 28, 35, 42, and 49 when compared with CTL (P < 0.001). Growth performance and feed efficiency did not differ among dietary treatments (P > 0.10). Improved vitamin D status as a result of feeding 25OHD3 increased the number of mitotically active (Pax7+;BrdU+) SC (P = 0.01) and tended to increase the density of Pax7+ SC (P = 0.07) in the PM muscles of broilers on d 21 and 35, respectively. Broiler chickens fed 25OHD3 also tended to have greater Myf-5+ SC density (P = 0.09) on d 14, greater total nuclear density (P = 0.05) on d 28, and a greater muscle fiber cross-sectional area (P = 0.09) on d 49 in their PM muscles compared with CTL birds. Collectively, these results suggest that improvement of vitamin D status by replacing the majority of D3 in the diet with 25OHD3 can stimulate SC activity in the predominantly fast-twitch PM muscle and provide evidence toward understanding the mechanism behind previously observed increases in breast meat yield in 25OHD3-fed commercial broiler chickens.

Cytogenetic analysis of a self-fertilizing fish, Rivulus marmoratus: remarkable chromosomal constancy over a vast geographic range

The aplocheiloid killifish Rivulus marmoratus is the only known self-fertilizing hermaphroditic vertebrate. Most natural populations consist almost entirely of hermaphrodites and comprise arrays of homozygous clones. However, in almost all populations thus far studied, clonal variation, as detected with molecular techniques, is very high. A karyological survey was carried out on specimens from Brazil, the Bahamas, Belize, and Florida (4 locales) by C-banding, silver staining, and fluorescent staining. The chromosome complement of R. marmoratus is surprisingly uniform over its vast geographic range, in terms of both chromosome number and morphology, heterochromatin distribution and composition, and nucleolar organizer region (NOR) distribution. The short arms of chromosome pair 15, where NORs are located, showed the only variation detected in this study: those of pattern A were consistently shorter than those of pattern B; moreover, the latter show positive heteropycnosis with Giemsa staining. The present data demonstrate that chromosomal variation is not a significant part of the clonal divergence in this species, even though its breeding system, by forming homozygotes for new rearrangements almost immediately, should make that variation easier to detect. The high chromosomal homogeneity is discussed in the light of the peculiar natural history of the species.

Co-regulation of survival of motor neuron and Bcl-xL expression: implications for neuroprotection in spinal muscular atrophy

Spinal muscular atrophy (SMA), a fatal genetic motor disorder of infants, is caused by diminished full-length survival of motor neuron (SMN) protein levels. Normally involved in small nuclear ribonucleoprotein (snRNP) assembly and pre-mRNA splicing, recent studies suggest that SMN plays a critical role in regulating apoptosis. Interestingly, the anti-apoptotic Bcl-x isoform, Bcl-xL, is reduced in SMA. In a related finding, Sam68, an RNA-binding protein, was found to modulate splicing of SMN and Bcl-xL transcripts, promoting SMNΔ7 and pro-apoptotic Bcl-xS transcripts. Here we demonstrate that Bcl-xL expression increases SMN protein by ∼2-fold in SH-SY5Y cells. Conversely, SMN expression increases Bcl-xL protein levels by ∼6-fold in SH-SY5Y cells, and ∼2.5-fold in the brains of transgenic mice over-expressing SMN (PrP-SMN). Moreover, Sam68 protein levels were markedly reduced following SMN and Bcl-xL expression in SH-SY5Y cells, suggesting a feedback mechanism co-regulating levels of both proteins. We also found that exogenous SMN expression increased full-length SMN transcripts, possibly by promoting exon 7 inclusion. Finally, co-expression of SMN and Bcl-xL produced an additive anti-apoptotic effect following PI3-kinase inhibition in SH-SY5Y cells. Our findings implicate Bcl-xL as another potential target in SMA therapeutics, and indicate that therapeutic increases in SMN may arise from modest increases in total SMN.

A cryptic lineage within the pupfish Cyprinodon dearborni suggests multiple colonizations of South America

The coastal South American species Cyprinodon dearborni contains two lineages distinct at both mitochondrial and nuclear loci. One appears to be a long-term South American endemic, whereas the other is a more recent colonizer related to the widespread Cyprinodon variegatus.

Chemotherapy Delays Progression of Motor Neuron Disease in the SOD1 G93A Transgenic Mouse

BACKGROUND

A significant proliferation of glial cells occurs in the spinal cord and brainstem of SOD1 G93A transgenic mice with familial amyotrophic lateral sclerosis (ALS). Since activated glia may contribute to motor neuron degeneration, we tested whether inhibition of gliosis using low-dose chemotherapy is beneficial in this mouse model.

METHODS

Mice were administered fortnightly intraperitoneal injections of 0.1 mg/kg vincristine (VIN) or saline commencing at postnatal day 68 before disease onset. Mice were sacrificed at end-stage disease, and spinal cords were examined for histology.

RESULTS

Survival of VIN-treated mice was significantly increased at 132.0 +/- 4.1 days compared to control animals at 117.8 +/- 2.1 days (p < 0.05). Furthermore, analysis of microglia and astrocyte populations suggests a reduction in the former following VIN therapy.

CONCLUSION

This study suggests that chemotherapy may offer an alternative therapy or co-therapy for ALS.

The serotonin precursor 5-hydroxytryptophan delays neuromuscular disease in murine familial amyotrophic lateral sclerosis

INTRODUCTION

Reduction in the levels of whole-blood serotonin is a common feature of Down syndrome (DS) individuals and transgenic mice overexpressing wild-type SOD1. Administration of the metabolic precursor 5-hydroxytryptophan (5-HTP) leads to reversal of both serotonin deficits and hypotonia in humans. The effect of 5-HTP treatment on the progression of motor neuron disease in mutant SOD1 mice was examined.

METHODS

Pre-disease transgenic SOD1 G93A mice and wild-type littermates were systemically administered 5-HTP thrice weekly (0, 5 or 50 mg/kg). Animal weights, locomotor function and survival were recorded weekly. Plasma serotonin levels were measured post-mortem.

RESULTS

Treatment with 5-HTP significantly delayed hindlimb weakness and mortality in SOD1 G93A mice in a dose-dependent manner. Wild-type mice were not adversely affected by 5-HTP administration. Baseline serotonin levels did not differ between wild-type and ALS mice. Blood platelet serotonin levels increased proportionally with dose.

CONCLUSIONS

Increased blood serotonin by administration of 5-HTP in SOD1 G93A mice led to improved locomotor function and survival. A role for serotonin metabolism in mice with elevated SOD1 expression and motor neuron disease is suggested by these studies.

Opposing effects of low and high-dose clozapine on survival of transgenic amyotrophic lateral sclerosis mice

Clozapine is a potent atypical neuroleptic or antipsychotic agent used to relieve symptoms of early-diagnosed schizophrenia. Aside from well-described dopamine and serotonin receptor blockade effects, clozapine may also be neuroprotective through its modulation of the p75 neurotrophin receptor (p75(NTR)) and superoxide dismutase 1 (SOD1) expression. The death-signalling activities of both p75(NTR) and mutant SOD1 are implicated in motor neuron degeneration in humans and transgenic mice with amyotrophic lateral sclerosis (ALS). We therefore investigated the effects of clozapine in cell culture and mouse models of ALS. Clozapine dose-dependently inhibited full-length and cleaved p75(NTR) but not SOD1 protein expression in the motor neuron-like (NSC-34) cell line. Furthermore, low concentrations of clozapine protected NSC-34 cells from paraquat-mediated superoxide toxicity, nerve growth factor (NGF)-induced death signalling, and serum deprivation, whereas high concentrations potentiated death. Systemic thrice-weekly administration of low and high-dose clozapine to mutant superoxide dismutase 1 (SOD1(G93A)) mice produced differential effects on disease onset and survival. Low-dose treatment was associated with delayed locomotor impairment and death, compared to high-dose clozapine, which accelerated paralysis and mortality (P < 0.05). Increased death was not attributable to toxicity, as clozapine-induced agranulocytosis was not detected from blood analysis. High-dose clozapine, however, produced extrapyramidal symptoms in mice manifest by hindlimb rigidity, despite reducing spinal cord p75(NTR) levels overall. These results suggest that although clozapine may exert p75(NTR)-mediated neuroprotective activity in vitro, its profound antagonistic effects on dopaminergic and serotonergic systems in vivo at high doses may exacerbate the phenotype of transgenic ALS mice.

Qualitative and quantitative assessments of HAART adherence of substance-abusing women

This study was set up to examine factors affecting adherence to highly active antiretroviral therapy (HAART) by substance abusing women and to conduct a pilot study of a reminder device intervention. Three focus groups totaling 24 HIV-positive women developed priority lists of issues affecting adherence. Another group of 24 HIV-positive women received a timer-reminder with structured interviews on adherence at baseline and two monthly follow up intervals. Focus groups described key barriers to HAART adherence as substance abuse, forgetting, feeling ill, others' negative attitudes, obtaining refills and confidentiality. Primary disadvantages to HAART were side effects, pill-taking schedule and burden of taking medications. Facilitators included reminders (e.g. pill boxes) and spirituality. After receiving the reminder, missing a dose was less common (p < 0.05) due to sleeping through dose, being busy and feeling too good while a favourable trend (p = 0.07) was seen for change in daily routine and having too many pills to take. Although well accepted, the reminder did not affect the proportion missing a dose in the past two weeks: baseline (33%), first follow-up (30%) and second follow-up (30%). Forgetting to take HAART was only one of many cited barriers to adherence in these HIV-positive women; well-received reminder devices did not affect adherence. To improve substance-abusing women's adherence, multidimensional interventions are warranted.

Models of care in New York State Medicaid substance abuse clinics. Range of services and linkages to medical care

PURPOSE

To explore the range of health care services in substance abuse clinics.

METHODS

Survey of directors of a stratified random sample of 125 substance abuse treatment clinics offering methadone, drug-free therapy, or both, representing 344 clinics participating in the New York State (NYS) Medicaid program. Survey asked about clinic services and referral patterns. We defined five categories of linkage of substance abuse to medical care ranging from unlinked (e.g. referral to distant sites) to highly linked (e.g. on site). To estimate the number of patients served, State data on licensed patient capacity for each clinic were used.

RESULTS

This sample represented 344 clinics statewide serving an estimated 60,914 patients. For patients with acute, chronic, or HIV-related medical conditions, weighted analyses showed highly linked care in 54 of the 344 (16%) clinics statewide, serving an estimated 13,741 patients. Unlinked care for all these medical conditions was found for 28% of statewide clinics, serving an estimated 8866 patients. Clinics offering both methadone and drug-free therapy were generally more likely to have medically related services on site.

IMPLICATIONS

The extent of medical care services available at substance abuse clinics varies widely. Over one-quarter of clinics offered only loosely connected medical and substance abuse care.

Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons

OBJECTIVE

To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use.

DESIGN

Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996.

MEASUREMENTS

Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART.

RESULTS

Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08).

CONCLUSIONS

Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.

Screening for cervical cancer in HIV-infected women receiving care in the United States

OBJECTIVE

We examined the sociodemographic, clinical and provider factors associated with screening for cervical cancer among HIV-infected women.

METHODS

We studied a national sample representing 43,490 women receiving treatment of HIV infection who completed first follow-up surveys of the HIV Cost and Service Utilization Study (HCSUS). All women were asked, "In the past 12 months, have you had a Pap test?" Women reporting an abnormal Pap test result were asked whether they had been told antibiotics could cure abnormal cells, and whether they were scheduled for another Pap test or for a colposcopy within 3 months.

RESULTS

Of the population represented, 81% had had a Pap test in the past 12 months. Women who reported having a gynecologist and primary care physician at the same clinical site were almost twice as likely (odds ratio, 1.9; 95% confidence interval, 1.3-3.0) as other women to report Pap testing. Among women who reported abnormal Pap test results and were not told antibiotics could cure abnormal cells, 95% were scheduled for a repeat Pap test or colposcopy, but 15% of the women had not received their repeat Pap test or colposcopy.

CONCLUSION

Although Pap test rates and appropriate referral for abnormal findings were high among HIV-tested women, many women with initially abnormal Pap test results did not actually receive follow-up Pap testing or colposcopy. Providing gynecologic care at the same site as primary HIV care would likely improve delivery of needed gynecologic care for women.

Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States

BACKGROUND

There have been no previous nationally representative estimates of the prevalence of mental disorders and drug use among adults receiving care for human immunodeficiency virus (HIV) disease in the United States. It is also not known which clinical and sociodemographic factors are associated with these disorders.

SUBJECTS AND METHODS

We enrolled a nationally representative probability sample of 2864 adults receiving care for HIV in the United States in 1996. Participants were administered a brief structured psychiatric instrument that screened for psychiatric disorders (major depression, dysthymia, generalized anxiety disorders, and panic attacks) and drug use during the previous 12 months. Sociodemographic and clinical factors associated with screening positive for any psychiatric disorder and drug dependence were examined in multivariate logistic regression analyses.

RESULTS

Nearly half of the sample screened positive for a psychiatric disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence during the previous 12 months. Factors independently associated with screening positive for a psychiatric disorder included number of HIV-related symptoms, illicit drug use, drug dependence, heavy alcohol use, and being unemployed or disabled. Factors independently associated with screening positive for drug dependence included having many HIV-related symptoms, being younger, being heterosexual, having frequent heavy alcohol use, and screening positive for a psychiatric disorder.

CONCLUSIONS

Many people infected with HIV may also have psychiatric and/or drug dependence disorders. Clinicians may need to actively identify those at risk and work with policymakers to ensure the availability of appropriate care for these treatable disorders.

Regular outpatient medical and drug abuse care and subsequent hospitalization of persons who use illicit drugs

CONTEXT

Patients and the public could benefit from identification of factors that prevent drug users' heavy reliance on inpatient care; however, optimal health care delivery models for illicit drug users remain ill-defined.

OBJECTIVE

To evaluate associations of outpatient medical and drug abuse care with drug users' subsequent hospitalization rates.

DESIGN AND SETTING

Retrospective cohort study of data from longitudinally linked claims for all ambulatory physician/clinic services and drug abuse services covered by the New York State Medicaid program.

SUBJECTS

A total of 11 556 human immunodeficiency virus (HIV)-positive and 46 687 HIV-negative drug users.

MAIN OUTCOME MEASURES

Hospitalization in federal fiscal year (FFY) 1997 compared by 4 patterns of care in FFY 1996: regular drug abuse care (>/=6 months in 1 program), regular medical care (>35% of care from 1 clinic, group practice, or individual physician), both, or neither.

RESULTS

Hospitalization occurred in 55.6% of HIV-positive and 37.5% of HIV-negative drug users, with a mean of 27.5 and 24.5 inpatient days, respectively. In HIV-positive drug users, the adjusted odds ratio (AOR) for hospitalization was lowest among those with both regular medical and drug abuse care (AOR, 0.76; 95% confidence interval [CI], 0.67-0.85) followed by those with regular medical care alone (AOR, 0.82; 95% CI, 0.74-0.91) and regular drug abuse care alone (AOR, 0.85; 95% CI, 0.76-0.96) vs those with neither. In HIV-negative drug users, the AOR of hospitalization was lower for those with regular medical and drug abuse care (AOR, 0.73; 95% CI, 0.68-0.79), regular drug abuse care alone (AOR, 0.71; 95% CI, 0.66-0.76), and regular medical care (AOR, 0.91; 95% CI, 0.86-0.95) vs those with neither. Both types of care showed favorable effects for all but drug abuse-related hospitalizations.

CONCLUSION

Our data indicate that regular drug abuse care with regular medical care for drug users is associated with less subsequent hospitalization.

Association of provider and patient characteristics with HIV-infected women's antiretroviral therapy regimen

OBJECTIVE

We explored the effect of patient and provider factors on the type of antiretroviral regimen among women receiving therapy.

PATIENTS

Five hundred ninety-five New York State nonpregnant HIV+ women with full Medicaid eligibility and at least 1 month of a prescribed antiretroviral regimen in federal fiscal years (FFY) 1997-1998 and intervals in FFY 1997-1998, who had delivered a liveborn baby within 5 years.

MEASUREMENTS

From pharmacy claims in 4 6-month intervals in FFY 1997-1998, data were extracted on (1) an acceptable > or = 2 antiretroviral combination regimen per expert guidelines; and (2) a highly active regimen, including a protease inhibitor or nonnucleoside analog (highly active antiretroviral therapy [HAART]).

RESULTS

Of 1514 woman-6-month intervals with filled antiretroviral prescriptions, 82% had an acceptable regimen, and of 1246 woman-6-month intervals on acceptable antiretroviral therapy, half demonstrated the use of HAART. Adjusted odds ratios (AORs) of acceptable antiretroviral therapy were higher (p < .05) for HIV specialty care (AOR = 1.71 for one or two visits; AOR = 2.10 for 3+ visits) or HIV clinical trials site care (AOR = 1.43; 95% confidence interval [CI]: 1.01, 2.04). Among women on acceptable antiretroviral regimens, those aged older than 25 years (AOR = 1.69; CI: 1.13, 2.53) or who were high school graduates (AOR = 1.50; CI: 1.09, 2.06) had higher odds of HAART. Methadone-treated women had twofold and nearly threefold higher AORs of acceptable antiretroviral regimens and HAART, respectively, than current drug users.

CONCLUSION

Provider HIV expertise is associated with receipt of an acceptable antiretroviral regimen in women, although receipt of HAART is affected more by age, education, and current drug abuse. Methadone treatment seems to improve access to acceptable antiretroviral regimens as well as to HAART.

Delayed medical care after diagnosis in a US national probability sample of persons infected with human immunodeficiency virus

OBJECTIVE

To identify health care and patient factors associated with delayed initial medical care for human immunodeficiency virus (HIV) infection.

DESIGN

Survey of a national probability sample of persons with HIV in care.

SETTING

Medical practices in the contiguous United States.

PATIENTS

Cohort A (N = 1540) was diagnosed by February 1993 and was in care within 3 years; cohort B (N = 1960) was diagnosed by February 1995 and was in care within 1 year of diagnosis.

MAIN OUTCOME MEASURE

More than 3- or 6-month delay.

RESULTS

Delay of more than 3 months occurred for 29% of cohort A (median, 1 year) and 17% of cohort B. Having a usual source of care at diagnosis reduced delay, with adjusted odds ratios (ORs) of 0.61 (95% confidence interval [CI], 0.48-0.77) in cohort A and 0. 70 (95% CI, 0.50-0.99) in cohort B. Medicaid coverage at diagnosis showed lower adjusted ORs of delay compared with private insurance (cohort A: adjusted OR, 0.52; 95% CI, 0.30-0.92; cohort B: adjusted OR, 0.48; 95% CI, 0.27-0.85). Compared with whites, Latinos had 53% and 95% higher adjusted ORs of delay (P<.05) in cohorts A and B, respectively, and African Americans had a higher adjusted OR in cohort A (1.56; 95% CI, 1.19-2.04). The health care factors showed similar effects on delay of greater than 6 months.

CONCLUSIONS

Medicaid insurance and a usual source of care were protective against delay after HIV diagnosis. After full adjustment, delay was still greater for Latinos and, to a lesser extent, African Americans compared with whites.

Antiretroviral use and pharmacy-based measurement of adherence in postpartum HIV-infected women

BACKGROUND

Antiretroviral treatment for HIV-infected women is standard during pregnancy to prevent vertical transmission, but data on postpartum therapy for the mother are lacking.

OBJECTIVE

The objective of this study was to examine the impact of provider and patient characteristics on receipt of antiretroviral therapy and pharmacy-based measurement of adherence by postpartum HIV-infected women.

RESEARCH DESIGN

This was a retrospective cohort study.

SUBJECTS

The study included 2,648 New York State Medicaid-enrolled HIV-infected women who delivered from January 1993 through October 1996 and were followed up through September 1997.

MEASURES

From Medicaid claims in the first postpartum year, the study examined any prescribed antiretroviral therapy and, among women treated >2 months, adherence, defined as > or =80% days covered by prescribed therapy from first to last antiretroviral prescription.

RESULTS

Antiretroviral therapy was prescribed for 681 (26%) study women. Of 292 women treated >2 months, 28% were adherent on the basis of the pharmacy-based measure. The proportion of treated women was highest in 1996 (40%), and adherence was best in 1995 (44%) when most women took monotherapy. The adjusted odds ratios (AORs) of treatment were 1.67 (95% CI, 1.24 to 2.25) for women receiving HIV-focused services and 2.71 (95% CI, 1.99 to 3.69) for women with a provider in an HIV-related specialty. The AORs of adherence were greater for women with HIV-focused services (2.13; 95% CI, 1.05 to 4.30) and for former illicit drug users versus nonusers (2.40; 95% CI, 1.05 to 5.50).

CONCLUSIONS

This population-based pharmacy analysis reveals improving antiretroviral use but continuing poor pharmacy-based adherence by postpartum HIV-infected women. Receipt of HIV-focused services appears to be particularly beneficial in increasing the likelihood of treatment and adherence.

Care of vaginal symptoms among HIV-infected women

OBJECTIVE

Gynecologic disease is common in HIV-infected women. We examine the sociodemographic, clinical, and provider factors associated with the care of women with vaginal symptoms.

METHODS

Women enrolled in the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults, were interviewed between January 1996 and April 1997. Women with vaginal symptoms who sought medical attention were asked, "Did your health care provider examine your vaginal area?" Women were also asked if they received medication for their symptoms.

RESULTS

Among 154 women with vaginal symptoms, 127 sought care for their symptoms. Of those who sought care, 48% saw a gynecologist and 52% sought care from nongynecologists, most often their usual HIV care provider. Women who saw a gynecologist for their symptoms were more likely to have received a pelvic examination (92% versus 76%; p =.06) and vaginal fluid collection (98% versus 88%; p =.06) than those who saw their regular HIV provider. Fifteen percent of women received medication for their symptoms without having a pelvic examination; gynecologists were less likely to prescribe without an examination (8% versus 21%; p =.12).

CONCLUSION

Gynecologists are more likely to provide adequate care of vaginal symptoms among HIV-infected women than nongynecologists who were HIV care providers. This specialty difference is consistent with quality of care studies for other medical conditions, but the potential gynecologic complications of inadequate evaluation and treatment warrants further investigation.

National estimates of HIV-related symptom prevalence from the HIV Cost and Services Utilization Study

OBJECTIVES

The objectives of this study were (1) to estimate the prevalence, bothersomeness, and variation of HIV-related symptoms in a nationally representative sample of HIV-infected adults receiving medical care and (2) to evaluate new aggregate measures of symptom frequency and bothersomeness.

METHODS

Beginning in January 1996, 76% of a multistage national probability sample of 4,042 HIV-infected adults receiving medical care were interviewed. Participants endorsed the presence and degree of bothersomeness of 14 HIV-related symptoms during the preceding 6 months. Sex-standardized symptom number and bothersomeness indices were constructed. After sampling weights were incorporated, symptom distributions were compared according to selected characteristics by analysis of variance and multiple linear regression modeling.

RESULTS

Prevalence of specific symptoms in the reference population was as follows: fever/night sweats, 51.1%; diarrhea, 51%; nausea/anorexia, 49.8%; dysesthesias, 48.9%; severe headache, 39.3%; weight loss, 37.1%; vaginal symptoms, 35.6% of women; sinus symptoms, 34.8%; eye trouble, 32.4%; cough/dyspnea, 30.4%; thrush, 27.3%; rash, 24.3%; oral pain, 24.1%; and Kaposi's sarcoma, 4%. Aggregate measures were reliable (Cronbach's alpha > or =0.75) and demonstrated construct validity when compared with other measures of disease severity. After adjustment for CD4 count, both symptom number and bothersomeness varied significantly (P <0.05) by teaching status of care setting, exposure/risk group, educational achievement, sex, annual income, employment, and insurance category. However, the magnitude of variation was small. Symptoms were greatest in women and injection drug users, as well as in persons with lower educational levels, lower income, and Medicare enrollment or those who were followed up at teaching hospitals.

CONCLUSIONS

The prevalence and bothersomeness of HIV-related symptoms are substantial and vary by setting of care and patient characteristics.

Delays in seeking HIV care due to competing caregiver responsibilities

OBJECTIVES

This study sought to describe the characteristics of HIV-infected persons who delay medical care for themselves because they are caring for others.

METHODS

HIV-infected adults (n = 2864) enrolled in the HIV Cost and Services Utilization Study (1996-1997) were interviewed.

RESULTS

The odds were 1.6 times greater for women than for men to put off care (95% confidence interval [CI] = 1.2, 2.2); persons without insurance and with CD4 cell counts above 500 were also significantly more likely to put off care. Having a child in the household was associated with putting off care (odds ratio [OR] = 1.8, 95% CI = 1.4, 2.3).

CONCLUSIONS

Women or individuals with a child in the household should be offered services that might allow them to avoid delays in seeking their own medical care.

Prenatal zidovudine use and congenital anomalies in a medicaid population

OBJECTIVES

To examine the association of prescribed zidovudine (ZDV) during pregnancy with congenital anomalies in a population-based cohort.

METHODS

Medicaid claims were used to assess prescribed ZDV and children's major congenital anomalies in 1932 liveborn deliveries from 1993 to 1996 to HIV-infected women in the state of New York (NYS), U.S.A. Prevalence of anomalies in the cohort was compared with that of a general NYS population. Within the cohort, adjusted odds of any anomaly were compared by receipt of ZDV and by trimester of first prescription.

RESULTS

The adjusted prevalence of any anomaly in the study cohort was 2.76 times greater than in the general population (95% confidence interval [CI], 2.36-3. 17). Children of study women who were prescribed ZDV had increased adjusted odds of any anomaly (adjusted odds ratio [OR], 1.55; 95% CI, 1.01-2.29). Adjusted ORs (with CIs) by trimester of first prescription were 1.20 (0.58-2.51), 1.47 (0.85-2.55), and 1.84 (1. 04-3.25) for the first, second, and third trimesters, respectively.

CONCLUSION

Children of HIV-infected women in this cohort had a greater prevalence of major anomalies than did the general NYS population. An increased risk of major anomalies was not evident for first trimester exposure when the association would have been most biologically plausible.

Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis

OBJECTIVE

To assess adherence to antiretroviral therapy with the use of Medicaid pharmacy claims data for human immunodeficiency virus (HIV)-infected pregnant women and to identify associated maternal and health care factors.

METHODS

We retrospectively studied a cohort of 2714 HIV-infected women in New York State who delivered live infants from 1993-96. Among 682 women prescribed antiretroviral therapy in the last two trimesters, we studied 549 who started therapy more than 2 months before delivery. Adherence was defined as adequate if the supplied drug covered at least 80% of the days from the first prescription in the last two trimesters until delivery. Multivariable analyses were used to examine associations between maternal and health care factors and adherence.

RESULTS

Only 34.2% of 549 subjects had at least 80% adherence based on pharmacy data, a rate that remained stable over time. The adjusted odds ratios (ORs) of adherence for black (OR 0.47, 95% confidence interval [CI] 0.30, 0.75) and Hispanic (OR 0.49, 95% CI 0.29, 0.82) women were nearly 50% lower than for white women. The OR of adherence was 0.32 (95% CI 0.12, 0.90) for teenagers compared with women aged 25-29 years and 0.56 (95% CI 0.34, 0.92) for women in New York City versus those residing elsewhere. Women on antiretroviral therapy before pregnancy were more likely to adhere (OR 1.55, 95% CI 1.02, 2.35).

CONCLUSION

Teenagers, women of minority groups, and women living in New York City had greater risks of poor antiretroviral adherence, whereas women already prescribed antiretrovirals before pregnancy had better adherence. Our conservative pharmacy data-based measure showed that most HIV-infected women adhered poorly and adherence did not improve over the 4-year study.

Improved birth outcomes among HIV-infected women with enhanced Medicaid prenatal care

OBJECTIVES

This study evaluated the impact of enhanced prenatal care on the birth outcomes of HIV-infected women.

METHODS

Medicaid claims files linked to vital statistics were analyzed for 1723 HIV-infected women delivering a live-born singleton from January 1993 to October 1995. Prenatal care program visits were indicated by rate codes. Logistic models controlling for demographic, substance use, and health care variables were used to assess the program's effect on preterm birth (less than 37 weeks) and low birthweight (less than 2500 g).

RESULTS

Of the women included in the study, 75.3% participated in the prenatal care program. Adjusted program care odds were 0.58 (95% confidence interval [CI] = 0.42, 0.81) for preterm birth and 0.37 (95% CI = 0.24, 0.58) for low-birthweight deliveries in women without a usual source of prenatal care. Women with a usual source had lower odds of low-birthweight deliveries if they had more than 9 program visits. The effect of program participation persisted in sensitivity analyses that adjusted for an unmeasured confounder.

CONCLUSIONS

A statewide prenatal care Medicaid program demonstrates significant reductions in the risk of adverse birth outcomes for HIV-infected women.

Sources of prenatal care data and their association with birth outcomes of HIV-infected women

OBJECTIVES

Different sources of prenatal care data were used to examine the association between birth outcomes of HIV-infected women and the Adequacy of Prenatal Care Utilization (APNCU) index.

METHODS

Adjusted odds ratios of birth outcomes for 1858 HIV-positive mothers were calculated for APNCU indexes on the basis of birth certificate data or 3 types of physician visits on Medicaid claims.

RESULTS

Claims- and birth certificate-based APNCU indexes agreed poorly (kappa < 0.3). Only the broadest claims-based APNCU index had lower adjusted odds ratios for low birthweight (0.64; 95% confidence interval [CI] = 0.49, 0.84) and preterm birth (0.70; 95% CI = 0.54, 0.91). The birth certificate-based index had a reduced adjusted odds ratio (0.73; 95% CI = 0.56, 0.95) only for preterm birth.

CONCLUSIONS

The association of birth outcomes and adequacy of prenatal care in this HIV-infected cohort differed significantly depending on the source of prenatal care data.

Effect of enhanced prenatal and HIV-focused services for pregnant women who are infected by human immunodeficiency virus on emergency department use

OBJECTIVES

This study examines whether the receipt of enhanced prenatal or human immunodeficiency virus (HIV) medical services is associated with in-pregnancy emergency department (ED) utilization by HIV-infected women.

METHODS

Medicaid and vital statistics records were linked for 1,826 women who are infected by HIV and who were delivered from 1993 to 1995 while receiving New York State Medicaid. The authors examined two types of ambulatory care--the Prenatal Care Assistance Program (PCAP) and enhanced care focused on HIV--that offer additional services in exchange for increased Medicaid reimbursement. From logistic regression models, the authors estimated adjusted associations of these types of care with ED use during pregnancy not leading directly to hospitalization.

RESULTS

Fifty-three percent of pregnant women visited the ED. Women with ED use averaged 2.0 visits (SD = 1.1). After adjustment for demographic and substance use factors, enhanced care focused on HIV was not associated with any ED use (OR = 1.11, 95% CI 0.94, 1.30) or, among those using the ED at least once, with number of visits (P = 0.84). Interactions of receipt of PCAP care with the Adequacy of Prenatal Care Utilization Index (APNCU) and having a usual source of care in pregnancy improved model fit (P < 0.001 and P = 0.06, respectively). PCAP was associated with increased ED use only among women with inadequate APNCU or no usual source of prenatal care.

CONCLUSION

Pregnant women infected with HIV receiving Medicaid relied heavily on ED care. Use of the ED was not associated with services focused on HIV but was positively associated with enhanced prenatal care. The association of enhanced prenatal care with greater ED use was curbed for women with more timely and adequate prenatal care visits or a usual source of prenatal care.

The impact of competing subsistence needs and barriers on access to medical care for persons with human immunodeficiency virus receiving care in the United States

OBJECTIVES

To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data.

DESIGN

Survey of a nationally representative sample of 2,864 adults receiving HIV care.

MAIN INDEPENDENT VARIABLES

Going without care because of needing the money for food, clothing, or housing; postponing care because of not having transportation; not being able to get out of work; and being too sick.

MAIN OUTCOME MEASURES

Having fewer than three physician visits in the previous 6 months, visiting an emergency room without being hospitalized; never receiving antiretroviral agents, no prophylaxis for Pneumocystis carinii pneumonia in the previous 6 months for persons at risk, and low overall reported access on a six-item scale.

RESULTS

More than one third of persons (representing >83,000 persons nationally) went without or postponed care for one of the four reasons we studied. In multiple logistic regression analysis, having any one or more of the four competing needs independent variables was associated with significantly greater odds of visiting an emergency room without hospitalization, never receiving antiretroviral agents, and having low overall reported access.

CONCLUSIONS

Competing subsistence needs and other barriers are prevalent among persons receiving care for HIV in the United States, and they act as potent constraints to the receipt of needed medical care. For persons infected with HIV to benefit more fully from recent advances in medical therapy, policy makers may need to address nonmedical needs such as food, clothing, and housing as well as transportation, home care, and employment support.

Primary care physicians' views on screening and management of alcohol abuse: inconsistencies with national guidelines

BACKGROUND

The effects of patients' abuse of and dependence on alcohol are well known, but screening for problem drinking by primary care physicians has been limited. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends that all patients be screened for alcohol use, all users be screened with the CAGE questionnaire, and all nondependent problem drinkers be counseled. We evaluated primary care physicians' screening methods for alcohol use and their management of problem drinkers to determine if they were following the NIAAA guidelines.

METHODS

We mailed a questionnaire to 210 internists and family physicians to assess their alcohol screening and management methods.

RESULTS

Only 64.9% of the respondents reported screening 80% to 100% of their patients for alcohol abuse or dependence during the initial visit; even less (34.4%) screened that many patients during an annual visit. Nearly all respondents (95%) reported "frequently" or "always" using quantity-frequency questions to screen for alcohol abuse, but only 35% "frequently" or "always" used the CAGE questionnaire. Only 20% of the respondents rated treatment resources as adequate for early problem drinkers, and 72% preferred not to counsel these patients themselves. A belief that a primary care physician could have a positive impact on an alcohol abuser was less likely to be held by respondents who were older, in a nonurban setting, or had more years in practice (P = .05).

CONCLUSIONS

A substantial proportion of the physicians in our survey sample were not following NIAAA recommendations. Most physicians preferred not to do the counseling of nondependent problem drinkers themselves, but to refer those patients to a nurse trained in behavioral interventions.

Frequency and predictors of medically attended injuries in HIV-infected children

The extent to which medically attended injuries complicate the clinical course of HIV-infected (HIV+) children is unknown. In a cohort of HIV+ children delivered from 1985 to 1990 and aged less than 60 months, we determined medically attended injuries per 100 child-years, Injury Severity Scores (ISS), and predictors of medically attended injuries by using New York State Medicaid claims from 1986 to 1992 linked to birth certificates. Injury rates and ISS were compared to those of a population of black, inner city children aged less than 60 months from emergency room records. HIV+ children had slightly more injuries (19.3 vs. 16.8/100 child-years) but similar ISS (2.4 vs. 2.3). Predictors of injuries in HIV+ children included younger maternal age (24/100 child-years, p = 0.008) and delivery outside of New York City (29/100 child-years, p = 0.02). Illicit drug use and alcohol use were associated with greater ISS while cocaine use was associated with a higher rate of possibly intentional injuries. Medically attended injuries affected one in five HIV+ children in our cohort annually, slightly more than the comparison population. Specific maternal and birth characteristics such as substance abuse and younger age at delivery may help target at-risk children.

Relationship between ambulatory care accessibility and hospitalization for persons with advanced HIV disease

Specific features of ambulatory care, such as accessibility, may influence hospital use for patients with HIV infection. To identify clinic features associated with a lower risk of hospitalization, 6,280 New York state Medicaid enrollees diagnosed with AIDS in 1987-1992 and managed by one of 157 surveyed clinics were studied. The odds of hospitalization in the year before AIDS diagnosis were associated with five clinic features that facilitate the accessibility of care: (1) evening/weekend hours, (2) case manager, (3) appointments within 48 hours, (4) telephone consultation, and (5) whether the clinic handled urgent care. Hospitalization in the year before AIDS diagnosis occurred for 49 percent of patients. Three of the five accessibility features had unadjusted associations with lower hospitalization rates. The adjusted odds of hospitalization were lower for patients in clinics with extended hours (OR = 0.77, 95% CI = 0.63, 0.93) and for patients in clinics with four or more accessibility features compared with those in clinics with less than two features (OR = 0.67; 95% CI = 0.50, 0.89).

Optimizing care for persons with HIV infection. Society of General Internal Medicine AIDS Task Force

Treatment advances and outcomes data have raised new concerns about how to optimize care for patients with HIV infection. This paper reviews evidence on 1) the relation between experience and type of training and patient outcomes, 2) the relation between the components of primary care and patient outcomes, and 3) primary care physicians' basic HIV knowledge and skills in screening and prevention. Several studies indicate that greater experience in HIV care leads to improved patient outcomes. The relation between outcomes and type of training (subspecialist or generalist) is less clear, and studies have not distinguished between type of training and experience. Less experienced physicians may be able to provide high-quality care if appropriate consultation from expert physicians is available. Components of primary care, including accessibility, continuity, coordination, and comprehensiveness, are associated with better patient outcomes. Optimal care of HIV infection requires a combination of disease-specific expertise and primary care skills and organization. Criteria for expertise in HIV management should focus on actual patient care experience and HIV expertise rather than on subspecialty training per se. The management of HIV has become sufficiently complex that primary care physicians cannot be routinely expected to have extensive specialized knowledge in this area. However, many primary care physicians have weaknesses in the basic HIV-related skills that are needed in most settings, such as HIV test counseling and recognition of important HIV-related symptom complexes. Primary care physicians need to strengthen these basic HIV-related medical skills.

Physician intention to recommend complete diagnostic evaluation in colorectal cancer screening

Primary care physicians (PCPs) often do not recommend complete diagnostic evaluation (CDE; i.e., diagnostic colonoscopy or the combination of flexible sigmoidoscopy and barium enema X-ray procedures) for patients with an abnormal screening fecal occult blood test (FOBT+) result. Information is needed to understand why PCPs do not recommend CDE. In the spring of 1994, a telephone survey was carried out using a random sample of 520 PCPs in Pennsylvania or New Jersey who had patients that were targeted for an FOBT screening program. Survey data were obtained from 363 (70%) PCPs on physician practice characteristics; personal background; perceptions concerning FOBT screening, CDE performance, and patient behavior; social influence related to CDE; and intention to recommend CDE for FOBT+ patients. Physician CDE intention scores were distributed as follows: low (22%), moderate (51%), and high (27%). Multivariate analyses demonstrate that physician board certification status, time in practice, belief in CDE efficacy, and belief that CDE is standard practice were positively associated with CDE intention, whereas concern about CDE-related costs was negatively associated with CDE intention. Among physicians in larger practices, perceived FOBT screening efficacy was negatively associated with CDE intention, and belief in the benefit of CDE was positively associated with outcome. There is substantial variability in CDE intention among PCPs. Physician perceptions about FOBT screening and follow-up are associated with CDE intention, are likely to influence CDE performance, and may be amenable to educational intervention. Additional research is needed to evaluate the impact of educational interventions on CDE intention and performance.

Translating clinical trial results into practice: the effect of an AIDS clinical trial on prescribed antiretroviral therapy for HIV-infected pregnant women

BACKGROUND

The success of Pediatric AIDS Clinical Trials Group (PACTG) Protocol 076 in preventing vertical HIV transmission prompted intensive efforts to inform lay-persons and professionals about the trial's results.

OBJECTIVE

To explore community responsiveness to these efforts by assessing temporal, maternal, and health care factors associated with prescribed antiretroviral therapy before and after PACTG Protocol 076.

DESIGN

Retrospective cohort study.

SETTING

New York State Medicaid program.

PATIENTS

2607 HIV-infected women who delivered a living child between January 1993 and September 1996.

MEASUREMENTS

Adjusted odds of being prescribed antiretroviral treatment in the second or third trimester for women who delivered in period 1 (during the trial [January 1993 to February 1994]), period 2 (after the trial's end and announcement of the results to publication of the results [March 1994 to November 1994]), and period 3 (after publication of the trial results [December 1994 to September 1996]).

RESULTS

The adjusted odds of being prescribed antiretroviral therapy increased 21% per month in period 2 and decreased to 3% per month in period 3. In all time periods, the adjusted odds of being prescribed antiretroviral therapy were at least 60% greater (P < 0.05) for women who were treated at an institution that performed HIV clinical trials, received HIV-focused ambulatory care, or had adequate prenatal care visits. After the trial, women receiving methadone treatment had at least twofold (95% CI, 1.5- to 4.3-fold) greater adjusted odds of being prescribed antiretroviral therapy than women who did not take any illicit drugs. Latin-American women, older women, and women born in the United States had greater adjusted odds (P < 0.05) of being prescribed treatment in period 3.

CONCLUSION

Community practice responded rapidly to efforts to disseminate the results of PACTG Protocol 076; however, the absolute increase in prescribed therapy was greatest for women who had adequate prenatal visits or were receiving HIV-focused care, care at a site that performed clinical trials, or methadone therapy.

Profile of Medicare beneficiaries with AIDS: application of an AIDS casefinding algorithm

This profile of Medicare beneficiaries with acquired immunodeficiency syndrome (AIDS) was developed by applying a casefinding algorithm to virtually all Medicare claims from 1991-93. The algorithm identified more than 37,000 beneficiaries with AIDS, approximately 21,000 of whom were living at the end of 1993. These estimates suggest that as many as 12 percent of people living with AIDS at the end of 1993 were covered by Medicare. Medicare expenditures for these beneficiaries averaged more than $2,400 per month and totaled more than $500 million in 1993. These expenditures are likely to rise as more people with AIDS live long enough to qualify for Medicare coverage.

A social marketing model for disseminating research-based treatments to addictions treatment providers

AIMS

Researchers must develop effective strategies for disseminating research-based treatments. This study evaluates the application of a dissemination model based on principles of social marketing and diffusion theory.

DESIGN

A case study describes how the model was implemented. A qualitative design was employed to examine rates of adoption and adaptation of an early intervention program by a targeted system of addictions agencies.

SETTING

The interventions were developed at the Addiction Research Foundation in Toronto and disseminated to Assessment and Referral (A/R) Centres in Ontario, Canada.

PARTICIPANTS

Study participants included the managers and a designated therapist for 33 participating A/R centres.

MEASUREMENTS

Managers were asked mainly open-ended questions concerning whether their agency had made a formal decision to adopt the intervention and whether therapists in their agency were using the early intervention program. "Adoption" was operationalized as offering the complete four-session intervention to at least one client.

FINDINGS

At 12 months after the completion of training workshops, 68% of 34 agencies in the target system had adopted the program while 85% of the agencies were using some components of the intervention with clients.

CONCLUSIONS

The dissemination model appeared to be effective although its application proved to be time-consuming and labour-intensive. The "market analysis", systems focus and field-test components of the model appeared to contribute to its success.

Improved birth outcomes associated with enhanced Medicaid prenatal care in drug-using women infected with the human immunodeficiency virus

OBJECTIVE

To evaluate the effectiveness of an intervention designed to enhance Medicaid prenatal care in improving birth outcomes of drug-using women infected with the human immunodeficiency virus (HIV).

METHODS

Medicaid and vital statistics records were linked for 353 HIV-infected drug-using women delivering in 1993 and 1994 while enrolled in New York State Medicaid. Of these, 68% were treated by providers participating in the Prenatal Care Assistance Program, designed to provide case management, improved continuity, referral services, and behavioral risk reduction counseling. In a series of logistic models, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of low birth weight (less than 2500 g) and preterm delivery (before 37 weeks), comparing women using and not using the program.

RESULTS

Women using the Prenatal Care Assistance Program were significantly less likely, after adjustments were made for maternal characteristics, to have low birth weight infants and preterm deliveries (OR 0.52, 95% CI 0.31, 0.89; and OR 0.57, 95% CI 0.34, 0.97, respectively). Adding measures of greater adequacy and continuity of prenatal care to the models explained just over 20% of the Prenatal Care Assistance Program's protective effect. The addition of maternal high-risk behavior, HIV-focused care, and drug use treatment variables altered program effect estimates less profoundly (together accounting for 4 and 9% of the program's protection against low birth weight and preterm delivery, respectively).

CONCLUSION

The Prenatal Care Assistance Program appeared to be successful in reducing the incidence of low birth weight and preterm delivery in this high-risk population. The program's success can be attributed, in part, to increased adequacy and continuity of prenatal care and, to a lesser extent, to more frequent receipt of special services and reduced maternal high-risk behaviors.

The relationship of clinic experience with advanced HIV and survival of women with AIDS

OBJECTIVE

Hospital and physician experience have been linked to improved outcomes for persons with HIV. Because many HIV-infected patients receive care in clinics, we studied clinic HIV experience and survival for women with AIDS.

DESIGN

Retrospective cohort study of women with AIDS whose dominant sources of care were clinics. Clinic HIV experience was estimated as the cumulative number of Medicaid enrollees with advanced HIV who used a particular clinic as their dominant provider up to the year of the patient's AIDS diagnosis: low experience (< 20 patients), medium (20-99 patients), high (> or = 100 patients). Proportional hazards models examined relationships between experience and survival.

SETTING

A total of 117 New York State clinics.

PATIENTS

A total of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989-1992.

MAIN OUTCOME MEASURE

Survival after AIDS diagnosis.

RESULTS

In later study years (1991-1992), patients in high experience clinics had an approximately 50% reduction in the relative hazard of death (0.53; 95% confidence interval, 0.35-0.82) compared with patients in low experience clinics. Adjusting for demographic and clinical variables, 71% of patients in high experience clinics were alive 21 months after diagnosis compared with 53% in low experience clinics. Experience and survival were not significantly associated in the early study years (1989-1990).

CONCLUSIONS

In more recent years, women with AIDS receiving care in high experience clinics survived longer after AIDS diagnosis than those in low experience clinics, providing further evidence of a relationship between provider HIV experience and outcomes.

Clinic characteristics associated with reduced hospitalization of drug users with AIDS

OBJECTIVE

To identify features of ambulatory care associated with reduced hospitalization among drug users with acquired immunodeficiency syndrome (AIDS).

METHODS

A nonconcurrent prospective study of hospital use by 1,369 drug users with AIDS was conducted using data from New York State Medicaid research data files linked to telephone interview data from directors of ambulatory care clinics serving this group.

RESULTS

Follow-up averaged 29 months, during which 88% of subjects were hospitalized at least once. On average, those hospitalized spent 14% of follow-up time as inpatients. Hospitalization was less likely for patients in clinics with case managers (adjusted odds ratio = 0.42, 95% confidence interval 0.25, 0.69) or high director's rating of coordination of care (adjusted odds ratio = 0.50, 95% confidence interval 0.29, 0.89). Multivariate analysis showed significantly less time in hospital for patients in clinics with methadone maintenance, case managers, high continuity ratings, and clinic physicians attending for hospitalized clinic patients.

CONCLUSIONS

Drug users with AIDS rely heavily on inpatient care, but those followed in clinics featuring greater coordination and offering special services, including methadone treatment and case management, appear to have significantly less hospital use.

Repeated emergency department use by HIV-infected persons: effect of clinic accessibility and expertise in HIV care

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patient's clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patient's clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for care.

Clinic HIV-focused features and prevention of Pneumocystis carinii pneumonia

OBJECTIVE

To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis.

DESIGN

Nonconcurrent prospective study.

SETTING

New York State Medicaid Program.

PARTICIPANTS

Medicaid enrollees diagnosed with AIDS in 1990-1992.

MEASUREMENTS AND MAIN RESULTS

We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP.

CONCLUSIONS

PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.

Prevention of vertical HIV transmission with zidovudine: projected impact of HIV testing and prenatal care

We sought to estimate the impact of maternal HIV testing and prenatal care on the potential to reduce vertical transmission through zidovudine (AZT) use by HIV-infected mothers. We evaluated the prepartum maternal HIV diagnosis rate, prenatal care, disease stage, and vertical transmission rate (from a two-part mixture model) using New York State Medicaid and vital statistics data for HIV-infected mothers and their singletons in 1985-90. We used published data to estimate the effect of AZT on vertical transmission and expert input to define other parameters for the model. Our HIV-infected (N = 1514) had a vertical transmission rate of 27.0%. HIV was diagnosed prepartum for 39.5% of women in 1990. Transmission would have been 22.2% if AZT had been taken only by the subset of women diagnosed prepartum with HIV and receiving prenatal care by 34 weeks gestation (86.7%). Transmission would have dropped to 11.2% if all women had been diagnosed prepartum with HIV and received adequate prenatal care. The observed deficiencies in prenatal care and maternal HIV diagnosis rates in this Medicaid population-based cohort must be addressed to realize the promise of AZT to reduce vertical transmission.