Faculty Bibliography

OBJECTIVES: Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data. METHODS: We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load. RESULTS: The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval. CONCLUSIONS: The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.

OBJECTIVES/OBJECTIVE:To improve individual health quality measures, which are associated with varying degrees of health benefit, and composite quality metrics, which weight individual measures identically. STUDY DESIGN/METHODS:We developed a health-weighted composite quality measure reflecting the total health benefit conferred by a health plan annually, using preventive care as a test case. METHODS:Using national disease prevalence, we simulated a hypothetical insurance panel of individuals aged 25 to 84 years. For each individual, we estimated the gain in life expectancy associated with 1 year of health system exposure to encourage adherence to major preventive care guidelines, controlling for patient characteristics (age, race, gender, comorbidity) and variation in individual adherence rates. This personalized gain in life expectancy was used to proxy for the amount of health benefit conferred by a health plan annually to its members, and formed weights in our health-weighted composite quality measure. We aggregated health benefits across the health insurance membership panel to analyze total health system performance. RESULTS:Our composite quality metric gave the highest weights to health plans that succeeded in implementing tobacco cessation and weight loss. One year of compliance with these goals was associated with 2 to 10 times as much health benefit as compliance with easier-to-follow preventive care services, such as mammography, aspirin, and antihypertensives. For example, for women aged 55 to 64 years, successful interventions to encourage weight loss were associated with 2.1 times the health benefit of blood pressure reduction and 3.9 times the health benefit of increasing adherence with screening mammography. CONCLUSIONS:A single health-weighted quality metric may inform measurement of total health system performance.

Aims: There has been a rise in hepatitis C virus (HCV) infection in HIV- positive (HIV+) men who have sex with men (MSM). HIV/HCV co-infection complicates management of HIV and HCV, and increases the risk of serious liver disease. The aim of this study was to carry out a systematic review and meta-analysis to characterize the epidemiology of sexually transmitted HCV infection in this population. Methods: The search encompassed EMBASE, PubMed and BIOSIS, plus proceedings of scientific conferences and footnote chasing. To be eligible, reports must be published or presented 1990-2013, and include data on HCV incidence or risk factors for infection in HIV +MSM who were not injecting drugs. Studies were assigned quality ratings based on the Newcastle-Ottawa Scale. Results: The search retrieved 687 abstracts after duplicates were removed. After screening, there were 12 eligible studies from Europe, Australia, North America and Asia including 10 cohort and 2 case-control studies. HCV seroconversion rates ranged between 0 and 1.18/100 person-years (PYs), median 0.39/100PYs (n = 67,426 PYs). Two studies reported that sex while high on methamphetamine (AOR 28.6) and rectal trauma or bleeding (AOR = 6.2) were significantly associated with HCV seroconversion. Few studies examined the role of non-injection drug use in HCV infection. Conclusions: Evidence points to blood as the medium of sexual HCV transmission in HIV +MSM, and the role of drug use appears to be via the facilitation of mucosally traumatic sexual practices. The shared use of implements to administer drugs intranasally has received little attention as a possible risk factor for HCV infection in this population

OBJECTIVE:: To compare the value and effectiveness of different prioritization strategies of pre-exposure prophylaxis (PrEP) in New York City (NYC). DESIGN:: Mathematical modelling utilized as clinical trial is not feasible. METHODS:: Using a model accounting for both sexual and parenteral transmission of HIV, we compare different PrEP prioritization strategies (PPS) with two scenarios - no PrEP and PrEP for all susceptible at-risk individuals. The PPS included PrEP for all MSM, only high-risk MSM, high-risk heterosexuals, and IDUs, and all combinations of these four strategies. Outcomes included HIV infections averted, and incremental cost-effectiveness (per-infection averted) ratios. Initial assumptions regarding PrEP included a 44% reduction in HIV transmission, 50% uptake in the prioritized population and an annual cost per person of $9762. Sensitivity analyses on key parameters were conducted. RESULTS:: Prioritization to all MSM results in a 19% reduction in new HIV infections. Compared with PrEP for all persons at-risk, this PPS retains 79% of the preventive effect at 15% of the total cost. PrEP prioritized to only high-risk MSM results in a reduction in new HIV infections of 15%. This PPS retains 60% of the preventive effect at 6% of the total cost. There are diminishing returns when PrEP utilization is expanded beyond this group. CONCLUSION:: PrEP implementation is relatively cost-inefficient under our initial assumptions. Our results suggest that PrEP should first be promoted among MSM who are at particularly high risk of HIV acquisition. Further expansion beyond this group may be cost-effective, but is unlikely to be cost-saving.

BACKGROUND: The surgical robot has been widely adopted in the United States in spite of its high cost and controversy surrounding its benefit. Some have suggested that a "medical arms race" influences technology adoption. We wanted to determine whether a hospital would acquire a surgical robot if its nearest neighboring hospital already owned one. METHODS: We identified 554 hospitals performing radical prostatectomy from the Healthcare Cost and Utilization Project Statewide Inpatient Databases for seven states. We used publicly available data from the website of the surgical robot's sole manufacturer (Intuitive Surgical, Sunnyvale, CA) combined with data collected from the hospitals to ascertain the timing of robot acquisition during year 2001 to 2008. One hundred thirty four hospitals (24%) had acquired a surgical robot by the end of 2008. We geocoded the address of each hospital and determined a hospital's likelihood to acquire a surgical robot based on whether its nearest neighbor owned a surgical robot. We developed a Markov chain method to model the acquisition process spatially and temporally and quantified the "neighborhood effect" on the acquisition of the surgical robot while adjusting simultaneously for known confounders. RESULTS: After adjusting for hospital teaching status, surgical volume, urban status and number of hospital beds, the Markov chain analysis demonstrated that a hospital whose nearest neighbor had acquired a surgical robot had a higher likelihood itself acquiring a surgical robot. (OR=1.71, 95% CI: 1.07-2.72, p=0.02). CONCLUSION: There is a significant spatial and temporal association for hospitals acquiring surgical robots during the study period. Hospitals were more likely to acquire a surgical robot during the robot's early adoption phase if their nearest neighbor had already done so.

INTRODUCTION: Rates of screening colonoscopies, an effective method of preventing colorectal cancer, have increased in New York City over the past decade, and racial disparities in screening have declined. However, vulnerable subsets of the population may not be reached by traditional surveillance and intervention efforts to improve colorectal cancer screening rates. METHODS: We compared rates of screening colonoscopies among black men aged 50 or older from a citywide random-digit-dial sample and a location-based sample focused on hard-to-reach populations to evaluate the representativeness of the random-digit-dial sample. The location-based sample (N = 5,568) was recruited from 2010 through 2013 from community-based organizations in New York City. Descriptive statistics were used to compare these data with data for all black men aged 50 or older from the 2011 cohort of the Community Health Survey (weighted, N = 334) and to compare rates by community-based setting. RESULTS: Significant differences in screening colonoscopy history were observed between the location-based and random-digit-dial samples (49.1% vs 62.8%, P < .001). We observed significant differences between participants with and without a working telephone among the location-based sample and between community-based settings. CONCLUSIONS: Vulnerable subsets of the population such as those with inconsistent telephone access are excluded from random-digit-dial samples. Practitioners and researchers should consider the target population of proposed interventions to address disparities, and whether the type of setting reaches those most in need of services.