Better Physician-Patient Relationship Reduces Hospital Readmissions for PLWHIV

Readmission within 30 days of discharge from the hospital is associated with adverse health outcomes, and the 30-day readmission rate serves as an important barometer of a hospital’s quality of care.¹ Hospital readmissions also represent a significant financial burden. The Agency for Healthcare Research and Quality estimated that in 2011, more than 3 million US adults were readmitted to a hospital within 30 days of discharge and accumulated $41 billion in hospital costs.² Several studies have determined that people living with HIV (PLWHIV) have a higher risk for 30-day readmission than the general population.^1,3 For example, a database study of American adults found that people with HIV were 1.5 times more likely than people without HIV to be readmitted to the hospital within 30 days of discharge.¹

Recently, the Seek and Treat for Optimal Prevention HIV/AIDS in British Columbia (STOP HIV/AIDS BC) study group in Vancouver, Canada, evaluated whether the relationship between PLWHIV and their providers affected a patient’s risk for readmission in the first 30 days after discharge from the hospital.³ The group noted that studies in the general population have shown continuity of care with a health provider reduces the risk for 30-day readmission.³ “Despite improvements in care changing HIV to a chronic condition, there has been a lack of studies exploring patient-provider attachment in detail. We wanted to better understand how family physicians might be able to improve the health outcomes of PLWHIV given this change,” explained study author Lianping Ti, PhD, in an interview. Dr Ti is a research scientist with the Epidemiology and Population Health program at the British Columbia Centre for Excellence in HIV/AIDS and an assistant professor in the department of medicine at the University of British Columbia in Vancouver, Canada. “We found that a higher percentage of patient-provider attachment was negatively associated with 30-day hospital readmission among PLWHIV,” she said.

Study Details and Findings

The STOP HIV/AIDS BC study group maintains a database of deidentified records for all individuals in British Columbia who were tested for HIV or received HIV-related care between January 1996 and March 2015.^3,4 The database tracks all physician and hospital visits, laboratory tests, medications dispensed, and other medical services.⁴ Dr Ti and colleagues searched this database for PLWHIV who were hospitalized at least once for ≥24 hours, had filled at least 1 prescription for antiretroviral therapy (ART) prior to being hospitalized, and had accessed >4 medical services per year (excluding laboratory and diagnostic procedures).³

The group identified 7013 eligible patients, 81% of whom were men. The median age of the cohort was 43 years, and roughly half the patients had a CD4+ cell count <350 cells/mm³. Because PLWHIV have multiple comorbidities, repeated hospitalizations are common. “Between 1996 and 2015, we found that 36% of PLWHIV were readmitted to a hospital at least once during the study period,” Dr Ti said. Only 13% (921/7013) of patients were readmitted to the hospital within 30 days of discharge.³ The study authors noted that the 13% rate was lower than 30-day readmission rates for PLWHIV in other North American studies and speculated that barriers to care in the United States increase the risk for readmission.³ In addition, 564 patients with HIV were readmitted with a diagnosis similar to the indexed admission; another study demonstrated this similarity in diagnoses in up to 43% of readmissions.¹

To measure patient-provider attachment, the researchers identified the physician who provided the most services to a specific patient in 1 year and calculated what percentage of all services the physician supplied to that patient.³ “For example, if a patient received 10 services in a year and 6 were from the same physician, the percent attachment would be 60%,” said Dr Ti. “Our study found that a large majority of PLWHIV were most attached to their family physician,” she said.

Family physicians provided the most services for 73% of patients in the cohort, internal medicine specialists for 10%, and psychiatrists for 5%.³ Overall, 38% of patients had a level of attachment between 30% and 50% and 35% had a level of attachment >50%.³ After adjusting for potential demographic and clinical confounders, analyses associated greater attachment to a primary physician with a lower risk for 30-day readmission (adjusted odds ratio, 0.85; 95% CI, 0.83-0.86).³ A higher proportion of patient-provider attachment was also associated with a reduced risk for 30-day readmission for a similar cause (adjusted odds ratio, 0.86; 95% CI, 0.84-0.88).

Conclusion

Dr Ti stated that the literature provides evidence “that strong communication and shared decision making between physicians and PLWHIV are particularly important for improving health outcomes.” She suggested that because ART has transformed HIV from an acute terminal illness to a chronic condition, the discovery that many PLWHIV turn to family physicians for most of their care is not surprising. The findings indicated that “an increasing need to expand capacity for treatment and care to trained family physicians in order to provide the spectrum of care that PWLHIV now need,” she said. To help accomplish this goal, Dr Ti recommended “integrating HIV care services within family practice.”

Stigma continues to discourage PLWHIV from seeking care, and Dr Ti said physicians need to be trained “to deliver trauma-informed and culturally appropriate care to remove the stigma associated with HIV and concurrent overlapping conditions, such as active drug use and psychiatric conditions.” Although her group’s study did not examine the relationship between patient-provider attachment and adherence with ART, she said “future research in this area should seek to explore this within the context of specific healthcare systems.”

References

1. Berry SA, Fleishman JA, Moore RD, Gebo KA. Thirty-day hospital readmissions for adults with and without HIV infection. HIV Med. 2016;17(3):167-177.
2. Hines AL, Barrett ML, Jiang H, Steiner CA. Conditions with the largest number of adult hospital readmissions by payer, 2011. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Healthcare Research and Quality (US); 2006-2014. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf. Published April 2014. Accessed February 13, 2019.
3. Parent S, Barrios R, Nosyk B, et al. Impact of patient-provider attachment on hospital readmissions among people living with HIV: a population-based study. J Acquir Immune Defic Syndr. 2018;79(5):551-558.
4. Heath K, Samji H, Nosyk B, et al; on behalf of the STOP HIV/AIDS Study Group. Cohort profile: seek and treat for the optimal prevention of HIV/AIDS in British Columbia (STOP HIV/AIDS BC). Int J Epidemiol. 2014;43(4):1073-1081.