The association of hospital, clinic and provider volume with HIV/AIDS care and mortality: systematic review and meta-analysis.
The objective of this systematic review and meta-analysis is to examine the association between hospital, clinic and provider patient volumes on HIV/AIDS patient outcomes including mortality, antiretroviral (ARV) use and proportion of patients on indicated opportunistic infection (OI) prophylaxis. We searched MEDLINE and nine other electronic databases from 1 January 1980 through 29 May 2009. Experimental and controlled observational studies of persons with HIV/AIDS were included. Studies examined the volume or concentration of patients with HIV/AIDS in hospitals, clinics or individual providers. Outcomes included mortality, ARV use and proportion of patients on indicated OI prophylaxis. We reviewed 22,692 titles and/or abstracts. Patient characteristics, study design, volume measures, medical outcomes and study confounders were abstracted. Data were extracted independently by two reviewers. Twenty-two studies were included in the final review. High volume hospital care was associated with lower in-hospital mortality (pooled odds ratio (OR) 0.71, 95% confidence interval [CI] 0.57-0.90 p = 0.004) and lower mortality 30 days from admission (pooled OR 0.62, 95% CI 0.47-0.81 p = 0.0004). Higher volume provider care was associated with significantly higher ARV use (pooled OR 4.41, 95% CI 2.70-7.18 p<0.00001). Differences in volume definitions and controlling for confounding variables did not appreciably alter the results. Higher volume hospitals, clinics and providers were associated with significantly decreased mortality for people living with HIV/AIDS and higher volume providers and clinics had higher ARV use. Heterogeneity of volume thresholds and absence of studies from resource-limited settings are major limitations.
Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada. handfordc@smh.ca
Curtis D
CD
Handford
Julia M
JM
Rackal
Anne-Marie
AM
Tynan
Damian
D
Rzeznikiewiz
Richard H
RH
Glazier
D017088:AIDS-Related Opportunistic Infections / Q000401:mortality / Q000628:therapy; D000163:Acquired Immunodeficiency Syndrome / Q000401:mortality / Q000628:therapy; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000401:mortality* / Q000628:therapy*; D006679:HIV Seropositivity / Q000401:mortality / Q000628:therapy; D006276:Health Facility Size / Q000706:statistics & numerical data*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D016896:Treatment Outcome
D019380:Anti-HIV Agents