title: Modelling clinical progression and health care utilization of HIV-positive patients in British Columbia prior to death.
abstract: OBJECTIVE
  The extent to which clinical progression of HIV-positive patients leads to an increase in health care utilization, especially prior to their death, is unknown. Thus, we modelled trends in CD4 cell count and emergency department utilization and the likelihood of an emergency department visit leading to a transfer to an acute care-level facility prior to a patient's death from nonaccidental causes.
  
  
  METHODS
  Eligible patients initiated highly active antiretroviral therapy (HAART) in British Columbia between August 1996 and June 2006 (n = 457). Patients were followed until their death, which occurred on or before 30 June 2007 (period in which the emergency department visit data were available). Trends were modelled using generalized mixed effects.
  
  
  RESULTS
  Patients experienced a significantly steep decline in CD4 cell count and a corresponding increase in the number of emergency department visits and transfers to acute-level facilities in the 5 years prior to death. For every 6-month interval prior to death, the CD4 cell count decreased by 13.22 cells/μL, the risk of experiencing an emergency department visit increased by 9%, and among those ever admitted, the odds ratio of being transferred to an acute care-level facility increased by 3%.
  
  
  CONCLUSIONS
  We showed that patients experienced a steep decline in CD4 cell count, which was associated with an increase in health care utilization prior to their death. These findings highlight the substantial residual avoidable burden that unsuccessfully managed HIV disease poses, even in the HAART era. Further strategies to enhance sustained and successful engagement in care are urgently needed to mitigate high health care utilization.
authors.affiliation: British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada; Statistical Department, University of British Columbia, Vancouver, BC, Canada.
authors.forename: Z
authors.initials: Z
authors.lastname: Cui
authors.forename: E
authors.initials: E
authors.lastname: Grafstein
authors.forename: B
authors.initials: B
authors.lastname: Yip
authors.forename: R
authors.initials: R
authors.lastname: Hogg
authors.forename: J S G
authors.initials: JS
authors.lastname: Montaner
authors.forename: V D
authors.initials: VD
authors.lastname: Lima
mesh_terms: D023241:Antiretroviral Therapy, Highly Active; D001955:British Columbia / Q000453:epidemiology; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D018450:Disease Progression; D004636:Emergency Service, Hospital; D015658:HIV Infections / Q000401:mortality* / Q000503:physiopathology; D017052:Hospital Mortality; D006760:Hospitalization; D006801:Humans; D010342:Patient Acceptance of Health Care; D016019:Survival Analysis; D019562:Viral Load
keywords: CD4 cell count; Canadian Triage and Acuity Scale (CTAS); emergency department visits; generalized mixed effect model; health care utilization; highly active antiretroviral therapy; mortality