title: Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study.
abstract: OBJECTIVE
  To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics.
  
  
  METHODS
  Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS.
  
  
  RESULTS
  Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior.
  
  
  CONCLUSIONS
  Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France. Electronic address: luis.sagaon-teyssier@inserm.fr.
authors.forename: Luis
authors.initials: L
authors.lastname: Sagaon-Teyssier
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France. Electronic address: lisa.fressard@inserm.fr.
authors.forename: Lisa
authors.initials: L
authors.lastname: Fressard
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France. Electronic address: marion.mora@inserm.fr.
authors.forename: Marion
authors.initials: M
authors.lastname: Mora
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France.
authors.forename: Gwenaëlle
authors.initials: G
authors.lastname: Maradan
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France. Electronic address: valerie.guagliardo@inserm.fr.
authors.forename: Valérie
authors.initials: V
authors.lastname: Guagliardo
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France. Electronic address: marie.suzan@inserm.fr.
authors.forename: Marie
authors.initials: M
authors.lastname: Suzan-Monti
authors.affiliation: INSERM, UMR_S1136, Pierre Louis Institute of Epidemiology and Public Health, Team Research in social epidemiology, F-75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S1136, Pierre Louis Institute of Epidemiology and Public Health, Team Research in Social Epidemiology, F-75013, Paris, France. Electronic address: rosemary.dray-spira@inserm.fr.
authors.forename: Rosemary
authors.initials: R
authors.lastname: Dray-Spira
authors.affiliation: INSERM, UMR912 "Economics and Social Sciences Applied to Health & Analysis of Medical Information" (SESSTIM), Marseille, France; Aix Marseille University, UMR_S912, IRD, Marseille, France; ORS PACA, Southeastern Health Regional Observatory, Marseille, France. Electronic address: bruno.spire@inserm.fr.
authors.forename: Bruno
authors.initials: B
authors.lastname: Spire
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D019090:Case Management / Q000458:organization & administration*; D005260:Female; D005602:France; D015658:HIV Infections / Q000188:drug therapy / Q000523:psychology* / Q000821:virology; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance; D011795:Surveys and Questionnaires; D016896:Treatment Outcome
chemical_list: D019380:Anti-HIV Agents
keywords: HIV clinical outcomes; Hospital merger; caseload size; multi-level modeling