愛滋病毒感染者使用的療養院品質評量的級數較低

 

滋病毒感染者使用的療養院品質評量的級數較低

Roger Pebody / aidsmap news/2019101/財團法人台灣紅絲帶基金會編譯

 

布朗大學的研究人員在《美國老年病學雜誌》上的兩篇文章中報告說,近年來,美國感染愛滋病毒的療養院居民其比例顯著增加,但是他們入住的設施在質量上較差。有三分之一的居民患有某種形式的癡呆或認知障礙。

許多療養院幾乎沒有照顧愛滋病毒感染者的經驗。同性戀者和少數族裔在療養院照護品質方面的差距已經被記錄在案。此外,更多的愛滋病毒感染者居住在低收入社區,這些社區的療養院通常提供較差的照護品質。

但是,對於愛滋病毒感染者使用療養院及其所獲得的照護品質上所知甚少。因此,研究人員分析了來自MedicareMedicaid的數據,這是美國的公共計劃,旨在為老年人,殘障人士和低收入人群提供健康照顧。

對於第一個分析, Susan Miller教授及其同事著重於研究占了美國HIV盛行率75%的14個州:紐約州,加利福尼亞州,佛羅里達州,德克薩斯州,馬里蘭州,新澤西州,賓夕法尼亞州,伊利諾州,喬治亞州,北卡羅萊納州,維吉尼亞州,路易斯安那州,俄亥俄州和麻薩諸塞州。

2001年至2010年之間,有9,245,009人在養老院中待了至少90天。 2001年,愛滋病毒感染者佔0.7%,到2010年上升到1.2%。在五個盛行率最高的州,2010年這一數字為2.0%(紐約,新澤西,馬里蘭,路易斯安那和佛羅里達)。如果這些趨勢繼續下去,這五個州的當前數字可能約為4%。

65歲以下的居民中有6%感染了愛滋病毒,而超過該年齡層的比例相較之下則為0.5%。平均而言愛滋病毒呈陽性的居民比沒愛滋病毒的居民年輕(60歲比80歲)。這可能部分是由於較早出現的健康問題。但這也反映出這樣一個事實,即在更廣泛的社區中,七,八十年代愛滋病毒感染者相對較少。

感染愛滋病毒的居民也更有可能是黑人(51%比14%)和男性(68%比33%)。

HIV感染者的常見診斷包括抑鬱症(39%),認知障礙(33%),糖尿病(28%),腦血管意外(19%),慢性阻塞性肺疾病(COPD15%),充血性心臟衰竭(13 %),腎衰竭(12%),焦慮症(10%),精神分裂症(9%),動脈粥樣硬化(6%),癌症(6%)和躁鬱症(5%)。

特別是對於認知障礙,重要的是要考慮人們的年齡。在所有年齡層中,愛滋病毒感染者的阿茨海默氏症盛行率均低於未感染愛滋病毒的人。例如,在55歲至64歲的人群中愛滋病毒感染者的比例約為1%,而沒有愛滋病毒的人群約為4%。在75歲至84歲的人群中,這一數字分別為15%和19%。

對於其他形式的癡呆,包括血管性認知障礙和與HIV相關的認知障礙,這種模式可以逆轉--儘管差異並不大。在55歲至64歲之間的人群中,約有23%的感染愛滋病毒的療養院居民患有另一種癡呆症,而20%的沒有感染愛滋病毒的人患有癡呆症。在75歲至84歲的人群中,這一數字分別約為43%和38%。

照護的品質

David Meyers也是布朗大學的同事,他們研究了為愛滋病毒感染者服務的療養院的品質。對於此分析,可獲得前述九個州的數據。

2001年至2012年之間,總共包括4,178個療養院。他們共收容了6,631,275人,其中包括了67,301名愛滋病毒感染者。

超過一半的療養院根本沒有為任何愛滋病毒感染者提供服務,而且大多數感染愛滋病毒者都去了一家愛滋病毒感染者的居民相對較少的機構。但是,透過居住在同一地理區域(縣)住民的比較,愛滋病毒感染者相較於純粹是隨機的分配更有可能去愛滋病毒陽性居民較集中的機構。

此外,這些療養院的品質評級往往較差,包括較低的星級(在Medicare的療養院比較網站上),監管機構指出更多的缺陷以及從療養院出院後更高的住院率。

對於其中收容5%至50%愛滋病毒感染居民的療養院來說,更是如此。他們的評級比那些收容愛滋病毒感染者人數較少或根本沒有為愛滋病毒感染者服務的療養院評級更差。這些療養院佔了所調查設施不到5%的比率,但卻照顧了三分之一的HIV感染者。

相反地,對於13個專業機構(全部在紐約或佛羅里達州),其一半以上的居民感染了愛滋病毒(實際上,愛滋病毒感染者平均佔94%),其品質得分卻很高。這些設施的平均星級和設施缺乏計數上比其他的任何一組療養院都要好。

研究人員說,為大量愛滋病毒感染者提供服務的療養院品質得分較低的一種可能解釋是「鄰里效應」--愛滋病毒感染者往往生活在品質較差的療養院附近的低收入社區。他們說,另一種可能性是醫院出院規劃人員將愛滋病患者轉到其中愛滋病毒/愛滋病感染者數量較多的設施中,而這些療養院的品質較差。

研究人員總結說:「隨著療養院中HIV感染者比例的增加,療養院的品質似乎會降低,只除了一部分愛滋病毒感染者比例很高的療養院」。「鑑於愛滋病毒感染者的全國人口老齡化加劇,需要做出更多的努力以確保愛滋病毒感染者被送入更高品質的療養院中」。

 

Nursing homes used by people living with HIV have poorer quality ratings

Roger Pebody/ 1 October 2019

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The proportion of nursing home residents living with HIV in the United States has increased markedly in recent years, but the facilities they are admitted to tend to be of poorer quality, researchers from Brown University report in two articles in the Journal of the American Geriatrics Society. One third of residents have some form of dementia or cognitive impairment.

Many nursing homes have little experience of caring for people with HIV. Disparities in the quality of nursing home care have already been documented for gay people and ethnic minorities. In addition, more people living with HIV live in low-income neighbourhoods whose nursing homes are known to often provide a lower quality of care.

However, little is known about the use of nursing homes by people living with HIV and the quality of care they receive. The researchers therefore analysed data from Medicare and Medicaid, the US public programmes that provide health coverage to older people, those with a disability and people with low incomes.

For the first analysis, Professor Susan Miller and colleagues focused on the 14 states that account for 75% of the HIV prevalence in the United States: New York, California, Florida, Texas, Maryland, New Jersey, Pennsylvania, Illinois, Georgia, North Carolina, Virginia, Louisiana, Ohio, and Massachusetts.

Between 2001 and 2010, there were 9,245,009 people who stayed in nursing homes for at least 90 days. In 2001, 0.7% had HIV, rising to 1.2% by 2010. In the five highest-prevalence states, the figure was 2.0% in 2010 (New York, New Jersey, Maryland, Louisiana and Florida). If these trends have continued, the current figure in those five states is likely to be around 4%.

Six per cent of residents under the age of 65 were living with HIV, compared to 0.5% of those over that age. On average, HIV-positive residents were younger (60 years vs 80 years) than those without HIV. This could be partly due to health problems occurring at an earlier age. But it also reflects the fact that there are relatively few people living with HIV in their seventies or eighties in the wider community.

Residents living with HIV were also more likely to be black (51% vs 14%) and male (68% vs 33%).

Common diagnoses in those living with HIV included depression (39%), cognitive impairment (33%), diabetes (28%), cerebrovascular accidents (19%), chronic obstructive pulmonary disease (COPD, 15%), congestive heart failure (13%), renal failure (12%), anxiety (10%), schizophrenia (9%), atherosclerosis (6%), cancer (6%) and bipolar disorder (5%).

Particularly for cognitive impairment, it is important to consider people’s ages. In all age groups, the prevalence of Alzheimer’s disease was lower in people with HIV than those without. For example, in those aged 55 to 64 years, it was around 1% in those with HIV and 4% in those without. In those aged 75 to 84, the figures were 15% and 19% respectively.

For other forms of dementia, including vascular cognitive impairment and HIV-associated cognitive disorder, this pattern was reversed – although the differences were not large. In those aged 55 to 64 years, around 23% of nursing home residents with HIV had another form of dementia and 20% of those without HIV had it. In those aged 75 to 84, the figures were around 43% and 38% respectively.

Quality of care

David Meyers are colleagues, also from Brown University, have looked at the quality of nursing homes that serve people with HIV. For this analysis, data were available for nine of the previously mentioned states.

A total of 4178 nursing homes were included. Between 2001 and 2012, they admitted 6,631,275 people, including 67,301 people living with HIV.

Over half of nursing homes did not serve any people living with HIV at all, and the majority of people with HIV went to a facility with relatively few residents living with HIV. However, comparing residents who live in the same geographic area (county) as each other, people with HIV were more likely to go to a home with a greater concentration of HIV-positive residents than would be expected by chance alone.

Moreover, these nursing homes tended to have poorer quality ratings, including a lower star rating (on Medicare’s Nursing Home Compare website), more deficiencies noted by regulators, and a higher rate of hospital re-admission after discharge from the nursing home.

This was particularly true of the group of those nursing homes in which between 5 and 50% of their residents were living with HIV. Their ratings were poorer than those of homes serving fewer people with HIV or none at all. These homes represent less than 5% of the facilities surveyed but look after a third of the residents living with HIV.

In contrast, quality scores were good for 13 specialist facilities (all in New York or Florida) in which over half of residents were living with HIV (in fact, an average of 94% were living with HIV). The average star rating and deficiency count for these facilities were better than for any other group of nursing homes.

The researchers say that one possible explanation for the lower quality scores of homes serving large numbers of people with HIV is a ‘neighbourhood effect’ – people living with HIV tend to live in low-income neighbourhoods near poorer-quality nursing homes. Another possibility, they say, is that hospital discharge planners steer patients with HIV towards facilities with a larger number of other residents living with HIV and these are of poorer quality.

“As the concentration of HIV in a nursing home increases, nursing home quality appears to be lower, with the exception of a subset of nursing homes with high HIV concentrations,” the researchers conclude. “Given increasing aging among the national population of patients with HIV, more efforts are needed to ensure people living with HIV are admitted to higher-quality nursing homes.”

References

Miller SC et al. Nursing Home Residents by Human Immunodeficiency Virus Status: Characteristics, Dementia Diagnoses, and Antipsychotic Use. Journal of the American Geriatrics Society 67: 1353-1360, 2019. https://doi.org/10.1111/jgs.15949

Meyers DJ et al. The Quality of Nursing Homes That Serve Patients With Human Immunodeficiency Virus. Journal of the American Geriatrics Society, online ahead of print, 2019. https://doi.org/10.1111/jgs.16155