Introduction
With the advent of potent HIV medications, many patients are staying healthier. We undertook this study to determine why HIV patients are admitted to the hospital in the Bronx, and to determine the status of their outpatient care.
Method
This study was done from 3-3-07 to 4-2-07. All admissions to the medical, surgical, and gynecologic services were reviewed. All HIV positive patients were identified then interviewed. This study was approved by the St. Barnabas Hospital IRB.
Results
There were 1551 admissions during this 31 day period. 119 HIV positive patients accounted for 127 (8%) admissions (8 patients were admitted more than once). The average age was 48 years, 58% are male. 49% of the patients acquired HIV through heterosexual contact, 23% through intravenous drug use, and in 18% acquisition was multifactorial. Figure 1 shows the underlying medical conditions in these patients. The high percentage of admitted patients with hepatitis C was higher than our HIV out-patient population (49.6% vs 26.2%).
The patients were divided into three groups based on the reason for their admission. Group I comprised patients who were admitted for HIV related problems, group II were patients who were admitted for non HIV related issues, and group III patients whose presentation was possibly but not necessarily related to their HIV. The details for these three groups are listed in table 1.
Length of Stay and Admissions
The average length of stay was 5.12 days. The length of stay was longer in the group of patients admitted for HIV related problems (6.94 days) compared to those admitted for non-HIV related admissions (4.74 days). 52 patients (44%) had more than one admission over a 3 month period. This was highest in the patients admitted for an HIV related problem (61%) compared to non-HIV related admissions (44%) or possible related HIV admission (30%).
Outpatient Care
18% of patients had no medical care. 36% had not seen a physician in the previous 12 weeks. 31% of patients for whom HIV medications were prescribed, admitted to not taking them.
Substance and Psychiatric History
The HIV patients admitted to the hospital had significant drug or alcohol use. 80% had a past history of drug use, 50% had a past history of alcohol use. 35% of these patients had been admitted to a drug or alcohol detoxification program (figure 2).
More importantly, 50 pts admitted to actively using drugs, and 33 pts admitted to actively using alcohol. Therefore, 65% of patients admitted to active drug or alcohol use. 22% were currently on methadone.
48 pts (40%) had psychiatric illness, 73% of whom were taking medications. The most common psychiatric illness was depression: 35 of 48 patients (73%). See figure 3. Overall, 70% of patients had either a psychiatric illness or substance use.
Housing History
59% of patients live alone. 20% had moved homes in the previous 6 months. In addition, 23% of patients were homeless or in a homeless shelter during the previous 6 months.
Immune Status and Compliance with Medications
The average CD4 was 235cells/mm3. 52% of the patients had CD4 below 200cells/mm3, only 10% had CD4 above 500cells/mm3. The average CD4 count in group I was 111cells/mm3, for group II 281cells/mm3 and for group III 229cells/mm3. Viral loads are not routinely obtained for in-patients. 45% of the patients had a viral load result within three months of admission. These patients were a subgroup of patients that were either followed in our HIV clinic or who had recently seen their physician. Of these patients 52% had viral loads below 500copies/ml. Not surprisingly, patients with the lowest CD4 and the highest viral load were the group of patients admitted for HIV related causes (group I).
Discussion
During the month of this study, HIV patients accounted for 8% of all hospital admissions. 50% of the admissions were definitely not related to their underlining HIV infection. 35% of the remaining patients fell into group III, patients admitted for possible but not definite HIV related causes. The majority of these patients were admitted for pneumonia. Group I, admissions definitely related to HIV infection, accounted for 14% of the HIV admissions. A third of group I admissions were due to complications from Candida. Not surprisingly, the average CD4 count was the lowest in this group (111cells/mm3).
HIV positive patients admitted to the hospital had multiple substance and psychiatric issues. 65% of admitted HIV patients actively use drugs or alcohol. This is a much higher than seen across the street at our HIV out-patient clinic. There 22% of patients admitted to actively using drugs. Furthermore, 40% of these patients had a psychiatric illness, most commonly depression. In addition, this group of patients had active housing problems as well as difficulties seeking medical care and adherence to antiretroviral therapy.
The multiple social issues facing these HIV patients may help explain the high rate of readmission. 43% of the patients were readmitted in a three month time span. Patients admitted with HIV related problems (group I) had the highest recurrent admissions (61%), averaging 2.39 admissions over three months. Additional reviews will need to be done to see if these patients represent a pool of patients that account for a stable amount of HIV re-admissions.
In view of the finding that many of the admitted HIV patients had significant substance use, housing difficulties, and have multiple recurrent admissions, an active referral and counseling program would greatly benefit these patients. Recruiting strategies are needed to ensure that these patients enter and are retained into primary HIV care in order to improve their health and prevent hospital admissions.
