Effect of Case Management on Unmet Needs and Utilization of Medical Care and Medications among HIV-Infected Persons

16 October 2001 | Volume 135 Issue 8 Part 1 | Pages 557-565

Background: Although case management has been advocated as a method for improving the care of chronically ill persons, its effectiveness is poorly understood.

Objective: To assess the effect of case managers on unmet need for supportive services and utilization of medical care and medications among HIV-infected persons.

Design: Baseline and follow-up interview of a national probability sample.

Setting: Inpatient and outpatient medical facilities in the United States.

Participants: 2437 HIV-infected adults representing 217 081 patients receiving medical care.

Measurements: Outcomes measured at follow-up were unmet need for supportive services, medical care utilization (ambulatory visits, emergency department visits, and hospitalizations), and use of HIV medication (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis).

Results: At baseline, 56.5% of the sample had contact with a case manager in the previous 6 months. In multiple logistic regression analyses that adjusted for potential confounders, contact with a case manager at baseline was associated with decreased unmet need for income assistance (odds ratio [OR], 0.57 [95% CI, 0.36 to 0.91]), health insurance (OR, 0.54 [CI, 0.33 to 0.89]), home health care (OR, 0.29 [CI, 0.15 to 0.56]), and emotional counseling (OR, 0.62 [CI, 0.41 to 0.94]) at follow-up. Contact with case managers was not significantly associated with utilization of ambulatory care (OR, 0.77 [CI, 0.57 to 1.04]), hospitalization (OR, 1.13 [CI, 0.84 to 1.54]), or emergency department visits (OR, 1.30 [CI, 0.97 to 1.73]) but was associated with higher utilization of two-drug (OR, 1.58 [CI, 1.23 to 2.03]) and three-drug (OR, 1.34 [CI, 1.00 to 1.80]) antiretroviral regimens and of treatment with protease inhibitors or non-nucleoside reverse transcriptase inhibitors (OR, 1.29 [CI, 1.02 to 1.64]) at follow-up.

Conclusions: Case management appears to be associated with fewer unmet needs and higher use of HIV medications in patients receiving HIV treatment.

Author and Article Information

From the Agency for Healthcare Research and Quality, Bethesda, Maryland; and Department of Public Health, San Francisco, Veterans Affairs San Diego Healthcare System, San Diego, University of California, Los Angeles, School of Public Health, and University of California, Los Angeles, Los Angeles, University of California, San Diego, and RAND, Santa Monica, California.

Grant Support: The HIV Cost and Services Utilization Study was conducted under cooperative agreement HS08578 (Martin F. Shapiro, Principal Investigator; Samuel A. Bozzette, Co-Principal Investigator) between RAND and the Agency for Healthcare Research and Quality. The Health Resources and Services Administration; the National Institute for Mental Health; the National Institute for Drug Abuse; and the National Institutes of Health, Office of Research on Minority Health through the National Institute for Dental Research provided additional support for this agreement. The Robert Wood Johnson Foundation, Merck and Co., Glaxo Wellcome, and the National Institute on Aging also provided support. Dr. Bozzette is a Health Services Research and Development Senior Research Associate of the Department of Veterans' Affairs.

Requests for Single Reprints: Mitchell H. Katz, MD, Department of Public Health, 101 Grove Street, Room 308, San Francisco, CA 94102; e-mail, mitch_katz{at}dph.sf.ca.us.

Current Author Addresses: Dr. Katz: Department of Public Health, 101 Grove Street, Room 308, San Francisco, CA 94102-4505.

Dr. Cunningham: UCLA Department of Health Services, Room 31-254A, Los Angeles, CA 90024-1736.

Dr. Fleishman: Agency for Healthcare Research and Quality, 1010 East Jefferson Street, Rockville, MD 209852-4908.

Dr. Anderson: UCLA School of Public Health, Los Angeles, CA 90095-1772.

Mr. Kellogg: Department of Public Health, 25 Van Ness Avenue, San Francisco, CA 94102-6056.

Dr. Bozzette: RAND, 1700 Main Street, Santa Monica, CA 90407-2138.

Dr. Shapiro: UCLA Department of Medicine, B552 Factor Building, Los Angeles, CA 90024-1361.

Author Contributions: Conception and design: M.H. Katz, W.E. Cunningham, R.M. Andersen, M.F. Shapiro.

Analysis and interpretation of the data: M.H. Katz, W.E. Cunningham, J.A. Fleishman, R.M. Andersen, T. Kellogg, M.F. Shapiro.

Drafting of the article: M.H. Katz, J.A. Fleishman.

Critical revision of the article for important intellectual content: M.H. Katz, W.E. Cunningham, J.A. Fleishman, R.M. Andersen, T. Kellogg, M.F. Shapiro.

Final approval of the article: M.H. Katz, W.E. Cunningham, J.A. Fleishman, R.M. Andersen, T. Kellogg, S.A. Bozzette, M.F. Shapiro.

Provision of study materials or patients: M.H. Katz, S.A. Bozzette, M.F. Shapiro.

Statistical expertise: M.H. Katz, R.M. Andersen, T. Kellogg.

Obtaining of funding: S.A. Bozzette, M.F. Shapiro.

Administrative, technical, or logistic support: T. Kellogg, M.F. Shapiro.

Collection and assembly of data: T. Kellogg, S.A. Bozzette.