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Abstract
The objective of this systematic review and meta-analysis is to examine the association between hospital, clinic and provider patient volumes on HIV/AIDS patient outcomes including mortality, antiretroviral (ARV) use and proportion of patients on indicated opportunistic infection (OI) prophylaxis. We searched MEDLINE and nine other electronic databases from 1 January 1980 through 29 May 2009. Experimental and controlled observational studies of persons with HIV/AIDS were included. Studies examined the volume or concentration of patients with HIV/AIDS in hospitals, clinics or individual providers. Outcomes included mortality, ARV use and proportion of patients on indicated OI prophylaxis. We reviewed 22,692 titles and/or abstracts. Patient characteristics, study design, volume measures, medical outcomes and study confounders were abstracted. Data were extracted independently by two reviewers.
Twenty-two studies were included in the final review. High volume hospital care was associated with lower in-hospital mortality (pooled odds ratio (OR) 0.71, 95% confidence interval [CI] 0.57–0.90 p = 0.004) and lower mortality 30 days from admission (pooled OR 0.62, 95% CI 0.47–0.81 p = 0.0004). Higher volume provider care was associated with significantly higher ARV use (pooled OR 4.41, 95% CI 2.70–7.18 p<0.00001). Differences in volume definitions and controlling for confounding variables did not appreciably alter the results. Higher volume hospitals, clinics and providers were associated with significantly decreased mortality for people living with HIV/AIDS and higher volume providers and clinics had higher ARV use. Heterogeneity of volume thresholds and absence of studies from resource-limited settings are major limitations.
Acknowledgements
The authors would like to thank the following individuals who helped with the preparation of this review: Kamyab Ghatan MD, for assistance with data analysis, manuscript and creation of tables; Alisha Olsthoorn, Megan Smith-Uffen and Ayda Agha for literature searches and identificaiton of studies. We also wish to thank Angela Eady, MLS for developing the search strategy.
Dr Handford had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The Centre for Research on Inner City Health is partially funded by the Ontario Ministry of Health and Long-Term care and the authors gratefully acknowledge this support. The views expressed in this report are the views of the authors and do not necessarily reflect the views of the Ontario Ministry of Health and Long-Term Care. The sponsor played no role in design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review, or approval of the manuscript.