The Association of Adherence to Antiretroviral Therapy with Healthcare Utilization and Costs for Medical Care

Article excerpt

Abstract Background: The association between antiretroviral adherence, healthcare utilization and medical costs has not been well studied.

Objective: To examine the relationship of adherence to antiretroviral medications to healthcare utilization and healthcare costs.

Methods: A retrospective cohort study was conducted using data from 325 previously antiretroviral medication-naive HIV-infected individuals initiating first antiretroviral therapy from 1997 through 2003. The setting was an inner-city safety net hospital and HIV clinic in the US. Adherence was assessed using pharmacy refill data. The average wholesale price was used for prescription costs. Healthcare utilization data and medical costs were obtained from the hospital billing database, and differences according to quartile of adherence were compared using analysis of variance (ANOVA). Multivariate logistic regression was used to assess predictors of higher annual medical costs. Sensitivity analyses were used to examine alternative antiretroviral pricing schemes. The perspective was that of the healthcare provider, and costs were in year 2005 values.

Results: In 325 patients followed for a mean (± SD) 3.2 (1.9) years, better adherence was associated with lower healthcare utilization but higher total medical costs. Annual non-antiretroviral medical costs were SUS7612 in the highest adherence quartile versus $US10 190 in the lowest adherence quartile. However, antiretroviral costs were significantly higher in the highest adherence quartile ($USI 7 513 vs $US8690), and therefore the total annual medical costs were also significantly higher in the highest versus lowest adherence quartile ($US25 125 vs $US18 880). In multivariate analysis, for every 10% increase in adherence, the odds of having annual medical costs in the highest versus lowest quartile increased by 87% (odds ratio 1.87; 95% CI 1.45, 2.40). In sensitivity analyses, very low antiretroviral prices (as seen in resource-limited settings) inverted this relationship - excellent adherence was cost saving.

Conclusion: Better adherence to antiretroviral medication was associated with decreased healthcare utilization and associated costs; however, because of the high cost of antiretroviral therapy, total medical costs were increased. Combination antiretroviral therapy is known to be cost effective; lower antiretroviral costs may make it cost saving as well.

Background and Objective

The cost of healthcare for individuals with HIV infection has been estimated to be $US18300$US25600 annually (values given are in 1996 $US,[1] 1998 euro,[2] 2001 $US[3] and 2004 $US.[4]) Prior to the introduction of potent combination antiretroviral therapy, most of the expenditures for HIV care were spent on hospitalizations and the treatment of opportunistic illnesses.[5] After the introduction of potent combination antiretroviral therapy, the need for hospitalization and the incidence of opportunistic illness decreased considerably.[6-8] It is now estimated that 54-64% of healthcare expenditures in HIV-infected populations in resource-rich settings are attributed to the cost of combination antiretroviral therapy.[1,4,8] Despite the expense, antiretroviral therapy is cost effective for HIV-infected individuals in resourcerich (and resource-limited) settings.[9-13]

Excellent adherence to antiretroviral therapy increases the likelihood of successful clinical outcomes and would thus be expected to decrease non-antiretroviral healthcare costs.[14-16] The association of level of adherence to antiretroviral therapy with medical expenditures has not been thoroughly evaluated. We sought to describe the competing costs attributable to antiretroviral medications and non-antiretroviral healthcare. In addition, we wanted to explore the effect that varying costs for antiretroviral therapy might have on this relationship in resource-rich settings. In previously antiretroviral medication-naive HIV-infected individuals initiating antiretroviral therapy, we quantified healthcare utilization and medical costs and assessed the association between level of adherence to antiretroviral therapy and these parameters. …