Emergency Department Utilization among a Cohort of HIV-positive Injecting Drug Users in a Canadian Setting

Abstract

Background HIV-positive injection drug users (IDU) are known to be at risk for multiple medical problems that may necessitate emergency department (ED) use, however, the relative contribution of HIV disease versus injection-related complications have not been well described. Objectives We examined factors associated with ED use among a prospective cohort of HIV-positive IDU in a Canadian setting. Methods We enrolled HIV-positive IDU into a community-recruited prospective cohort study. We modeled factors associated with the time to first ED visit using Cox regression to determine factors independently associated with ED use. In sub-analyses, we examined ED diagnoses and subsequent hospital admission rates. Results Between December 5, 2005, and April 30, 2008, 428 HIV-positive IDU were enrolled, among whom the cumulative incidence of ED use was 63.7% (95% Confidence Interval [CI]: 59.1% – 68.3%) at 12 months after enrollment. Factors independently associated with time to first ED visit included: unstable housing (Hazard Ratio [HR] = 1.5, 95% CI: 1.1–2.0) and reporting being unable to obtain needed health care services (HR = 2.2, 95% CI: 1.2–4.1), whereas CD4 count and viral load were non-significant. Skin and soft tissue infections (SSTIs) accounted for the greatest proportion of ED visits (17%). Of the 2461 visits to the ED, 419 (17%) were admitted to hospital. Conclusions High rates of ED use were observed among HIV-positive IDU, a behavior that was predicted by unstable housing and limited access to primary care. Factors other than HIV infection appear to be driving ED use among this population in the post-HAART era.

Emergency department use by people with HIV in Ontario: a population-based cohort study

“…Our results are also similar to those of a Canadian study involving 438 HIVinfected injection drug users, in that the cumulative incidence of emergency depart ment use during the 1year study period was 63.7%, with skin and softtissue infections accounting for 17.6% of visits. 11 However, our study was populationbased in nature, and therefore included all individuals with HIV who entered care, including those who never injected drugs.…”

“…In contrast, skin and softtissue infections accounted for most of these episodes in people with HIV, pos sibly reflecting complications of injection drug use among sus ceptible individuals. 11 As of 2011, injection drug use was the mode of acquisition for about 10% of people living with HIV in Ontario. 41 Finally, people with HIV had a greater burden of comorbid illness relative to the control population.…”

“…However, as noted earlier, there were few visits attributable to underlying HIV infection, and an earlier study did not find an association between these indices and emergency department use in peo ple with HIV. 11 Although we adjusted for comorbidity burden and neighbourhood income quintile, residual confounding related to severity of underlying illness and socioeconomic sta tus is possible. Misclassification or ascertainment bias is possi ble if a tendency exists to overcall certain diagnoses (e.g., cellu litis, pneumonia) or upgrade the CTAS category in the context of HIV.…”

“…Yet, in contrast to studies examining inpatient and out patient health care use, [2][3][4][5][6] comparatively few contemporary studies exist examining emergency department use among people with HIV. [7][8][9][10][11] Studies conducted in the years pre ceding the introduction of combination antiretroviral ther apy demonstrated that people with HIV had rates of emer gency department visits that were three to fourfold higher than those of the general population. 12,13 Although subse quent studies found persistently heightened rates of emer gency department use following the introduction of com bination antiretroviral therapy, inferences were limited by samples that were small and not populationbased.…”

Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?

“…Keywords: marginalized populations, patient safety, procedural sedation and analgesia Injection drug users (IDUs) frequently seek assistance in emergency departments (EDs) [1][2][3][4][5][6] and occasionally require painful treatments such as incision and drainage or fracture reduction, which necessitate procedural sedation and analgesia (PSA). Although IDUs appear to have a rate of adverse events (AEs) similar to that of non-IDUs, they require slightly higher doses of sedatives and analgesics and have longer recovery times.…”