Retention in Medical Care Among Insured Children with Diagnosed HIV Infection — United States, 2010–2014

Mary R. Tanner, MD^1,2; Tim Bush, MS¹; Steven R Nesheim, MD¹; Paul J. Weidle, PharmD¹; Kathy K. Byrd, MD¹ (View author affiliations)

In 2014, an estimated 2,477 children aged <13 years were living with diagnosed human immunodeficiency virus (HIV) infection in the United States (1). Nationally, little is known about how well children with a diagnosis of HIV infection are retained in medical care. CDC analyzed insurance claims data to evaluate retention in medical care for children in the United States with a diagnosis of HIV infection. Data sources were the 2010–2014 MarketScan Multi-State Medicaid and MarketScan Commercial Claims and Encounters databases. Children aged <13 years with a diagnosis of HIV infection in 2010 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic billing codes for HIV or acquired immunodeficiency syndrome (AIDS), resulting in Medicaid and commercial claims cohorts of 163 and 129 children, respectively. Data for each child were evaluated during a 36-month study period, counted from the date of the first claim containing an ICD-9-CM code for HIV or AIDS. Each child’s consistency of medical care was assessed by evaluating the frequency of medical visits during the first 24 months of the study period to see if the frequency of visits met the definition of retention in care. Frequency of medical visits was then assessed during an additional 12-month follow-up period to evaluate differences in medical care consistency between children who were retained or not retained in care during the initial 24-month period. During months 0–24, 60% of the Medicaid cohort and 69% of the commercial claims cohort were retained in care, among whom 93% (Medicaid) and 85% (commercial claims) were in care during months 25–36. To identify areas for additional public health action, further evaluation of the objectives for national medical care for children with diagnosed HIV infection is indicated.

National goals for HIV prevention and care include increasing retention in HIV care (3). One indicator for assessing progress toward this goal uses laboratory data reported to the National HIV Surveillance System to track retention in care for adults with diagnosed HIV infection; however, children with diagnosed HIV infection are not included in this assessment (3,4). The Health Resources and Services Administration evaluates retention in care by assessing the frequency of HIV-related medical visits (2). Health insurance claims databases contain information about medical encounters and have been used to assess retention in care for adults with diagnosed HIV infection (5,6). However, little information is available about retention in care metrics for children with diagnosed HIV infection in the United States.

Data from the 2010–2014 MarketScan Multi-State Medicaid and MarketScan Commercial Claims and Encounters databases were analyzed. MarketScan databases contain de-identified, patient-level health data, including inpatient, outpatient, and pharmaceutical services claims. A unique enrollee identifier is assigned to each client, allowing persons to be tracked across different types of data over multiple years (5). The MarketScan Medicaid databases include pooled Medicaid data from 6–12 unidentified geographically dispersed states (5). MarketScan Commercial claims databases contain medical data from employees and their spouses and dependents who are covered by employer sponsored private health insurance in the United States (6).

Two cohorts were defined from the Medicaid and commercial claims MarketScan databases, using the following eligibility criteria: 1) an ICD-9-CM diagnostic billing code for HIV or AIDS in 2010; 2) aged <13 years in 2010; 3) enrollment in the relevant insurance program for ≥10 months out of each 12-month period during months 0–24; and 4) one or more outpatient visits with a physician, nurse practitioner, or physician’s assistant during the first 6 months of the study period. Children with an ICD-9-CM code for HIV infection or AIDS on only one date were excluded. The study period for each subject extended 36 months from the date of the first claim containing an ICD-9-CM code for HIV infection or AIDS. Using a standard metric, retention in care was defined as at least one medical visit in each 6‐month period during months 0–24, with a minimum of 60 days from the first medical visit in the prior 6‐month period to the last medical visit in the subsequent 6‐month period (2). During months 25–36, being in care was defined as having at least one medical visit in each 6‐month period with a minimum of 60 days from the first medical visit in the prior 6‐month period to the last medical visit in the subsequent 6‐month period. This clinic-based definition was used to assess medical visits with clinical providers. Medical visits were counted in the analysis if they were associated with a qualifying outpatient visit Current Procedural Terminology (CPT) code and a provider type code indicating a visit with a physician, nurse practitioner, or physician’s assistant or were associated with a consultation CPT code and a provider type code indicating a visit with an infectious diseases specialist. Visits associated with only a facility type code (e.g., acute care hospital) were not counted.

Demographic characteristics were described, and the unweighted proportion of children in each cohort who were retained in care during months 0–24 was determined. Each cohort was further categorized into retained and not retained subgroups, and within each subgroup, the unweighted proportions of children who met the definition for being in care during months 25–36 were determined. Records for persons not enrolled in the relevant insurance program for ≥10 months during months 25–36 were excluded.

Univariate logistic regression analyses were used to determine odds ratios (ORs) and 95% confidence intervals (CIs) to assess associations between available demographic factors and retention in care during months 0–24. Reference groups for regression were the following: male sex; age ≤1 year (compared with all other ages); basis of Medicaid eligibility was child (compared with blind/disabled individual, foster care child, and eligibility status unknown); and, for the Medicaid database, white race (compared with black, Hispanic, and other). Information on race/ethnicity was not available in the commercial claims database.

Cohorts consisted of 163 children from 4,713,171 unique persons in the Medicaid database, and 129 children from 45,239,752 unique persons in the commercial claims database (Table 1). The Medicaid cohort was predominately black (65%) and included equal proportions of males and females and a higher proportion of children aged 6–10 years (37%) (Table 2). The commercial claims cohort also had nearly equal proportions of males and females but similar proportions of children in all age groups. The most common basis of Medicaid eligibility category was child (not a child of unemployed adult or a foster care child). All children in the commercial claims cohort had a relationship to primary beneficiary category of child/other.

During months 0–24, 60% of the Medicaid cohort and 69% of the commercial claims cohort were retained in care (Figure). In the Medicaid cohort, 148 children remained in the study after month 24, and 117 (79%) were in care during months 25–36. Ninety-three percent of children in the retained in care subgroup and 59% of children in the not-retained subgroup were in care during months 25–36. In the commercial claims cohort, 91 children remained in the study after month 24, and 64 (70%) were in care during months 25–36. Eighty-five percent of children in the retained in care subgroup and 32% of children in the not-retained subgroup were in care during months 25–36, although a high rate of loss from the commercial claims cohort occurred after month 24 (Figure).

Compared with the reference groups, the basis of Medicaid eligibility categories of blind/disabled and foster child were associated with increased odds of retention in care (OR = 2.45, 95% CI = 1.09–5.53 and OR = 3.40, 95% CI = 1.16–9.99, respectively). In the commercial claims cohort, age ≤1 year was associated with decreased odds of retention in care (OR = 0.38, 95% CI = 0.16–0.88). No other covariates were significantly associated with retention in care in either cohort.

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Corresponding author: Mary R. Tanner, mtanner@cdc.gov, 404-639-6376.

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¹Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC; ²Epidemic Intelligence Service, CDC.

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References

1. CDC. Diagnoses of HIV infection in the United States and dependent areas, 2015. HIV surveillance report, vol. 27. Atlanta, GA: CDC; 2016. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2015-vol-27.pdf
2. Health Resources Services Administration. HIV/AIDS Bureau performance measures. Washington, DC: US Department of Health and Human Services, Health Resources Services Administration; 2017. https://hab.hrsa.gov/deliverhivaidscare/coremeasures.pdf
3. Secretary’s Minority AIDS Initiative Fund. National HIV/AIDS strategy for the United States: updated to 2020. Indicator supplement. Washington, DC: US Department of Health and Human Services, Secretary’s Minority AIDS Initiative Fund; 2016. https://files.hiv.gov/s3fs-public/nhas-indicators-supplement-dec-2016.pdf
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TABLE 1. Selection criteria for study cohorts of Medicaid and commercially insured children aged <13 years with diagnosed human immunodeficiency virus infection — MarketScan Multi-State Medicaid and Commercial Claims and Encounters databases, United States, 2010

Abbreviations: AIDS = acquired immunodeficiency syndrome; CPT = current procedural terminology; HIV = human immunodeficiency virus; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification.
* ICD-9-CM code for HIV or AIDS: inpatient or outpatient service claims that listed one or more ICD-9-CM diagnostic codes indicating HIV infection (042, V08, or 079.53). For ICD-9-CM code 795.71 (nonspecific serologic evidence of HIV), children were included only if another qualifying ICD-9-CM code was assigned to them over the course of the study period because code 795.71 is sometimes used to designate HIV-exposed infants before loss of maternal antibodies.
^† Continuously enrolled was defined as enrolled in the relevant insurance program for ≥10 months out of each 12-month measurement period.
^§ Qualifying outpatient visit criteria: an outpatient claim with a physician, nurse practitioner, or physician’s assistant in the first 6 months of the study period. A qualifying visit had to meet one of the following criteria: 1) Outpatient Office Visit CPT code 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0463, or T1015, and Physician, Nurse practitioner or Physician’s Assistant Provider Type code 200–460, 825, or 845, or 2) Consultation CPT code 99241, 99242, 99243, 99244, or 99275 and Infectious Diseases Specialist Provider Type code 285 or 448.
^¶ Medicaid: excluded because 1) ICD-9-CM code for HIV/AIDS on only one date (n = 31) and 2) Implausible Basis of Eligibility code was “adult, not based on employment,” “aged individual,” or “adult unemployed” (n = 4).
** Commercial Claims: excluded because 1) ICD-9-CM code for HIV/AIDS on only one date (n = 27) and 2) Implausible Relationship to Employee code was “employee” or “spouse” (n = 2).

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TABLE 2. Characteristics of Medicaid and commercially insured children aged <13 years with diagnosed human immunodeficiency virus infection — MarketScan Multi-State Medicaid and Commercial Claims and Encounters databases, United States, 2010

Abbreviation: NA = not available.
* No race/ethnicity information is collected within the MarketScan Commercial Claims and Encounter database.

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FIGURE. Retention in care* and in-care^† status among Medicaid^§ and commercially^¶ insured children aged <13 years with diagnosed human immunodeficiency virus infection** — United States, 2010–2014

* Retention in care defined as one or more qualifying outpatient visit in successive 6-month periods over 24 months (months 0–24), with ≥60 days between visits.

^† In care is defined as having one or more qualifying outpatient visit during each 6-month period (months 25–36), with ≥60 days between visits.

^§ MarketScan Medicaid Multi-State databases.

^¶ MarketScan Commercial Claims and Encounters databases.

** Records of children who were not enrolled in insurance for ≥10 months out of each 12-month period were excluded.

The figure above is a diagram showing the retention in care and in-care status among Medicaid and commercially insured children aged <13 years with diagnosed HIV infection in the United States during 2010–2014.

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