New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV

BACKGROUND:
Routine evaluation of immune function with CD4 testing has long been regarded as an essential part of care for patients with HIV. However, recent studies suggest that patients who are not immuno-compromised and successfully use anti-retroviral therapy to suppress HIV do not benefit from periodic CD4 testing. In 2012, the Department of Health and Human Services recommended CD4 testing every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Using VA data, investigators analyzed CD4 and viral load tests for 28,530 Veterans who received VA care for HIV from FY2009 through FY2013, evaluating trends in CD4 testing frequency and the number, cost, and results of CD4 tests considered optional under the guidelines.

FINDINGS:

• VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year.
• Veterans participated in this study for a mean of 3.5 years, and had an average of 3.3 CD4 tests and 3.4 viral load tests per year. At the end of the study, 20% were eligible for optional monitoring, 16% were eligible for minimal monitoring, while 65% did not qualify for reduced monitoring.
• Most of the Veterans entered the study with viral control (65%) and good immune function (71%).

IMPLICATIONS:

• VA has made substantial progress in reducing the frequency of optional CD4 testing, but it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care.

LIMITATIONS:

• Investigators evaluated direct cost of testing only, and did not consider the cost of provider time spent discussing CD4 results with patients, any additional visits prompted by testing, travel or other patient-borne costs, or the cost of interventions prompted by clinically meaningless changes in CD4 counts.
• Investigators did not explore whether the small number of low CD4 results found in persons eligible for minimal or optional monitoring were persistent or clinically significant.

AUTHOR/FUNDING INFORMATION:
Drs. Barnett, Schmitt, and Yu are part of HSR&D's Health Economics Resource Center (HERC), Palo Alto, CA. This study was funded through VA HSR&D's Quality Enhancement Research Initiative (QUERI).




Barnett P, Schmitt S, Yu W, et al. How Will New Guidelines Affect CD4 Testing in Veterans with HIV?? Clinical Infectious Diseases. July 1, 2016;63(1):96-100.