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Emergency Department Utilization Among a Cohort of HIV-Positive Injecting Drug Users in a Canadian Setting Fairbairn, Nadia; Milloy, M-J; Zhang, Ruth; Lai, Calvin; Grafstein, Eric; Kerr, Thomas; Wood, Evan Jun 29, 2011

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EMERGENCY DEPARTMENT UTILIZATION AMONG A COHORTOF HIV-POSITIVE INJECTING DRUG USERS IN A CANADIANSETTINGNadia Fairbairn, BSc1, M-J Milloy, MSc1, Ruth Zhang, MSc1, Calvin Lai, MSc1, EricGrafstein, MD2, Thomas Kerr, PhD1,3, and Evan Wood, MD, PhD1,31 British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, Canada2 St. Paul's Hospital and Department of Emergency Medicine, University of British Columbia3 Department of Medicine, University of British ColumbiaAbstractBackground—HIV-positive injection drug users (IDU) are known to be at risk for multiplemedical problems that may necessitate emergency department (ED) use, however, the relativecontribution 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 determinefactors independently associated with ED use. In sub-analyses, we examined ED diagnoses andsubsequent 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 firstED visit included: unstable housing (Hazard Ratio [HR] = 1.5, 95% CI: 1.1–2.0) and reportingbeing unable to obtain needed health care services (HR = 2.2, 95% CI: 1.2–4.1), whereas CD4count and viral load were non-significant. Skin and soft tissue infections (SSTIs) accounted for thegreatest proportion of ED visits (17%). Of the 2461 visits to the ED, 419 (17%) were admitted tohospital.Conclusions—High rates of ED use were observed among HIV-positive IDU, a behavior thatwas predicted by unstable housing and limited access to primary care. Factors other than HIVinfection appear to be driving ED use among this population in the post-HAART era.KeywordsEmergency Service; Injection Drug Use; HIV; Canada© 2011 Elsevier Inc. All rights reserved.Send correspondence to: Evan Wood, MD, PhD BC Centre for Excellence in HIV/AIDS 608-1081 Burrard Street, Vancouver, B.C.V6Z 1Y6 CANADA Tel: (604) 806-9116 Fax: (604) 806-9044 uhri-ew@cfenet.ubc.ca.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptJ Emerg Med. Author manuscript; available in PMC 2013 August 01.Published in final edited form as:J Emerg Med. 2012 August ; 43(2): 236–243. doi:10.1016/j.jemermed.2011.05.020.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptINTRODUCTIONIllicit injection drug use is associated with an array of health-related harms and health careexpenditures, including emergency department (ED) use.1-2 Injection drug users (IDU) oftenhave poor health status attributable to drug abuse and infectious diseases such as HIV andhepatitis C (HCV).3-5 Skin and soft tissue infections (SSTIs) are also common injection-related complications that bring IDU to the ED.1-2, 6-7 Socio-demographic factors such ashomelessness have also been linked to elevated ED and hospital use among IDU andbarriers such as lack of access to primary care services have been described in severalsettings.2, 8-9Though remarkable advances to HIV/AIDS treatment and care have been made over the pasttwo decades since the advent of highly active antiretroviral therapy (HAART), there isevidence that HIV-positive IDU continue to have unmet health needs with respect to HIVand related care.10-11 IDU have been shown to be more likely to have poorly managed HIVinfection due to decreased uptake of HAART and there is some evidence to suggest thatHIV-positive IDU continue to have increased use of EDs and more frequent hospitalizationsin the post-HAART era compared with other IDU. 2, 12-15Given the dual susceptibilities of HIV-positive IDU to the complications of poorly managedHIV infection and injection drug use, and potential barriers to health care this populationmay experience, understanding factors associated with acute care service utilization isessential to better serve seropositive IDU in the ED. We therefore examined the prevalenceand correlates of ED use, as well as primary ED diagnoses and hospital admission rates,among a community-recruited cohort of HIV-positive IDU.METHODSData for these analyses were derived from a community-recruited open prospective cohortstudy of HIV-positive IDU, which has been described in detail previously.16-17 The studyinstrument was developed from validated United States (US) instruments.18-19 The studywas created to examine issues related to access to HIV/AIDS care among IDU.20 In brief,recruitment for the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS)occurred through extensive street-based outreach and word of mouth. Beginning in May1996, participants were recruited through self-referral and street outreach from Vancouver'sDowntown Eastside (DTES), a neighborhood that ranks below the city average in almost allsocial and economic indicators. There is a large open-drug scene with an estimated 4,700IDU residing in an area of approximately ten city blocks.21 The ACCESS office is situatedin the hub of the city's Downtown Eastside where the majority of injection drug use isconcentrated. Study participants are seen on a semi-annual basis at which time they answer astandardized interviewer administered questionnaire and provide a blood sample forresearch purposes. The study has five full-time staff conducting interviews, many of whomhave worked in the community for several years. All variables, with the exception of EDcontact and CD4 cell count and viral load determinations, were based on responses to thequestionnaire. The location and longevity of both the study site and interview staff aidsfollow-up and may improve reliability of self-reported stigmatizing behaviors.Participants were eligible for the study if they were 18 years of age or older, resided in thegreater Vancouver region, tested HIV-positive upon entry, had injected an illegal drugduring the previous month, and provided informed consent. HIV infection was detectedusing ELISA and positive test results were confirmed using western blot. At baseline andsemi-annual follow-up, participants completed a lengthy interviewer-administeredquestionnaire that elicits information regarding sociodemographic characteristics, drug useFairbairn et al. Page 2J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptpatterns, sexual behaviors, and other relevant exposures. At baseline and semi-annually, allHIV-positive participants provide blood samples to monitor disease progression andcomplete an interviewer-administered questionnaire. The questionnaire elicits demographicdata as well as information about participants’ drug use, including information about type ofdrug, frequency of drug use, involvement in drug treatment and periods of abstinence. Allparticipants provide informed consent and are remunerated $20 CDN for each study visit.The study is approved on an annual basis by the University of British Columbia/ProvidenceHealthcare Research Ethics Board at its St. Paul's Hospital site.The primary endpoint of interest in the present analysis was time to first ED visit amongcohort participants and we were particularly interested in the potential role of clinicalcharacteristics and unstable housing on ED use. Health record linkages were accessed viathe electronic health records department at St. Paul's hospital (SPH), the local tertiary carecentre that provides the majority of health care to local IDU, to determine the time to firstED use.1-2, 8 Since we were interested in the role of HIV/AIDS disease progression on EDuse, individuals were further eligible if baseline CD4 count and viral load measures wereavailable within one year of recruitment to allow ascertainment of progression of HIVdisease at baseline. We considered Aboriginal ethnicity due to the large representation ofAboriginal persons in the Downtown Eastside and the significantly elevated burden of HIVinfection in this population.22 Based on a sample size of 428 participants and a known eventrate of 73.6% from past research among local IDU, formal sample size calculations weredeemed unnecessary.23Kaplan-Meier methods and Cox regression was used to determine factors associated withtime to first ED visit during the study period. The primary explanatory variables were age;gender (male vs. female); Aboriginal ethnicity (yes vs. no); Downtown Eastsideneighbourhood residence (yes vs. no); unstable housing; daily crack cocaine smoking (≥daily vs. less); daily heroin injection (≥ daily vs. less); daily cocaine injection (≥ daily vs.less); sex trade involvement (yes vs. no); history of physical assault (yes vs. no); inability toaccess health services (yes vs. no); current participation in methadone maintenance therapy(MMT) (yes vs. no); baseline CD4 cell count (per 100 cells/mm3) and baseline plasmaHIV-1 RNA viral load (per log10). All variable definitions were identical to earlierreports.24-25 Aboriginal ethnicity was defined by self-report as First Nations, Inuit, Metis, orAboriginal. In Canada, First Nations is typically defined as indigenous peoples of NorthAmerica, Inuit refers to indigenous peoples inhabiting Arctic regions, Metis refers to peopleof mixed First Nations and European descent, and Aboriginal can refer to any of the above.Unstable housing was defined as previously as living in a single room occupancy hotel,shelter, recovery or transition house, jail, on the street, or having no fixed address.26-27 Thevariable for ability to access health services was based on responses to the question:“reporting inability to obtain needed health services (including hospital, nurse, doctor orclinic care [yes vs. no].” Unless otherwise noted, all variables refer to the six-month periodprior to the interview and the multivariate model treated all behavioural variables as time-updated based on each semi-annual follow-up visit. Specifically, if during follow-up aparticipant changed from stable to unstable housing, the statistical model considered thiswithin individual variation. The same was done for other behavioral variables.The final multivariate model included all variables that were statistically significant atp<=0.05 level in the univariate analysis, and baseline CD4 count and baseline viral load thatwere forced into the model. All continuous variables met the assumption of linearity.Examinations showed no sign of non-linearity in CD4 count and using dichotomized CD4count (≥200 vs. <200) gave similar results. The proportional hazards assumption for time-independent variables was assessed to be valid. When time-updated variables were used inFairbairn et al. Page 3J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptthe Cox regression model it was no longer a proportional hazards model. The VIF (varianceinflation factor) test showed no evidence of collinearity.In sub-analyses, we identified the primary ICD-9 diagnosis code for each hospitaladmission, and examined the number of hospital admissions. The ICD-9 Diseases/InjuriesTabular Index has been used in previous studies to analyze the characteristics of ED andhospital discharge diagnoses in HIV-positive patients.28-29 All statistical analyses wereperformed using SAS 9.1 (SAS, Cary, NC). All p-values are two-sided.RESULTSBetween 5 December 2005, and 30 April 2008, 437 HIV-positive IDU were recruited forthis study. Nine individuals were excluded for lack of baseline CD4 count or baseline viralload data. Among 428 eligible participants, the cumulative incidence of ED use was 63.7%(95% Confidence Interval [CI]: 59.1% – 68.3%) at 12 months after enrollment. The medianduration of follow-up was 6.5 months (IQ range: 1.8 – 18.3) and among the entire sample of428 individuals that were seen at the start of the study period, 152 (35%) had at least twostudy visits. Baseline characteristics are presented in Table 1.Unstable Housing (Kaplan-Meier Analyses)As shown in Figure 1, at 12 months after recruitment, the Kaplan-Meier cumulativeincidence rate of ED use was 69.2% (63.9%-74.4%) among those who had unstable housingat baseline and 50.5% (42.1%-59.5%) among those who did not have unstable housing atbaseline (log-rank p = 0.004).Predictors of Time to First ED visit (Cox Regression Analyses)Table 2 shows the unadjusted and adjusted relative hazards (RH) for factors associated withtime to first ED visit. In the univariate analysis, DTES residence (Hazard Ratio [RH] = 1.37;95% Confidence Interval [CI]: 1.08 – 1.73; p =0.009), unstable housing (RH = 1.54 [95%CI: 1.21–1.96]; p < 0.001), inability to access needed health services (RH = 2.14 [95% CI:1.17–3.91]; p < 0.014), and history of physical assault (RH = 1.30 [95% CI: 1.00–1.69]; p=0.05) were each significantly associated with less time to first ED visit. In the multivariateanalysis, participants in unstable housing (RH = 1.47 [95% CI: 1.11–1.96]; p = 0.007) andself-reported inability to access needed health services (RH= 2.24 [95% CI: 1.22–4.12]; p =0.01) were significantly associated with less time to first ED visit.ED Diagnoses & Hospital AdmissionsThe most common ED diagnoses are presented in Table 3. Of the 2461 visits to the ED,2242 (91.1%) had diagnosis code data. SSTI such as abscesses and cellulitis accounted forthe greatest number of ED visits (17.6%), followed by medical refills and aftercare (17.5%).Substance misuse and overdoses accounted for 6.0% per cent of ED visits.Discharge data were obtained for 2381 (96.7%) of the 2461 ED visits. The majority 1778(74.7%) were discharged from the ED with advice, 419 (17.6%) were admitted to hospital,93 (3.9%) left the ED without being seen, and 91 (3.8%) were discharged from the EDagainst medical advice.DISCUSSIONOur study demonstrates high rates of ED use among a cohort of HIV-positive IDU.Interestingly, living in unstable housing and being unable to obtain needed health careservices were both independently associated with time to first ED visit during the studyFairbairn et al. Page 4J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptperiod, whereas baseline CD4 cell count and viral load did not predict ED use. SSTI,including abscesses and cellulitis (17.6%), and medication refills and aftercare (17.5%)accounted for the greatest proportion of ED visits. Of the 2461 visits to the ED, 419 (17.6%)were admitted to hospital.A key finding of the present study is the independent association between residing inunstable housing environments and shorter time to first visiting the ED. The challengesassociated with living in unstable housing may act as a barrier for IDU to access primarycare services, as the immediate sustenance needs implicit in being homeless (e.g., dailyacquisition of food and shelter) must compete with health care needs.30 Delays in seekingtreatment may result in more frequent and lengthy hospital admissions.12, 23, 31 Further,previous studies have clearly demonstrated that unstable housing among IDU is associatedwith hazardous and unhygienic injecting practices that may also predispose individuals toinfection. Unsafe injection practices associated with rushed injections in public placesinclude the use of unclean water sources, decreased sanitization of the skin with alcoholprior to injecting, and the preparation of drugs directly in the barrel of the syringe by addingwater and “shaking” without cooking or filtering.32 In our local setting, unstable housingwas found to be independently associated with SSTI among IDU who used Vancouver'ssupervised injection facility.33 This may also help to account for the observation in thepresent study that SSTI, a common injection-related complication, was the most commonED diagnoses.The link between ED use and unstable housing is particularly concerning here in Vancouver,Canada, where the number of homeless persons rose by 106% from 2002 to 2005.34Additionally, there have been recent losses of low-income housing and an increase inhomelessness as a result of urban renewal for the 2010 Olympic Winter Games.35 Increasedproperty speculation and increasing property values in the Downtown Eastsideneighborhood led to reductions in available low-income housing and a predicted homelesspopulation in excess of 3000 by the start of the 2010 Olympics.34 The high cumulativeincidence of ED visits among local IDU and the association with unstable housing indicatesa pressing need for affordable housing, especially given the increasing shortage in oursetting. Stable living environments can facilitate an individual's ability to stay connectedwith primary care services and seek care earlier on in disease progression and reducehospital ED and inpatient service use.36-38 In the ED, case management for unstably housedHIV-positive individuals has also been found to be a successful method in improvingadherence to HAART and biological outcomes.39It is noteworthy that clinical markers of HIV/AIDS disease at baseline, such as CD4 cellcount and HIV-1 RNA plasma viral load, were not significantly associated with ED use inthe present study. Since baseline CD4 and viral load serves as a significant prognosticindicator of treatment outcome and response to HAART therapy,40-41 recent expansion ofHAART coverage and initiation of HAART therapy at higher CD4 counts in our setting mayexplain somewhat the strong associations with socio-demographic characteristics andinjection-related complications as the primary reason for ED use.42-43 This contrasts withED use patterns in the pre-HAART era when ED presentations frequently related to theacute complications of HIV/AIDS disease, including opportunistic infections.44-45Inability to access needed health services was also independently associated with time to EDuse in multivariate analyses. Though there have been conflicting findings in our setting onthe relationship between access to primary care and hospital-based service use, our findingsprovide support for an association between ED use and a perceived barrier to accessingother needed health care services.1-2, 8 Primary care services that implement an integratedmodel of care, including harm reduction and drug treatment, may be viewed as lessFairbairn et al. Page 5J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptstigmatizing of drug use and prove to be more effective in reducing perceived barriers tohealth care access.46 One example is supervised injection facilities (SIFs) that integrateharm reduction strategies, including preventative education on sterile injection, with primarycare and addiction counseling.46-47 Indeed, integrating wound management care intoexisting harm reduction services, such as needle exchange programs and SIF, in communitysettings has been found to be feasible, cost-effective and beneficial for preventing andtreating SSTI, the most common presenting ED complaint in our study.46-48 Additionally,previous research has found decreased ED use with methadone maintenance and other drugtreatment programs with health care access.49-52 Screening for substance misuse in the EDand referral to harm reduction and drug treatment programs that provide primary careservices may therefore prove to be beneficial in this population.LIMITATIONSThis study has several limitations. First, we may have underestimated the level of ED use asparticipants may have sought care at other facilities in the city. However, we did considerthe hospital ED that is used by the vast majority of people living in this community.1Second, the current study relies on self-report of drug use and other stigmatized behaviors(e.g. sexual behaviors) and may be susceptible to socially desirable reporting. In this regard,it is noteworthy that CD4 and viral load information were not susceptible to this concern.Third, although ED usage was ascertained through a linkage to an external database,migration away from the city or other reasons for loss of participants to follow-up maynevertheless introduce some degree of bias into the study results. Fourth, although ourcohort includes an estimated 20 per cent of all IDU living in the Downtown Eastside, oursample may not be representative of all IDU in the area. Finally, our study was unable toaccess follow-up information on health care use after discharge from the ED. Future studiesshould assess the impact of interventions for this population in the ED on subsequent healthcare utilization patterns including return to the ED.CONCLUSIONSIn summary, our study documents a high incidence of ED use among HIV-positive IDU.Individuals more likely to visit the ED represented those most severely disadvantaged interms of housing and access to primary care services, and the most common ED diagnoseswere due to preventable injection-related infections. This study indicates that socio-demographic factors and injection-related complications play a major role in ED visitsamong HIV-positive IDU in the post-HAART era. While expanding use of HAART amongIDU is an urgent concern,53-54 the clinical markers of HIV disease status at baseline did notappear to play a role in predicting ED use in this setting.AcknowledgmentsWe would particularly like to thank the ACCESS participants for their willingness to be included in the study, aswell as current and past ACCESS investigators and staff. We would specifically like to thank Deborah Graham,Tricia Collingham, Caitlin Johnston, and Steve Kain for their research and administrative assistance. The study wassupported by the US National Institutes of Health and the Canadian Institutes of Health Research. Thomas Kerr issupported by the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research.REFERENCES1. Kerr T, Wood E, Grafstein E, et al. High rates of primary care and emergency department useamong injection drug users in Vancouver. J Public Health (Oxf). Mar; 2005 27(1):62–66. [PubMed:15564279]Fairbairn et al. 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Accessing care for injection-relatedinfections through a medically supervised injecting facility: a qualitative study. Drug AlcoholDepend. Nov 1; 2008 98(1-2):159–162. [PubMed: 18650034]48. Grau LE, Arevalo S, Catchpool C, Heimer R. Expanding harm reduction services through a woundand abscess clinic. Am J Public Health. Dec; 2002 92(12):1915–1917. [PubMed: 12453808]49. Pollack HA, Khoshnood K, Blankenship KM, Altice FL. The impact of needle exchange-basedhealth services on emergency department use. J Gen Intern Med. 2002; 17(5):341–348. [PubMed:12047730]50. Laine C, Lin YT, Hauck WW, Turner BJ. Availability of medical care services in drug treatmentclinics associated with lower repeated emergency department use. Med Care. 2005; 43(10):985–995. [PubMed: 16166868]51. Gourevitch MN, Chatterji P, Deb N, Schoenbaum EE, Turner BJ. On-site medical care inmethadone maintenance: associations with health care use and expenditures. J Subst Abuse Treat.2007; 32(2):143–151. [PubMed: 17306723]52. Turner BJ, Laine C, Yang CP, Hauck WW. Effects of long-term, medically supervised, drug-freetreatment and methadone maintenance treatment on drug users’ emergency department use andhospitalization. Clin Infect Dis. 2003; 37(Suppl 5):S457–463. [PubMed: 14648464]53. Nosyk B, Sun H, Li X, Palepu A, Anis AH. Highly active antiretroviral therapy and hospitalreadmission: comparison of a matched cohort. BMC Infect Dis. 2006; 6:146. [PubMed: 17022826]54. Celentano DD, Galai N, Sethi AK, et al. Time to initiating highly active antiretroviral therapyamong HIV-infected injection drug users. AIDS. Sep 7; 2001 15(13):1707–1715. [PubMed:11546947]Fairbairn et al. Page 9J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFigure 1.Time to first emergency department (ED) use among a prospective cohort of HIV-positiveinjection drug users, stratified by unstable housing at baseline.Fairbairn et al. Page 10J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFairbairn et al. Page 11Table 1Baseline characteristics of the 428 ACCESS participants in Vancouver, CanadaCharacteristic median Interquartile (IQ) range n(%)Age (years) 41 36 - 47Female Gender 170 (39.72)Aboriginal Ethnicity 178 (41.59)DTES Residence * 291 (68.00)Viral Load (Copies/mL) † 3,845 49 – 45,150CD4 Count (Copies/mL) † 290 170-460*Behaviours refer to activities in the last six months.†Indicates baseline value.J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFairbairn et al. Page 12Table 2Univariate and multivariate Cox proportional hazard analyses of time to first emergency department visit among 428 HIV-positive injection drug users.Unadjusted Relative Hazard (RH)Adjusted** Relative Hazard (RH)VariableRH(95% CI)p-valueRH(95% CI)p-valueAge    (Per year old)0.99(0.98–1.01)0.250Gender    (Female vs. male)1.10(0.89–1.37)0.376Ethnicity    (Aboriginal vs. other)0.94(0.76–1.17)0.573DTES Residence*    (Yes vs. no)1.37(1.08 – 1.73)0.0091.12(0.85 – 1.47)0.431Unable to access services*    (Yes vs. no)2.14(1.17 – 3.91)0.0142.24(1.22 – 4.12)0.010Unstable Housing*    (Yes vs. no)1.54(1.21 – 1.96)<0.0011.47(1.11 – 1.96)0.007Sex Trade Involvement*    (Yes vs. no)1.28(0.94 – 1.73)0.118Daily Crack Cocaine Smoking*    (Yes vs. no)1.22(0.98 – 1.52)0.075Daily Heroin Injection*    (Yes vs. no)1.17(0.90 – 1.54)0.247Daily Cocaine Injection*    (Yes vs. no)1.22(0.85 – 1.75)0.273History of Assault*    (Yes vs. no)1.30(1.00 – 1.69)0.0501.28(0.98 – 1.66)0.067Viral load (copies/mL) †    (per log 10)0.99(0.91 – 1.07)0.807J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFairbairn et al. Page 13Unadjusted Relative Hazard (RH)Adjusted** Relative Hazard (RH)VariableRH(95% CI)p-valueRH(95% CI)p-valueCD4+ count (cells/mm3) †    (Per 100 cells)1.01(0.97 – 1.06)0.634Methadone Use*    (Yes vs. no)0.84(0.68 – 1.05)0.126*Behaviours refer to activities in the last six months.† Indicates baseline value.**Model was fitted adjusting for all variables significant in unadjusted analyses.J Emerg Med. Author manuscript; available in PMC 2013 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptFairbairn et al. Page 14Table 3Most frequent reasons for ED visits among IDU(N = 2242)Reason n %Skin and soft tissue infections eg. Abscesses, cellulitis 394 (17.6%)Medication refills and aftercare* 392 (17.5%)Respiratory infections and disorders 264 (11.8%)Wounds, lacerations & contusions 252 (11.2%)Gastrointestinal & urological disorders 203 (9.1%)Miscellaneous bacterial and viral infections 191 (8.5%)Cardiac and circulatory system diseases 147 (6.6%)Substance misuse and overdose 134 (6.0%)Neurological disorders or seizures 125 (5.6%)Psychiatric disorders 69 (3.1%)Fractures and dislocations 44 (2.0%)Other 27 (1.2%)*Aftercare includes wound care & IV antibiotic administration.J Emerg Med. Author manuscript; available in PMC 2013 August 01.

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