Transcript Slide 1

Meet the Author
Webinar
January 12, 2012
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Agenda
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Welcome & Introductions, 5min
Meet the Author: Dr. Thomas Giordano, 30min
Q & A Session, 15min
ABMS Certification Program, 5min
Campaign Next Steps, 5min
Retention in HIV Care:
What the Clinician
Needs to Know
Thomas P. Giordano, MD, MPH
Associate Professor of Medicine
Sections of Infectious Diseases and Health Services Research
Baylor College of Medicine
Medical Director of HIV Services
Thomas Street Health Center and Harris County Hospital District
Research Scientist
Health Services Research and Development Center of Excellence
Michael E. DeBakey VA Medical Center
Houston, Texas
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Giordano TP Topics Antiviral Med 2011 19:12
Adherence to the Spectrum of Care
• Link to care after HIV diagnosis
• Generally, attend one visit with a provider who can
prescribe highly active antiretroviral therapy
• Be retained (persist) in care, or stay in care
chronically
• Attend required provider visits for primary HIV care
• Adhere to medications
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Outline
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Why retention in care?
Magnitude of the problem
Impact on outcomes
Predictors
Interventions
Challenges
Recommendations
Why is retention important?
Retention in Care:
• Is modifiable
• Affects outcomes
• Individual and population levels
• Affects quality of care measures
• HAB, HIVQUAL
• Affects utilization
• RVU, clinic efficiency
• Clinicians can affect change
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Magnitude of the Problem
• HCSUS: 1/3 to 2/3 of persons with HIV in US are not
in regular care, half of whom know they have HIV
• CDC: 17-40% of PLWHA who know status are not in
regular care
• Deaths with HIV in B.C., Canada, 1997-2001
• Of 554 non-accidental deaths, 69% were HIV-related
• Median proportion of time on HAART = 20%
• >50% not on HAART at death
• ARTAS: 40% of patients newly diagnosed did not see
provider within 6 months
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Bozzette, NEJM 1998, 339:1897; Fleming, 2002, 9th CROI: abstract 11; Recksy,
JID 2004, 190:285; Gardner, AIDS 2005, 19:423;
Newer data…
• 2010 meta-analysis found 41% of patients in 28
studies did not attend multiple clinic visits over
varying intervals—averaging 12 months.
• in+Care data from first round:
• 17% of patients had a gap in care
• 39% of patients not retained in care for 2 years
• 42% of new patients not retained for 1 year
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Marks, AIDS 2010, 24.
Impact on Outcomes
• Poor retention in care
• Less likely to get HAART
• Higher rates of HAART failure
• Worse retention in care associated with
increased HIV transmission behavior
• More hospitalizations
• Worse survival
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Giordano, JAIDS 2003, 32:399; Lucas, Annals Intern Med 1999, 81; Berg, AIDS Care 2005:902;
Mugavero, JAIDS 2009, 50:100; Macharia, JAMA 1992, 267:1813; Coleman, APCSTD 2009,
23:639; Fleishman, HSR 2008, 43:76; Giordano, CID 2007, 44:1493; Mugavero ,CID 2009, 48:248
US Nationwide VA Patients Starting ART
Quarters in First Year with Visits
N=2619
Quarters with Visit
Visit in 4 quarters
Visit in 3 quarters
Visit in 2 quarters
Visit in 1 quarter
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Giordano, CID 2007, 44:1493
N
1685
479
286
169
%
64%
18%
11%
6%
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Giordano, CID 2007, 44:1493
Adjusted Analyses (Cox)
(n=2619)
Characteristic
Visit in 4 quarters
Visit in 3 quarters
Visit in 2 quarters
Visit in 1 quarter
AHR
95% CI
P
value
referent
1.41
1.10-1.82 <0.01
1.68
1.24-2.26 <0.001
1.94
1.36-2.76 <0.001
Adjusted for age, race/ethnicity, baseline CD4 cell count, HAART
use, hepatitis C virus coinfection, non-HIV-related comorbidity
score, alcohol abuse, hard drug use, and social instability.
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Giordano, CID 2007, 44:1493
Predictors of Poor Linkage and Appointment
Adherence or Retention in Care
• Demographic characteristics
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Younger age
Female sex
Racial/ethnic minority status
No or public insurance
Lower socioeconomic status
Rural residence
No usual source of care
Samet, AJM 1994, 97:347; Samet, Arch Internal Med 1998, 158:734; Turner, Arch Internal Med 2000, 160:2614; Giordano, AIDS Care
2005:773; Mugavero, CID 2007, 45:127; Gardner AIDS Pt Care STD 2007, 6:418; Kissinger JNMA 1995:19; Catz, AIDS Care
1999:361; McClure AIDS & Behav 1999:157; Israelski, Preventive Medicine 2001:470; Arici, HIV Clin Trials 2002:52; Samet J Health Care
Poor Underserved 2003:244; Giordano HIV Clin Trials 2009: 10:299; Mugavero, JAIDS 2009, 50:100; Krentz, CID 2007, 45:1527
Predictors of Poor Linkage and Appointment
Adherence or Retention in Care
• Disease severity
• Less advanced HIV disease
• Fewer non-HIV comorbidities
• Psycho-social characteristics
• Substance use
• Low readiness to enter care
• Less social support
• System and patient factors
• Less use of ancillary services
• Greater unmet need
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Samet, AJM 1994, 97:347; Samet, Arch Internal Med 1998, 158:734; Turner, Arch Internal Med 2000, 160:2614; Giordano, AIDS Care
2005:773; Mugavero, CID 2007, 45:127; Gardner AIDS Pt Care STD 2007, 6:418; Kissinger JNMA 1995:19; Catz, AIDS Care
1999:361; McClure AIDS & Behav 1999:157; Israelski, Preventive Medicine 2001:470; Arici, HIV Clin Trials 2002:52; Samet J Health Care
Poor Underserved 2003:244; Giordano HIV Clin Trials 2009: 10:299; Mugavero, JAIDS 2009, 50:100; Krentz, CID 2007, 45:1527
Accessing ART After Prison Release,
Texas 2004-2007, n=1215
% w/ ART filled
100
80
60
40
20
0
10 days
30 days
60 days
Days fo llo wing release fro m priso n
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Adapted from: Baillargeon et al. JAMA 2009;301:848-57.
Slide courtesy of M. Mugavero, UAB
SPNS Outreach Intervention
• Baseline engagement predicts subsequent engagement,
though not completely
Baseline status
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N
% Engaged
at 12months
Adjusted odds
ratio (95% CI)
P value
Engaged
290
75.9
Reference
---
Somewhat engaged
260
59.6
0.52 (0.36, 0.76)
0.002
Not engaged
68
52.9
0.41 (0.23, 0.72
0.001
Rumptz, AIDS Pt Care STD 2007, 21:S-30
Published Interventions
• ARTAS study
• Randomized controlled trial on Linkage to Care
• HRSA Ancillary Services Use set of studies
• Retrospective observational data
• Published as supplement AIDS Care 2002
• SPNS Outreach Initiative
• Non-randomized intervention
• Published as supplement AIDS Pt Care and STD 2007
• Bridging Case Management
• Randomized study, state prison releasees, negative study
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Gardner, AIDS 2005, 19:423; AIDS Care Supp 1, 2002; AIDS Pt Care STD Supp
2007; Wohl, AIDS Behav 15:356
SPNS Model for Opportunities to Improve
Adherence to Care
Persons in Care
Interventions to
Engage in
Care
Pivotal Points
Opportunities
Persons Unstable
in Care
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Rajubian, AIDS Pt Care STD 2007, 21:S-20
Interventions to
Prevent Falling
out of Care
SPNS Outreach Intervention
• Baseline engagement predicts subsequent engagement,
though not completely
• Factors associated with retention at 12 month follow-up
(adjusted for race and last CD4)
• Discontinued drug use, decreased structural barriers,
decreased unmet needs, and stable beliefs about HIV
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Rumptz, AIDS Pt Care STD 2007, 21:S-30
Other Interventions
• Interest in patient navigation and peer outreach
▫ SPNS Outreach Intervention
▫ Technical assistance on this topic
• Various research projects funded by NIH
• HRSA-CDC Multi-site trial
▫ 6 clinics (Baltimore, Birmingham, Boston, Houston, Miami,
New York City)
▫ 3-arm randomized study comparing intensive intervention,
limited intervention, usual care
▫ Intervention based on skills building with MI and strengthbased approach (results in one year)
▫ Clinic-wide marketing and brief messaging intervention,
pre/post design (modest effect seen; Gardner National HIV
Prevention Conference, 2011 abstract 2018)
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Challenges
• Patient and provider / system level
• Staffing and resources
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Challenges: Patient & Provider Level
• Patient level changes
• Changing behavior, similar to medication adherence
• Improving trust, communication, stigma
• Removing structural barriers and unmet need
(transportation, housing, child care, financial)
• Reducing substance use
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Challenges: Patient & Provider Level
• Provider and system level changes
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Provider communication and decision-making style
Appointment scheduling systems
Improving clinic access (extended clinic hours?)
Maintaining accurate contact information
De-fragmenting health insurance and health care processes
Reorganizing healthcare delivery for decades of HIV care
Staffing and resources limitations
Challenges: Staffing and Resources
• ARTAS: 120 clients per year, so about 10-15 new case managers for
Houston
• SPNS Outreach Initiative had average of 4.9 contact hours per new
client per month, for 12 months
• 168 work hours per month; 168 / 4.9 = 34.3 clients per outreach worker. At
TSHC (300 newly diagnosed patients per year) = 9 dedicated outreach workers
• SPNS Outreach Initiative effective if ≥9 contacts in 90 days
• If 15 minutes each contact, at TSHC (1000 patients with poor retention) = 5
dedicated outreach workers
• Translation, dissemination, and sustainability
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Gardner, AIDS 2005, 19:423; Naar-King, AIDS Pt Care and STD 2007,
21:S-40; Cabral AIDS Pt Care STD 2007, 21:S-59
What can we do now?
Two questions:
• In what proportion of patient encounters do you discuss
ART medication adherence?
• In what proportion of patient encounters do you discuss
the importance of adherence to clinic visits?
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Imagine you missed your last dental cleaning and it has
been a year. I tell you, “You know, you really need to get
your teeth cleaned every 6 months. Bad things could
happen to your teeth if you don’t. They might even fall
out.” This statement makes you most feel:
1.
2.
3.
4.
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More knowledgeable
Guilty and imperfect
More motivated
Mad, like you are being treated like a child
Recommendations for Now
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4.
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Track no-show rates and out of care
Examine your processes of care: bringing patients
back is much more difficult once out of care
completely
Work with ER and inpatient services, CBOs, public
health agencies, jails/prisons, other RW providers to
identify poorly retained in care and build or
strengthen re-linkage processes
Build or strengthen outreach or peer navigator
programs
Recommendations for Now
5.
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9.
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Work with the resources you have: spread the word
about the importance of retention, have staff
advocate with patients for retention
Improve the customer’s experience
Minimize unmet need: Strengthen substance use,
mental health, case management, and social services
Minimize time between appointment making and
appointment date
Accomodate the patient’s preferences when
scheduling appointments
Recommendations for Now
10. Remember that patients generally know they should
be in care. Corollaries:
a. Reminders help but are likely not enough
b. Admonishments or encouragements alone
will not work
c. Problem solve collaboratively with your
patients just as you would for adherence to
medications
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Acknowledgements
Patients
Institutions
Baylor College of Medicine
Thomas Street Health Center
Harris County Hospital District
DeBakey VA Medical Center
M.D. Anderson Cancer Center
Funding/Support
NIH R34MH074360
HRSA H97HA03786
Contract 200-2007-23685 (CDC HRSA)
NIH R01MH085527
NIH U18HS016093
BCM/UTH CFAR
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Colleagues
Rivet Amico, PhD
Monisha Arya, MD
April Buscher, MD, MPH
Jeff Cully, PhD
Jessica Davila, PhD
Michael Kallen, PhD
Nancy Miertschin, MPH
Michael Mugavero, MD, MPH
William Slaughter
Melinda Stanley, PhD
Research Staff
Sallye Stapleton
Elizabeth Soriano
Christine Hartman
Hina Budhwani
Marisela Weaver
Time for Questions
and Answers
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American Board of Medical Specialties (ABMS)
Multi-specialty Maintenance of Certification (MOC)
Portfolio Approval Program
Physician’s involved in quality improvement activities through HIVQUAL-US can earn
maintenance of certification credit from the following Boards:
• The American Board of
• The American Board of
• The American Board of
• The American Board of
• The American Board of
• The American Board of
• The American Board of
• The American Board of
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Internal Medicine (ABIM) – www.abim.org
Family Medicine (ABFM) – www.theabfm.org
Pediatrics (ABP) – www.abp.org
Allergy and Immunology – www.abai.org
Obstetrics and Gynecology – www.abog.org
Physical Medicine and Rehabilitation – www.abpmr.org
Surgery – www.absurgery.org
Otolaryngology – www.aboto.org
Earning credit
• Participating physicians must be enrolled in their respective Board’s MOC
program at the time MOC credit is requested.
• Physician participation is expected to take approximately 50 hours/year.
• Enrollment must occur no later than June 1 in the calendar year, with annual
report submitted by November 1.
• Physician must currently provide diagnostic and hospital or clinic treatment
services to HIV-positive patients in the physician’s clinics.
• Physician must demonstrate active participation as a lead or as a member of the
quality improvement team.
• Physician must implement at least one quality improvement project.
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How to Enroll
• Enrollment and Agreement forms are available on the HIVQUALUS website at www.hivqualus.org/abms
• Applicants should work with their HIVQUAL-US consultant to
initiate enrollment and develop a work plan for completion of
requirements as soon as possible to ensure submission of annual
report no later than November 1.
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Documentation and
Approval Process
Annual report
 Performance Measurement: documented experience with eHIVQUAL or
other data collection, sampling, indicator selection, results
 Quality Management Program: your role on quality team, name of QI
project, setting of quality goals, HIVQUAL OA
 Quality Improvement methodology: improvement methods implemented,
detailed description of QI project, team members, clinical indicators targeted,
interventions tested, beginning and end scores, changes implemented as a
result of project, how will improvements be sustained, barriers and challenges,
lessons.
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Documentation and
Approval Process continued…
Supplemental Materials
*Additional materials must be submitted with the annual report to demonstrate:
 Direct physician involvement in the QI project(s) AND
 In support of the QI project described in the annual report
• Performance Measurement: eHIVQUAL performance measurement reports, charts,
graphs and other reports prepared by physician or quality improvement team
• Quality Management Program: Annual Quality Management Plan, Annual Quality
Workplan, quality team or committee minutes, HIVQUAL-US Organizational
Assessment
• Quality Improvement methodology: reports, documentation, process tools pertaining
to the quality improvement project.
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Questions/Comments
Contact: Joshua Bardfield
[email protected]
212-417-4539
OR
Your local HIVQUAL-US consultant
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Next Steps
• Office Hours: Every Monday and Wednesday,
4-5pm ET
• Improvement Update Submission Deadline:
January 15, 2012
• Next Webinar: January 18, 2012 at 12pm ET
• Data Submission Deadline: February 1, 2012
• Webinar on Incarceration: Dr. Brian Montague
March 14, 2012 at 3:00pm ET
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Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
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