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Meet the Author Webinar January 12, 2012

Meet the Author Webinar January 12, 2012. Ground Rules for Webinar Participation. Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6)

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Meet the Author Webinar January 12, 2012

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  1. Meet the AuthorWebinar January 12, 2012

  2. Ground Rules for Webinar Participation Actively participate and write your questions into the chat area during the presentation(s) Do not put us on hold Mute your line if you are not speaking (press *6, to unmute your line press #6) Slides and other resources are available on our website at incareCampaign.org All webinars are being recorded

  3. Agenda • Welcome & Introductions, 5min • Meet the Author: Dr. Thomas Giordano, 30min • Q & A Session, 15min • ABMS Certification Program, 5min • Campaign Next Steps, 5min

  4. Thomas P. Giordano, MD, MPHAssociate 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 Giordano TP Topics Antiviral Med 2011 19:12 Retention in HIV Care:What the ClinicianNeeds to Know

  5. 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

  6. Outline • Why retention in care? • Magnitude of the problem • Impact on outcomes • Predictors • Interventions • Challenges • Recommendations

  7. 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

  8. 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 Bozzette, NEJM 1998, 339:1897; Fleming, 2002, 9th CROI: abstract 11; Recksy, JID 2004, 190:285; Gardner, AIDS 2005, 19:423;

  9. 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 Marks, AIDS 2010, 24.

  10. 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 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

  11. US Nationwide VA Patients Starting ARTQuarters in First Year with Visits N=2619 Giordano, CID 2007, 44:1493

  12. Giordano, CID 2007, 44:1493

  13. Adjusted Analyses (Cox) (n=2619) 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. Giordano, CID 2007, 44:1493

  14. Predictors of Poor Linkage and Appointment Adherence or Retention in Care • Demographic characteristics • 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; SametJ Health Care Poor Underserved 2003:244; Giordano HIV Clin Trials 2009: 10:299; Mugavero, JAIDS 2009, 50:100; Krentz, CID 2007, 45:1527

  15. 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 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; SametJ Health Care Poor Underserved 2003:244; Giordano HIV Clin Trials 2009: 10:299; Mugavero, JAIDS 2009, 50:100; Krentz, CID 2007, 45:1527

  16. Accessing ART After Prison Release, Texas 2004-2007, n=1215 Adapted from: Baillargeon et al. JAMA 2009;301:848-57. Slide courtesy of M. Mugavero, UAB

  17. SPNS Outreach Intervention • Baseline engagement predicts subsequent engagement, though not completely Rumptz, AIDS Pt Care STD 2007, 21:S-30

  18. 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 Gardner, AIDS 2005, 19:423; AIDS Care Supp 1, 2002; AIDS Pt Care STD Supp 2007; Wohl, AIDS Behav15:356

  19. SPNS Model for Opportunities to Improve Adherence to Care Persons in Care Interventions to Prevent Falling out of Care Interventions to Engage in Care Pivotal Points Opportunities Persons Unstable in Care Rajubian, AIDS Pt Care STD 2007, 21:S-20

  20. 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 Rumptz, AIDS Pt Care STD 2007, 21:S-30

  21. 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 strength-based 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)

  22. Challenges • Patient and provider / system level • Staffing and resources

  23. 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

  24. Challenges: Patient & Provider Level • Provider and system level changes • 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

  25. 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 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

  26. 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?

  27. 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: • More knowledgeable • Guilty and imperfect • More motivated • Mad, like you are being treated like a child

  28. Recommendations for Now • 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

  29. Recommendations for Now • 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

  30. Recommendations for Now • Remember that patients generally know they should be in care. Corollaries: • Reminders help but are likely not enough • Admonishments or encouragements alone will not work • Problem solve collaboratively with your patients just as you would for adherence to medications

  31. Acknowledgements 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 • 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

  32. Time for Questions and Answers

  33. 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 Internal Medicine (ABIM) – www.abim.org • The American Board of Family Medicine (ABFM) – www.theabfm.org • The American Board of Pediatrics (ABP) – www.abp.org • The American Board of Allergy and Immunology – www.abai.org • The American Board of Obstetrics and Gynecology – www.abog.org • The American Board of Physical Medicine and Rehabilitation – www.abpmr.org • The American Board of Surgery – www.absurgery.org • The American Board of Otolaryngology – www.aboto.org

  34. 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.

  35. How to Enroll • Enrollment and Agreement forms are available on the HIVQUAL-US 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.

  36. 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.

  37. 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.

  38. Questions/Comments Contact: Joshua Bardfield jeb16@health.state.ny.us 212-417-4539 OR Your local HIVQUAL-US consultant

  39. 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 MontagueMarch 14, 2012 at 3:00pm ET

  40. Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floor New York, NY 10007Phone 212-417-4730 incare@NationalQualityCenter.orgincareCampaign.org youtube.com/incareCampaign

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