engaging health care providers in various settings in ... -day 2-workshop 5 engaging h… · •...

Engaging Health Care Providers in

Various Settings in Routine Offer of

HIV Testing

1

Engaging Health Care Providers in Various Settings

• Has been one of our greatest challenges … with the greatest reward

• Previously HIV tests were offered to individuals “at risk” for HIV

• Now HIV tests are offered to everyone at all health care encounters

Rationale

• We do not know who is at risk

• There is stigma in recommending a test to only at risk groups

• A routine offer of an HIV test reduces stigma, is well accepted and

results in increased, earlier diagnoses

2

Engaging Health Care Providers in Various Settings

So how do we make this happen? Recognize that changing practice is

one of the hardest things you will do and requires that you:

Establish a visible, committed leadership

Communicate vision and rationale over and over

Identify and engage champions

Understand current processes and workflows

Build on existing processes

Educate and support – shoulder to shoulder support

Provide tools to support practice change

Anticipate arguments and have answers

Collect and share data regularly

Reinforce good practice and celebrate successes

3

HIV Testing: CHANGING HIVSTORY

Rationale and Evidence

for Routine Testing

Dr. Réka Gustafson

4

Clinical Rationale for

Early Diagnosis and

Treatment

5

Estimates of Benefits of Early

Treatment

Life expectancy as a function of disease stage

at start of treatment:

Disease stage at start of

Treatment

Can expect to live to

(years)

CD4 < 100 57.9

CD4 100 - 199 61.0

CD4 200 - 350 73.4

Modified from May M et al. BMJ 2011;343:d6016 6

Life expectancy from age 20-65 by CD4 count at start of

antiretroviral therapy compared with UK population

May M et al. BMJ 2011;343:d6016 ©©2011 by British Medical Journal Publishing Group

2000-2006

2000-2008

7

Public Health Rationale

for Early Diagnosis and

Treatment

8

Evidence: HIV Prevention

Trials Network 052 Study 1,763 serodiscordant couples

HIV positive partner with CD4 350-550 97% heterosexual

N=886 Immediate ART

1 linked transmission

N=877 Delayed ART

CD4 of 250

27 linked transmissions

Cohen MS, et al. HPTN052 Study Team Prevention of HIV-1 Infection with

Early Antiretroviral Therapy. N Engl J Med 2011 Aug 11; 365(6):493-505

p < 0.001

10

CD4 350-500

CD4 200-349

CD4 < 200

CD4 > 500

December

Early diagnosis is the goal

11

Multiple missed opportunities for

earlier diagnosis Percent & proportion of new HIV diagnoses with ≥

1 prior Outpatient, Lab, ER or Inpatient encounter,

by CD4 count

•Only 57.5% (291/506) of new HIV Dx had a CD4 count on

* Only 57.5% (291/506) of new HIV Dx had a CD4 count on

record at time of Dx

CD4 Count* ≥ 1 prior encounter

< 200 58% (30/52)

< 350 60% (64/107)

< 500 55% (97/177)

12

Cost effective Conservative threshold for cost

effectiveness is estimated to be

1/1000 new diagnoses*

or 2/1000 diagnosed prevalence

Paltiel AD, et al. Expanded screening for HIV in the United States - an analysis of

cost-effectiveness. N Engl J Med 2005; 352(6):586-595.

Paltiel AD, et al. Expanded HIV screening in the United States: effect on clinical

outcomes, HIV transmission, and costs. Ann Intern Med 2006; 145: 797–806.

Sanders GD, Bayoumi AM, Sundaram V, Bilir SP, Neukermans CP, Rydzak CE et

al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral

therapy. N Engl J Med 2005; 352(6):570- 585.

*Walensky RP, et al. Routine human immunodeficiency virus testing: an economic

evaluation of current guidelines. Am J Med 2005; 118(3):292-300.

Yazdanpanah Y et al. Routine HIV Screening in France: Clinical Impact and Cost-

Effectiveness. PLoS One. 2010;5(10):e13132.

13

Guidelines US:

• Centers for Disease Control and Prevention. Revised

Recommendations for HIV Testing of Adults,

Adolescents, and Pregnant Women in Health-Care

Settings. MMWR 2006;55(No. RR-14).

UK:

• UK national guidelines for HIV testing 2008. London

(UK): British HIV Association, British Association for

Sexual Health and HIV, British Infection Society; 2008.

EU:

• Poljak M, Smit E, Ross J. 2008 European Guideline on

HIV testing. Int J STD AIDS February 2009; 20:77-83;

doi:10.1258/ijsa.2008.008438

14

Summary

• Early diagnosis prolongs life and prevents transmission

• Late diagnosis remains common

• Those infected with HIV are being seen in health care,

but not being tested

• Routine HIV testing of all patients is cost effective at

quite low diagnostic yields

• Countries with similar prevalence and health care

systems are incorporating HIV testing as part of routine

care for all patient

15

New HIV Testing

Recommendations BCMJ, 2011, 53:49

Offer an HIV test to all adults in your practice who have not had one in the past year

in acute and community care as part of blood work for any other reason every time you test for STIs, HCV,

tuberculosis

Vancouver Coastal Health Public Health

16

New HIV Testing

Recommendations BCMJ, 2011, 53:49

If aware of a specific risk, recommend an HIV test now, and more often

clinical symptoms every time you diagnose another STI every 3-6 months if you are aware of

ongoing high risk

Vancouver Coastal Health Public Health

17

What routine testing is not

• Not annual testing

• Not routine testing of those at risk

• Not an abandonment of case finding

based on risk

18

HIV Testing:

CHANGING HIVSTORY

Routine HIV Testing in Acute Care

Afshan Nathoo

19

Why - Engage Health Care

Providers? • Late diagnosis and missed opportunities for early diagnosis

• The epidemic has changed, but our testing paradigm has remained

the same

• There is an identified gap and opportunity to improve the quality of

life for individuals and reduce HIV incidence

20

Who - Are the Health Care

Providers to Engage

• Those who have been doing HIV testing for many years

• Those who provide care to recognized high risk populations

• Those who provide care in general medical settings

21

How – Engaging Health Care

Providers

Establish a visible committed leadership:

• Chief MHO/VP Public Health

• SET, MAC, VP Medicine

• Operations Directors

• Department Heads

• Chief Residents

• Share both leadership and the journey with these individuals

22

How – Engaging Health Care

Providers

Education

• Broad and sustainable strategy for all providers (MDs, RNs, UCs)

• Work within existing education & communication networks

• Tailor educational content to your audience (impact on work)

• Maintain the momentum

23

What We Learned

Operations:

• Develop a ‘task group’ that directs implementation and evaluation,

and provides support for best practices

• Embed testing into existing workflow

• Address all concerns and don’t underestimate the magnitude of the

practice change

• Ensure a delegate follow-up pathway has been established and

communicated

• Multiple-level engagement

24

What We Learned

Overall:

• Most effective strategy to increase testing is to collect, analyze and

present testing data and case based data to leadership and

physicians

• Health care providers really know their area. Listen and learn.

• The verbal offer of an HIV test is a significant barrier, however, the

acceptance rate is exceedingly high – present this and continuously

work to incorporate the offer rate into practice

• Introduce testing into departments/units where entry pathways are

simple and the process for ordering bloodwork is streamlined

25

Conclusions

• In Vancouver, routine testing in acute care is acceptable to patients

and providers

• Routine testing is cost-effective

• Diagnosed individuals from late stage disease to acute infection

(expanding access to those that don’t access testing and those do

access testing)

• Implementing routine HIV testing into acute care can provide the

‘pulse’ of HIV in your community

• It will require commitment from leadership and an investment in HR

• Is effective in changing the understanding of HIV, HIV testing and

treatment among HCPs, patients and the general public

26

Targeted Testing

27

Be Flexible

28

Build Excitement/Sense of Urgency

29

Use a Real Life Story

30

Explain Why Data Collection is Important

31

Ask Teams for their Contribution

32

Presentation by

Dr. David Hall

33

BC-CfE Clinical Education Program

Dr. Silvia Guillemi

Director of Clinical Education, BC Centre for Excellence in HIV/AIDS

Clinical Associate Professor, UBC Family Practice

34

BC CfE Clinical Education Model

Educational Events

Training Programs

Ongoing Support for Health

Care Providers

35

BC-CfE Educational Events

• Semi-annual HIV Update (June & December)*

• Bi-weekly AIDS Care Rounds*

• IDC Journal Club Reviewed articles and summaries available at the BC-CfE website

• Forefront Lectures

*Approved by the College of Family Physicians of Canada for CME credits, and archived on the BC-CfE website

36

• Online Course in HIV Diagnosis and Management

• REACH phone line to provide support for HIV treating clinicians (Vancouver: 604-681-5748; outside Vancouver 1-800-665-7677)

• BC-CfE Clinical Guidelines: HIV Primary Care

Therapeutic Guidelines for Adult and Pediatric Patients

Opportunistic Infections

Accidental Exposure

BC-CfE HIV Clinical Resources for Health Care Providers

37

Online Course HIV Diagnosis and Management

• 10 learning modules

• Topics related to HIV diagnosis; BC’s HIV epidemic; initial clinical assessment of patients; treatments and side effects; opportunistic infections; hepatitis co-infections, etc.

• Self-evaluation with quizzes

• CME credits from the College of Family Physicians

• Registration on the BC-CfE website

38

• VCH Intensive Preceptorship for family physicians and NPs

• Preceptorship program for NPs

• UBC Enhanced Skills program for family physicians

• Interdisciplinary UBC Course — IHHS 402

• Elective rotations for UBC family practice, community

medicine and other residency programs fellow

BC-CfE Clinical Training Program

39

BC-CfE Clinical Training Program

Clinical Sites

Immunodeficiency clinic (IDC)

• Primary care site

• HIV and other specialist clinic

AIDS ward

External sites

• Oak Tree Clinic

• Downtown Eastside Clinics

• Others

40

Primary Care Providers Trained in Last 8 Years: 61 (2004 - Jan 2013)

Family Physicians Total: 46

• UBC Enhanced Skills Program

(1-3 months of training) : 15

• Community physicians sponsored by Health Authorities (1-8 weeks average) : 11

• VCH Intensive Preceptorship Program: 20

Nurse Practitioners Total: 15

• Community NPs sponsored by

Health Authorities: 9

• VCH Intensive Preceptorship Program: 6

41

VCH Intensive HIV Preceptorship for FPs and NPs - Program Structure -

MODULE 3: CLINICAL MENTORSHIP

One-to-one support for 3 to 6 months after completion of clinical rotations

MODULE 2: ONE WEEK ON-SITE CLINICAL PRECEPTORSHIP

To achieve clinical competency in primary care management of

HIV-positive patients

MODULE 1: ONLINE COURSE IN HIV DIAGNOSIS AND MANAGEMENT

The foundations of HIV/AIDS

42

VCH Intensive Preceptorship Outcome

• 26 family physicians and NPs were trained from September 2011 to September 2012

• Out of the 21 survey responses received, 11 (52.4%) were highly satisfied, and 10 (47.6%) trainees were very satisfied or satisfied with the program

43

VCH Intensive Preceptorship Outcome

• Data from BC-CfE DTP was reviewed in January 2013 to assess changes in antiretroviral (ARV) prescribing patterns in the 26 trainees.

• Only one trainee had prescribed ARVs to 2 patients before participating in the preceptorship.

• After the preceptorship 12 FPs initiated 45 patients on ARTs and 13 (3 NPs and 10 FPs) had refilled 162 ART prescriptions.

44

Future Clinical Education and Support Initiatives

• Webinar sessions for health care providers and community workers in remote and/or underserved areas

• On-line/ telemedicine consultations with the BC-CfE HIV experts for community family physicians.

45

• BC-CfE website: www.cfenet.ubc.ca

• Training program information: e-mail

[email protected]

• REACH line: 604-681-5748 and 1-800-665-7677

• Dr. Silvia Guillemi: [email protected]

Contact Information

46

http://www.cfenet.ubc.ca

mailto:[email protected]

Thank you

47

MOBILE PRIMARY CARE GUIDELINES

Marianne Harris, MD, CCFP

AIDS Research Program, St. Paul’s Hospital

Dept. of Family Practice, Faculty of Medicine, UBC

48

Objectives

• To support the expansion of HIV care and treatment throughout the province

• To provide consensus guidelines for the management of HIV-infected individuals in the primary care setting

• To provide this information in a concise, accessible, and user-friendly format

49

Primary Care Guidelines for the Management of HIV/AIDS in B.C.: Expert Panel

• Rolando Barrios, MD

• Linda Akagi, BSc Pharm

• Silvia Guillemi, MD

• Marianne Harris, MD

• Paul Kerston, Positive Living Society of BC

• Martin Payne, NP (F), MScN, Dr. Peter AIDS Foundation

• Peter Phillips, MD

• Neora Pick, MD, Oak Tree Clinic

• Aida Sadr, MD, Vancouver Native Health Clinic

50

Primary Care Guidelines for the Management of HIV/AIDS in B.C.: History

• March 2011: original pdf version completed

http://cfenet.ubc.ca/therapeutic-guidelines/primary-care

• November 2012: Updated and converted to

mobile-accessible format

• Launched November 23, 2012

http://www.cfenet.ubc.ca/guidelines/

51


Supported devices

Mobile devices

• iPhone and iPad

• Android 2.1+

• Windows Phone 7

• Blackberry 5+

• Blackberry Playbook

Desktop web browsers

• Firefox 4+

• Safari 4+

• Google Chrome 11+

• Internet Explorer 7+

• Opera 10+

52

Topics

• Assessment of the HIV+ individual

History, physical exam, HIV-specific testing

Screening for infectious and non-infectious comorbidities

• Management of the HIV+ individual

Immunizations

Monitoring

Prophylaxis for opportunistic infections

Lifestyle and psychosocial issues

53

Topics

• Optimizing adherence to ARV therapy

• Acute HIV Infection

• Special issues in women with HIV

• Special issues in addictions

• HIV Patient Care Flow Sheets

• Contact List for referrals and information

54

Demo


55


Future Plans

• Increase awareness and improve accessibility of

guidelines e.g. by links on other websites

– Clinical Practice Guidelines and Protocols in BC

(www.bcguidelines.ca)- BC Ministry of Health

• Update and convert other CfE guidelines

– Accidental Exposure Guidelines

– Therapeutic Guidelines for ARV Treatment of Adult

HIV Infection

56

http://www.bcguidelines.ca)-/

http://www.bcguidelines.ca)-/

57

Thank you

57

engaging health care providers in various settings in ... -day 2-workshop 5 engaging h… · •...

Documents