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Meet the AuthorWebinar

January 12, 2012

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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

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Agenda

• Welcome & Introductions, 5min• Meet the Author: Dr. Thomas Giordano,

30min• Q & A Session, 15min• ABMS Certification Program, 5min• Campaign Next Steps, 5min

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Retention in HIV Care:Retention in HIV Care:What the ClinicianWhat the Clinician

Needs to KnowNeeds to Know

Thomas P. Giordano, MD, MPHThomas P. Giordano, MD, MPHAssociate Professor of Medicine

Sections of Infectious Diseases and Health Services ResearchBaylor College of Medicine

Medical Director of HIV ServicesThomas Street Health Center and Harris County Hospital District

Research ScientistHealth Services Research and Development Center of Excellence

Michael E. DeBakey VA Medical Center

Houston, Texas

Giordano TP Topics Giordano TP Topics Antiviral Med Antiviral Med 2011 19:122011 19:12

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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

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

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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

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

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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.

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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

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US Nationwide VA Patients Starting ARTQuarters in First Year with Visits

N=2619

Quarters with Visit

N %

Visit in 4 quarters

1685 64%

Visit in 3 quarters

479 18%

Visit in 2 quarters

286 11%

Visit in 1 quarter

169 6%Giordano, CID 2007, 44:1493

12 Giordano, CID 2007, 44:1493

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Adjusted Analyses (Cox) (n=2619)

Characteristic AHR 95% CI P value

Visit in 4 quarters

referent

Visit in 3 quarters

1.41 1.10-1.82

<0.01

Visit in 2 quarters

1.68 1.24-2.26

<0.001

Visit in 1 quarter

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.

Giordano, CID 2007, 44:1493

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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; 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

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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; 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

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Accessing ART After Prison Release, Texas 2004-2007,

n=1215

0

20

40

60

80

100

10 days 30 days 60 days

Days following release from prison

% w

/ A

RT fi

lled

Adapted from: Baillargeon et al. JAMA 2009;301:848-57. Slide courtesy of M. Mugavero, UAB

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SPNS Outreach Intervention

Baseline status N % Engaged

at 12-months

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

•Baseline engagement predicts subsequent engagement, though not completely

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

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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 Behav 15:356

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SPNS Model for Opportunities to Improve Adherence to Care

Rajubian, AIDS Pt Care STD 2007, 21:S-20

Interventions to Engage in

Care

Interventions to Prevent Falling

out of Care

Persons Unstable in Care

Persons in Care

Pivotal Points Opportunities

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SPNS Outreach Intervention

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

• 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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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)

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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• 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

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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

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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. More knowledgeable 2. Guilty and imperfect3. More motivated 4. Mad, like you are being treated like a child

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Recommendations for Now1. Track no-show rates and out of care2. Examine your processes of care: bringing

patients back is much more difficult once out of care completely

3. 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

4. Build or strengthen outreach or peer navigator programs

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Recommendations for Now5. Work with the resources you have: spread the

word about the importance of retention, have staff advocate with patients for retention

6. Improve the customer’s experience7. Minimize unmet need: Strengthen substance

use, mental health, case management, and social services

8. Minimize time between appointment making and appointment date

9. Accomodate the patient’s preferences when scheduling appointments

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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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AcknowledgementsPatients

InstitutionsBaylor College of MedicineThomas Street Health CenterHarris County Hospital DistrictDeBakey VA Medical CenterM.D. Anderson Cancer Center

Funding/SupportNIH R34MH074360HRSA H97HA03786Contract 200-2007-23685 (CDC HRSA)NIH R01MH085527NIH U18HS016093BCM/UTH CFAR

ColleaguesRivet Amico, PhDMonisha Arya, MDApril Buscher, MD, MPHJeff Cully, PhDJessica Davila, PhDMichael Kallen, PhDNancy Miertschin, MPHMichael Mugavero, MD, MPHWilliam SlaughterMelinda Stanley, PhD

Research StaffSallye StapletonElizabeth SorianoChristine HartmanHina BudhwaniMarisela Weaver

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Time for Questions and Answers

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American Board of Medical Specialties (ABMS)

Multi-specialty Maintenance of Certification (MOC)

Portfolio Approval ProgramPhysician’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

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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 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.

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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 Bardfieldjeb16@health.state.ny.us212-417-4539

OR

Your local HIVQUAL-US consultant

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• 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

Next Steps

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign