the association between ancillary services and clinical and healthcare utilization outcomes for hiv-...
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The Association between Ancillary Services and Clinical and Healthcare
Utilization Outcomes for HIV-Infected Children
Pediatric AIDS Clinical Trials Unit Meeting
New Orleans, Louisiana 25 April 2001
AuthorsManya Magnus, Norine Schmidt,
Barbara Brown, and Patricia Kissinger for the FACES Program at Children’s
Hospital, New Orleans
Acknowledgements
The authors gratefully acknowledge the staff and clients at FACES and HOP for their assistance.
A special thanks to FACES volunteer Joe Park, who
contributed enormously to the collection of additional data regarding ER and hospital visits.
The data for this study were collected as part of the
Health Resources and Services Administration (HRSA) grant number 250-OA-13(8); the analyses were supported under HRSA contract number 98-0702(P).
Introduction Evaluation of the association
between ancillary services and clinical outcomes entry and retention into health care
This study performed under a HRSA contract as an extension of an existing comprehensive evaluation plan at FACES
Description of FACES Located in metropolitan New Orleans The only provider of comprehensive
ancillary services to HIV-infected women and children in the area
The majority of the program’s clients are low-income and from minority groups
Provides a wide range of clinical and supportive services to clients
Services provided by FACES include intensive case management home visits transportation services referrals for financial assistance referrals for housing assistance mental health counseling substance abuse counseling psychosocial support crisis management medications not covered by other sources
Services, continued child care respite care activities for children developmental assessments and interventions concrete items (e.g., formula, diapers, etc.) funeral assistance vocational employment and coordination referrals for legal assistance health education peer education/counseling community advisory board
Background Ryan White Care Act
Provides support for approximately 500,000 people infected or affected by HIV/AIDS who lack insurance or are underinsured
RWCA funds services through “titles”
Received $1.4 Billion in funding for fiscal year 1999; administered by HRSA
Soon up for re-authorization
Background
Competitive contract
Eight sites awarded
Only one other maternal-child site
Study completed in January 2000
Research question
What is the association between ancillary services, clinical outcomes, and entry and retention into health care?
Research question
Neediest clientsleast likely to have positive outcomes & most likely to use services
Clients with fewer needsfewer servicesbest outcomes
Time
Databases set up to track services and not outcomes
Research question
Common problems in evaluation/outcomes research
Prospective studies best
Better study designs: pre-post design, randomized trials
Ethical issues
Study Design
Retrospective
Used existing data sources
Study period from 1/1/97 through 12/31/98
Longitudinal, individual-level data
Methodology Component I Component II Component III
comparative descriptive descriptive
Women who receive FACES services and
attend HOP
Women who receive FACES services and
attend HOP Children who receive FACES services and
attend HOP vs.
Women who attend HOP only
Inclusion criteria: Women of childbearing age who enrolled in HOP and FACES between 1/ 1/ 97 and 12/ 31/ 98 were included (new clients)
Inclusion criteria: Women enrolled in FACES between 1/ 1/ 97 and 12/ 31/ 98 Enrolled in HOP at any time
Inclusion criteria: Children (0-13 yrs.) who received any FACES service between 1/ 1/ 97 and 12/ 31/ 98 Enrolled in HOP at any time
N=155 at baseline N=198 at baseline N=42 at baseline
Data Sources
Association between ancillary
services an outcomes
Data Analysis
Univariate and bivariate analyses
Multivariate analysis with Generalized Estimating Equations (GEE)
Stata software (College Station, Texas) was used for all analysis
Bonferonni correction (=0.006)
Data Analysis Difficulty in using frequency of contacts as proxy
for need
To adjust for the confounding effect of need, a dynamic needs adjustment factor was developed
The needs adjustment factor (NAF) included clinical, behavioral, and social stressors and was re-calculated for each six-month interval
The needs adjustment factor was included in the multivariate analysis, along with other confounders
EligibilityTo be eligible for this study, the child had
to:
Be HIV-infected Have received at least one FACES
service during the study period Receive medical care within the
MCLNO system
Results 58 children eligible from FACES
10 (17%) excluded due to no clinical data available during study period
6 (10%) excluded due to not being seen within MCLNO system
42 (72%) children included in study
Selected Baseline Characteristics of FACES
Children (N=42)Characteristic Percent
1 to 5 years old 50
African-American 88
Perinatally infected 98
Permanent housing 86
Primary caregiver 64
No immune suppression (Cat. 1) 62
Use of ARV treatment (any) 83
On study 33
Percentage of Children Utilizing FACES Services (N=42)
0102030405060708090
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Results*
Number of services received:
Receipt of more than one transportation service per month was associated with the development of moderate or severe immune suppression
OR 4.31, 95% CI 1.98-9.35, p<0.0001
*all ORs are adjusted for age, NAF (calculated for particular outcome) (including immune status), length of time enrolled in primary care and FACES.
ResultsReceipt of any versus no:Ancillary service was associated with:
more than 75% adherence with required appointments
OR 4.35, 95% CI 1.85-10.00, p<0.006
improved retention OR 8.28, 95% CI 2.04-33.60, p<0.006
ResultsReceipt of any versus no:Transportation service was associated with:
Being prescribed an antiretroviral treatment OR 13.55, 95% CI 6.25-29.42, p<0.006
having one or more ER visit per monthOR 6.71, 95% CI 2.35-19.18, p<0.006
ResultsReceipt of any versus no:Case management contact was
associated with:
having no ER visits per monthOR 4.76, 95% CI 1.64-14.29,
p<0.006
ResultsReceipt of any versus no:Neurodevelopmental service was associated
with:
being prescribed a protease inhibitorOR 4.86, 95% CI 1.59-14.81, p<0.006
having one or more ER visit per monthOR 6.09, 95% CI 1.92-9.32, p<0.006
Results Number of contacts varied by the level
of client needs. Children with higher levels of need Received more services overall per
month (mean 3.63 vs. 2.26, p<0.05) Received more transportation
services per month (mean 0.86 vs. 0.26, p<0.001)
than those with lower levels of need
A thorn in the side…
What about the finding of increased increased ER visits???
Additional Analyses
Additional data were collected to further explore the association between ER visits and hospital visits, and ancillary services
Methods A FACES volunteer abstracted data on
all ER and hospital visits analyzed in Component II
Discharge diagnoses for each visit were recorded in narrative form and then coded as one of the following categories:
MethodsVisits were coded as:
acute HIV-related
non-acute HIV-related
acute non-HIV-related
non-acute non-HIV-related
Results
There were 24 ER visits:• 3 (13%) resulted in a hospital admission• 2 (8%) were HIV-related but not acute• the remainder (79%) were HIV-related
or -unrelated acute and necessary
Discussion Ancillary services are associated with
improved retention and several improved clinical outcomes for high-risk, HIV-infected children
Children receive appropriate changes in services as needs change suitable allocation of resources
Limitations Sample size Selection bias
selection for services referral patterns available medical records
Retrospective design Use of secondary data Lack of control group Some social services are available from multiple
sources besides FACES Blurring of maternal and child service receipt Complex needs -- difficult to quantify stressors
Strengths One of few evaluations of HIV- and
child-specific ancillary service programs
Longitudinal analysis with individual-level data
Needs adjustment factor adjusts for changing needs in a dynamic fashion
For more information...
Please contact FACES at 504-821-4611
or email [email protected]
Please accept our thanks for your attention.