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DataforCare(D4C)AlabamaAClinic-Wide,RiskStra<fica<onReten<oninCareInterven<onMichaelJ.Mugavero,MD,MHSconbehalfofD4CALTeamUniversityofAlabamaatBirmingham(UAB)Co-DirectorUABCenterforAIDSResearch
HIVTreatmentCascade(CareConInuum),2014–U.S.
hNps://www.cdc.gov/hiv/pdf/library/slidesets/cdc-hiv-prevenIon-and-care-outcomes.pdf
Background
§ ImprovingretenIonincare(RiC)thegreatestopportunityalongcareconInuumtoadvanceprevenIonandtreatmentbenefitsforPLWH
§ Incontrasttolinkagetocare(e.g.,ARTAS)and
re-engagementincare(e.g.,D2C),nolargescaleprogramsimplementedforRiC
§ UniqueinfrastructureaffordedbyRWHAPforsystemaIc,clinic-wideHIVRiCprogram(s)
DataforCare(D4C):“BigPicture”
§ RiskstraIficaIon:Clinic-wideriskstraIficaIonbaseduponmissedvisitsprior12months
§ ResourceallocaIon:DeliveryofREPC
intervenIontointermediateandhighriskpaIents(+bestavailableRiCresourcesforHR)
§ ConInuousqualityimprovement:IteraIveclinic-wide(andindividual)monitoring,riskstraIficaIon,andtargetedRiCservicedelivery
WhyFocusonMissedVisits?
§ Missed(“noshow”)HIVvisit(s)associaIons:Ø DelayedARTiniIaIon&longerImetoVSØ Gapsincare&losstofollow-upØ GreatercumulaIveviralloadØ Racial/ethnicdispariIesØ Mortality
§ Missed(“noshow”)HIVcarevisits
Ø UniquelycapturedbyHIVmedicalclinicsØ Immediatelymeasured&acIonable
Mugaveroetal.ClinInfectDis2009;48,Zinskietal.AJPH2015;105,Thompsonetal.AnnalsofInternalMedicine2012;156
Retention in Care measure
Need missed visit data?
Ease of calculating
Follow-up time
Missed visits Yes Easy ~1 day
Appointment adherence
Yes Moderate ~1 yr
No-show rate Yes Moderate ~1 yr
Constancy: Visit per 3, 4 or 6 mo intervals
No Moderate ~1 yr
Gap in care No Easy ~1 yr
HRSA/HAB No Mod-to-difficult 1 yr
DHHS No Mod-to-difficult 2 yrs
Adaptedfrom:GiordanoTP(2012)MeasuringretenIoninHIVcare.www.medscape.com.
D4CRiskStraIficaIon
§ Dataquery:missedprimaryHIVcarevisitsprior12monthsØ LOWrisk:zeromissedvisitsØ INTERMEDIATErisk:1-2missedvisitsØ HIGHrisk:>3missedvisits
§ Matchclinic-wideriskstraIficaIonwith
appointmentschedulingsystemforupcoming3monthsidenIfyingscheduledappointmentsforINTERMEDIATEandHIGHriskpaIents
CNICSRiskStraIficaIon(n~12,000)
Pence.11thInternaIonalConferenceonHIVTreatmentandPrevenIonAdherence,FtLauderdale,FL;9-10May2016,AIDS&Behavior(underreview)
D4CResourceAllocaIon
§ INTERMEDIATEandHIGHriskpaIentsreceiveevidence-basedretenIonthroughenhancedpersonalcontact(REPC)
D4CResourceAllocaIon:REPC
Enhancedpersonalcontact(EC)
Interim phone call
Reminder phone calls
Missed visit phone calls
Brief face-face visits
ECplusbehavioralskills(EC+)
Strengths-based discussion at 2-week visit
Unmet needs assessment & skills modules:
Organizational skill
Communicating skills
Problem skills
Standardofcare(SOC)
Usual practices for established and new patients
Referrals to social worker or case manager, as usually done
Usual visit reminders (automated or individual, telephone or written, etc)
D4CResourceAllocaIon:REPC
GardnerLIetal.ClinInfectDis2014;59;ShresthaRKetal.JAIDS2015;68
REPCTakeHomePoints:§ 10%increaseinRiCbyConstancy&HRSAHAB§ 5%increaseinvisitadherence§ Noaddedbenefitofskillsmodules(EC+)§ Efficacious:women,AA/Black,lowSES§ Dose-responseb/t#ofcontacts&RiC§ NOTefficacious:unmetneed(s),illicitdruguse
D4CResourceAllocaIon
§ INTERMEDIATEandHIGHriskpaIentsreceiveevidence-basedretenIonthroughenhancedpersonalcontact(REPC)
§ HIGHriskpaIentsreceivehighestintensityresourcesavailableateachclinic(e.g.,intensivecasemanagement,peermentor,outreach)
§ LOWriskpaIentsreceive24-48hourmissedvisitcallandtransiIontoINTERMEDIATEriskforremindercontacts
D4CAlabama(D4CAL)
§ Design:Non-randomizedstepwedge§ Sites:7RyanWhiteHIVClinicsinAlabama
§ Data:Individual-levelandclinic-widesocio-demographic,lab,andvisitdatamirroringRSR
§ EvaluaIon:Processandoutcomemetrics
“TheAlabamaRegionalQualityManagementGroupexiststoensurethatthoselivingwithHIV/AIDSinthestateofAlabamareceivequalityhealthcarethroughthecollaboraIonofhealthcarepartnersthroughoutthestate.ThiscollaboraIonaimstoconInuouslyimprovethequalityofHIVcareconsistentwithrecognizednaIonalstandardsandcurrentHIVresearch”
CourtesyofAshleyTarrant,MAO,andJiteshParmar,ThriveAlabama
AlabamaRegionalQualityManagementGroup(ALRQG)
A B
D
G H
CourtesyofAshleyTarrant,MAO,andJiteshParmar,ThriveAlabama
ALRQG;Missedvisitindicator
D4CAL:CQIusingPDSAFramework
D4CAlabama(D4CAL):Timeline
D4CAlabama(D4CAL)Metrics
§ Process:Ø Fidelityofclinic-wideriskstraIficaIonØ FidelityofREPCreminder&missedvisitcallsØ Measuring“best”RiCprogramsforHR@sitesØ FidelityofHRpaIentsreceiving“best”RIC
§ Outcomes:Individual-levelandclinicwideØ Missedvisits,visitadherence&HRSAHABØ ViralSuppression
§ ImplementaIonScienceMetrics?
Acknowledgements
§ JiteshParmar(THRIVE),AshleyTarrant(MAO)&ALRQGSiteLeadsandClinicDirectors