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1-4 April 2014, Arena and Convention Centre Liverpool
THIRD JOINT CONFERENCE
OF BHIVA AND BASHH 2014
Dr Alastair TeagueGuy’s and St Thomas’ NHS Foundation Trust, London
Validation of the rationalization of routine blood tests and visits for
HIV-1 infected individuals
Olubanke Davies, Juan Tiraboschi, AnnemiekDe Ruiter, Alastair Teague, Julie Fox
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Guy’s & St Thomas’ NHS Foundation Trust has over
3000 regular HIV attendees
Majority of the patients are stable attending routine follow
up
Too many tests too frequently
Variation between clinicians as to which tests and when
Need for frequent monitoring reduced in view of newer
ARVs with improved efficacy and less toxicity
Already existing trend to request less pathology tests
Background
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Consultation process within the department to
review
Frequency of visits
Routine tests done
Review any changes in terms of Cost savings
Patient safety
Patient acceptability
HCP acceptability
2011
Stable uncomplicated patients
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Uncomplicated patients categorised into: New patient Stable not on ART Starting ART Stable on ART
Visit schedules created for each patient group Overall reduction visit frequency (eg six monthly) Increased use of non physician clinicians
Annual physician visit interim CNS visits
Algorithms placed in all clinic rooms
Consultation outcomes
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
pathology tests rationalised and formalised for each patient group and
visit
Eg on ARV annual visit bloods, on ARV interim visit bloods
Reduction in CD4 and VL monitoring
Annual CD4 when on treatment, annual VL when off it.
CD4 count 3/12 into treatment not at 1/12
Reduction in lipids to annual
Some instances just total cholesterol vs full lipid profile
Less frequent FBC
Measures in place to prevent inappropriate ordering
E.g. Hep B core antibody +
Consultation outcomes
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Pathology summary sheets created
Consultation outcomes
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Pathology order sets
on electronic ordering system created
Consultation outcomes
Demographics
April 2011-Mar 2012 April 2012- Mar 2013
Total cohort 2976 3132
Patient attendances 17610 17277
Median age 42.8 (IQR 30.1-55.5) 42.4 (IQR 30-55)
% Male 70.8 70.8
Median CD4 504 512
New Patients 320 304
Patients not on ART 485 501
Patients starting ARVS 196 181
Patients on ART 2492 2631
Outcomes- Pathology savings
April 2011-
Mar 2012
April 2012-
Mar 2013
Change/
saving
Number of CD4 tests done 9620 7528 - 22%
Total amount spent on CD4
tests
£23,280 £18,218 £5072
Number of VL tests done 8403 7882 - 6%
Total amount spent on VL tests £112,600 £105,619 £6981
Total amount spent on other
pathology tests
£491,120 £446,663 -9%
£44457
Total saving of £56,510
Safety
April 11-
Mar 12
April 12-
Mar 13
P-value
Total cohort 2976 3132
No of admissions 183 175 0.35
Number of emergency clinic visits 1215 894 <0.00001
-26%
Total no. of Resistance tests requested 373 429 0.18
Resistance tests requested 2° virological
failure
109 122 0.63
On ARVs with one or more major mutations 31 39 0.47
Lost to follow up 269 245 0.72
Number with CD4<350 off ART 53 55 0.97
148 patients surveyed
Asked to rate on 1 -5 scale (1- strongly disagree 5-strongly agree)
Outcomes-patient opinions
0% 25% 50% 75% 100%
Q1. I had not noticed any change in the numberof tests and frequency of visits.
Q2. I like having fewer test results to focus on.
Q3. I worry that there are risks in having fewerCD4 and viral load tests.
Q4. I would have liked to be told to expect thechanges.
Q5. I prefer the focus on more important tests.
Q6. I am happy with how the clinic manages mycare.
strongly disagree
disagree
neither agree nordisagreeagree
strongly agree
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
15 clinicians surveyed within the HIV department
87 % agreed in test rationalisation
100% said they would follow in practice !
Outcomes- clinician opinion
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Reduction in frequency of routine tests and visits in stable HIV-infected patients in our cohort has led to significant cost savings (£56.5k) with no short term safety concerns.
Conclusions
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
BHIVA monitoring guidelines released during our process – GSTT very similar
Increased use of non physician clinicians !
Evaluations carried out at other centres have found similar results: Gale HB, Gitteman SR, Hoffman HJ, et al. Is frequent CD4 T-lymphocyte count
monitoring necessary for persons with counts >300cells/μl and HIV-1 suppression. Clin Infect Dis 2013 56(9):1340-1343
Whitlock GG, Ahmed N, Benn P, Edwards S, Waters L. Stop routine CD4 monitoring in HIV infected patients with fully suppressed virus and CD4≥350 cells/ml. Clin Infect Dis 2013 57(2):327-328
Discussion
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
Dr Samuel Iff
Anna Tostevin, UK Drug Resistance database
Dr Siobhan O’Shea, Lead Clinical Scientist, GSTS Pathology
Department received a Gilead fellow ship grant
Acknowledgements
Third Joint Conference of BHIVA with BASHH (Liverpool 2014)
