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THE GREATER CLEVELAND HIV CARE
CONTINUUM
FINDINGS FROM THE GREATER CLEVELAND HIV HEALTH
INFORMATION PROJECT (CHHIP)
Ann Avery, MDMetroHealth Medical Center
Objectives
1. Describe the local HIV care continuum
2. Understand trends and factors affecting HIV retention in care and viral suppression
Disclosures
Gilead- Participated in the Steering Committee for PrEP
HIV Continuum of Care
Test and Treat- and problems with the concept
MMWR Dec 2,2011. Vol. 60 , No. 47
35%
National HIV/AIDS Strategy ( NHAS)
Reducing New HIV infections (by 25%)
Increasing Access to Care and Improving Health Outcomes for People Living with HIV
Reducing HIV-Related Health Disparities
Challenges to a local Health Care Continuum (HCC)
• Ohio Department of Health (ODH) does not provide data to care information ( though planned)
• Local Health Dept ( CDPH) data is different than ODH
• Ryan White data does not cover entire population
• Patients that move in or out of area and not necessarily accounted for by health department
• A single system would limit generalizability
• No one single source for desired information
CHHIPGREATER CLEVELAND HIV HEALTH
INFORMATION PROJECT
LEVERAGING EMRS TO IMPROVE HEALTH OF PATIENTS LIVING WITH HIV/AIDS (PLWHA)
The GoalDevelop & pilot community-wide clinical information systemoBuild data system that integrates quality metrics (i.e., CD4 count, viral load, treatment adherence) with patient characteristics & needs (i.e., demographics, risk factors, co-morbidities, food stamp use)
Optimize individual and population healthoCoordination of intervention activities for all practicesdelivering care to PLWHA
Electronic Medical Records (EMR)
Epic is used in most partner organizations, all have some type of EMRoLabs
oAmbulatory visits
oMedical co-morbidities
oUtilization (hospital, ED)
Outcome vs Process
Process
-was the appropriate diagnostic or monitoring test completed or captured?
Outcome
-what was the result?
Better Health Greater ClevelandIndependent, grant-funded 501(c)(3)oEstablished in 2007oRobert Wood Johnson Foundation’s Aligning Forces for Quality initiativeoLeverages data to identify opportunities & best practices in improving care & outcomes within a peer network of primary care professionalsDiabetesHypertensionHeart failure
Why Cleveland Rocks!
•Comprehensive connection of HIV care providersoCurrent CHHIP partners oUH, CCF, Care Alliance, Free Medical
oAgreed upon HIV care standards & metricsoMaximize delivery impact on both individual & community•Dedicated manpower for population management•Consistent identifier to track movement
CDPH participation for all reported cases
Bi-directional sharing to determine:
1. people who are HIV+ but not reported to the health department
2. people who have died or moved out of the area
3. people who are HIV+ (tested by health department) but not linked to care
Who is missing from data?
Veteran’s Administration Medical Center ( VAMC)
AIDS Health Care Foundation
St Vincent Charity
Some community CCF sites ( new in 2016)
Free Medical Clinic (missing only for 2015-16)
Small non- affiliated providers
Ryan White HIV Care Continuum
Cuyahoga County Board of Health Ryan White Part A program- CareWare data
0
500
1000
1500
2000
2500
3000
3500
4000
Total unique #reported in the
time period(year)
# linked (1 visitin year)
# engaged (visitin 1st and 2nd
half)
# engaged (CD4or VL in 1st and
2nd half
prescribed HIVmeds in any
quarter
# undetectable
2777
2532
17931695
2226
1545
3729
3192
21481982
2288
2552
Cuyahoga County HIV HCC 2016
Y2012 Y2013 Y2014 Y2015 Y2016
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
# linked (1 visit inyear)
# engaged (visit in1st and 2nd half)
# engaged (CD4 orVL in 1st and 2nd
half
prescribed HIV medsin any quarter
undetectable (<200)
Cuyahoga County HIV Care Continuum 2012-2016
Y2012 Y2013 Y2014 Y2015 Y2016
Source: Ohio Department of Health Persons Living with a Diagnosis of HIV Infection Reported in Ohiohttps://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/health-statistics---disease---hiv-aids/2016/Ohio2016.pdf?la=en
39544179
4381 45124662
27772994
31893338
3729
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Y2012 Y2013 Y2014 Y2015 Y2016
Reported HIV Prevalence in Cuyahoga County by ODH vs CHHIP data
Reported number living with HIV Reported in CHHIP data
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
Y2012 Y2013 Y2014 Y2015 Y2016
39.1%42.4%
50.2%50.5%
54.7%
Cuyahoga County undetectable (<200)
Uses CHHIP data 2016 and reported prevalence from ODH for denominator
Data from MHS, UH, Care Alliance and Cleveland Clinic
0
500
1000
1500
2000
2500
3000
3500
4000
Total unique #reported in the
time period(year)
# linked (1visit in year)
# engaged(visit in 1st
and 2nd half)
# engaged(CD4 or VL in1st and 2nd
half
prescribedHIV meds inany quarter
#undetectable
(< 200)
CHHIP Cuyahoga County 2016
80%%
Males n=2914, Females n=815
85.4 86.3
56.860.6
52.555.6
79.9 80.2
Cuyahoga County HCC by gender
Data from CHHIP 2016
12271098
775710
946
2288
1912
12461163
1455
0
500
1000
1500
2000
2500
Total unique # reported inthe time period (year)
# linked (1 visit in year) # engaged (visit in 1stand 2nd half)
# engaged (CD4 or VL in1st and 2nd half
# undetectable
2016 Cuyahoga County HCC AA vs White
White or Caucasian African American or Black
76%
86%
Data from CHHIP 2016
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Total unique #reported in the time
period (year)
# linked (1 visit inyear)
# engaged (visit in1st and 2nd half)
# engaged (CD4 orVL in 1st and 2nd
half
# undetectable
HCC 2016 Ethnicity
Non-Hispanic (n=3412) Hispanic (n=298)
Data from CHHIP 2016
2016 HCC by age group
85.7
77.5 79
.581
.0 85.5 89
.0 91.7
57.1
38.0 43
.451
.4 56.4
63.4
72.1
57.1
35.7 39
.946
.8 52.3
59.3
65.3
75.0
60.0
67.2
75.0 79
.886
.287
.1
Data from CHHIP 2016
Data from CHHIP 2016
84.1
89.6
97.8
53.9
68.0
87.5
51.2
57.9
72.8
80.1 78.782.7
Depression/Psych Status 2
Total unique # reported in the
time period (year)
# linked
(1 visit
in year)
# engaged
(visit in 1st and
2nd half)
# engaged (CD4 or
VL in 1st and 2nd
half
prescribed HIV meds
in any quarter
medical visit
within period
# undetectable
None 2928 2463 1577 1498 1558 2463 1973Yes, < 2 Psych Visits 665 596 452 385 599 596 469
Yes, >= 2 Psych Visits 136 133 119 99 131 133 110
Primary Insurance Class
Total unique # reported in the
time period (year)
# linked
(1 visit
in year)
# engaged
(visit in 1st and
2nd half)
# engaged (CD4 or
VL in 1st and 2nd
half
prescribed HIV meds
in any quarter
medical visit
within period
# undetectable
Missing or Unavailable 46 46 21 9 37 46 24Commercial or Private 1035 926 604 571 608 926 789
Medicaid 1576 1338 880 795 992 1338 997Medicare 794 715 548 517 513 715 618
Uninsured or Self-Pay 207 106 55 56 74 106 69Other Class 71 61 40 34 64 61 55
Data from CHHIP 2016
89.584.9
90.1
51.2
85.9
58.455.8
69.0
26.6
56.3 55.250.4
65.1
27.1
47.9
85.2
74.5
86.4
65.1
90.2
Cuyahoga County HCC by Insurance Status
Neighborhood Income
Total unique # reported in the time
period (year)
# linked (1 visit
in year)
# engaged
(visit in 1st and
2nd half)
# engaged (CD4 or
VL in 1st and 2nd
half
prescribed HIV meds
in any quarter
medical visit
within period
# undetectable
($0K ,$20K] 215 183 108 95 188 183 129($20K , $30K] 850 701 447 373 707 701 523($30K , $40K] 753 607 391 340 618 607 483($40K , $50K] 734 641 441 367 613 641 497($50K, ] 585 515 329 286 499 515 427
Data from CHHIP 2016
85.5 85.1 83.988.4
86.0
51.956.5 55.0
62.159.0
47.751.3 50.7
56.0 57.1
70.9
77.880.1 81.0
85.8
Cuyahoga County 2016 HCC by Neighborhood Income
97.3 97.2 98.2 98.3
69.9
80.877.4 79.1
76.5
84.9
78.7 78.9
59.5
81.884.3
92.0
Cuyahoga County 2016 HCC by Immune Status
Data from CHHIP 2016
Highest rate of reported cases 65%
viral suppression
2nd highest rate of
reported cases 70%
viral suppression
Conclusion
Viral suppression is excellent among patients who engage in the care system- even if just once in a year
Efforts should be coordinated and target to address disparities
Priority groups are youth, poverty and those with advanced disease
Acknowledgements
CHHIP PartnersAlan Taege & Sarah Schram(CC)Barbara Gripshover & Michelle Kucia (UH)Lisa Navracruz & Rachel Deighton (CA) Adriana Whelan & Fatima Warren (Circle)Sister Susan (St Aug)
IS staff at MHS, CC and OCHIN
Data Management and StatsSteve LewisAshley TillisonMichelle Del Toro
FundingMelissa FedermanThe Board of AIDS Funding Collaborative
