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in+care CampaignMeet the Author

December 12, 2012

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Agenda

• Welcome & Introductions, 5min• Low-Effort Clinic-Wide Intervention to

Increase Patient Retention In Care, 30min• Q & A Session, 20min• Updates & Reminders, 5min

Preliminary Findings From CDC/HRSA

Retention in Care Project

Division of HIV/AIDS Prevention

Centers for Disease Control and Prevention

The findings and conclusions in this presentation are those of the presenters and do not necessarily represent the view of CDC or HRSA

CDCLytt Gardner, lead CDC investigator

Gary Marks, Co-I

Jason Craw, Co-I/study coordinator

HRSA InvestigatorsFaye Malitz, Robert Mills, Laura Cheever

Mountain Plains AETCLucy Bradley-Springer, Marla Corwin

6 HIV Clinics InvestigatorsBoston University Medical Center, Center for Infectious Diseases

Meg SullivanMari-Lynn Drainoni

STAR Health Center, SUNY Downstate Medical Center, Brooklyn, NY

Tracey Wilson

Moore HIV Clinic, Johns Hopkins University, Baltimore, MD

Richard MooreJeanne Keruly

Jackson Memorial Hospital Adult HIV Clinic, Miami, FL

Allan RodriguezLisa Metsch

1917 HIV Clinic, University of Alabama, Birmingham

Michael MugaveroMichael Saag

Thomas Street Health Center, Baylor College of Medicine, Houston

Tom GiordanoJessica Davila

Objective• To identify clinic-based interventions to promote regular

attendance for primary care and prevent loss to care

Two Studies Conducted in Two Phases

Characteristics of Intervention

Study 1 / Phase 1: low-dose, low effort, clinic-wide intervention

• Provider messages, brochures, visual cues (posters)

Study 2 / Phase 2: 3-arm randomized controlled trial (~300 patients per clinic)

• Enhanced contact with patients across time

• Improvement/reinforcement of patient skills relevant for clinic attendance

Timeline For The Two Phases

6/09 6/10 6/11 6/12 |------------|------------|------------|-------------|-------------|------------|------------| ▼ PHASE 1 clinic-wide intervention

▼ PHASE 2 RCT enrollment

▼ 12-month intervention period begins, per enrollee, and monitoring of attendance

▼ After

intervention ends, monitor attendance for 12 months, per enrollee

Focus of The Talk

Phase 1

•Brief description of methodology of clinic-wide intervention (Gary)

•Findings and conclusions (Lytt)

Phase 1: Features of Clinic-Wide Intervention

• Theme: “Stay Connected for Your Health”

• Provider messages about importance of regular care and keeping appointments

Working as a team Keeping you healthy Best possible care Staying ahead of the virus

• Brochure

• Posters (waiting room, exam rooms)

Anonymous Patient Exit Surveys (After Exam)6 months after the intervention started

(January, 2010 through April, 2010)

% Responding YES (n/N)

MD, NP or PA talked with them about the importance of keeping all appointments

88% (255/291)

Received “Stay Connected” brochure today or at any previous visit

58% (170/295)

Comparison Strategy & Outcome Measures for Phase 1

Serial cross-sectional comparisons

Pre-intervention period ▼ Intervention period 6/08 6/09 6/10 |---------------------|--------------------|--------------------|---------------------|

Comparison strategyOf patients exposed to intervention in first 6 months, looked at behavior after exposureCompared with behavior of patients in pre-intervention period after they had an anchor visit in the first 6 monthsOutcomes (attendance from clinic databases)•% who kept two consecutive PC appts after exposure•Appointment adherence: proportion of scheduled PC appts kept (excluding appts cancelled ahead of time)

Percent Who Kept Two Consecutive PC Appts After Exposure to Intervention

Percent Keeping Next Two PC ApptsOverall

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

Overall 49.3% N=8,535

52.7% N=9,227

7.0% < 0.001

Adjusts for changes across time in undetectable VL, age, health insurance, number of scheduled PC appointments, clinic

Percent Keeping Next Two PC Appts by Number of Scheduled PC Appts

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

2 -3 52.6%N=3,270

55.1%N=4,098

4.7% 0.003

4 - 6 49.4%N=3,589

53.4%N=3,600

8.2% <0.001

7 or more 45.4%N=1,676

50.8%N=1,529

12.0% 0.001

Adjusts for changes across time in undetectable VL, age, health insurance, clinic

Percent Keeping Next Two PC Apptsby Viral Load Status

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

Detectable VL >400 copies

44.4%N=2,998

51.5%N=2,940

16.0% < 0.001

Undetectable VL ≤ 400 copies

57.2%N=5,537

60.4%N=6,287

5.6% < 0.001

*Adjusts for changes across time in age, health insurance, number of scheduled appointments, clinic

Percent Keeping Next Two PC Apptsby CD4 Cell Count

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

CD4 cell count <350

49.8%N=3,443

55.0%N=3,616

10.3% < 0.0001

CD4 cell count≥ 350

53.3%N=5,012

56.4%N=5,376

5.7% < 0.0001

*Adjusts for changes across time in undetectable VL, age, health insurance, number of scheduled appointments, clinic

Percent Keeping Next Two PC Appts by New/Re-engaging vs. Active Patients

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

New orre-engaging patients

45%N=1,147

58% N=1,210

28.2% < 0.001

Active patients

48%N=7,388

51%N=8,017

5.3% <0.0001

*Adjusts for changes across time in undetectable VL, age, health insurance, number of scheduled appointments, clinic

Percent Keeping Next Two PC Apptsby Patient Age

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

16-29 40.5%N=470

48.6%N=577

19.9% 0.006

30-39 45.9%N=1,485

51.4%N=1,534

11.9% 0.0003

40-49 50.9%N=3,201

54.6%N=3,299

7.2% 0.0006

50-85 57.0%N=3,379

60.5%N=3,817

6.1% 0.0002

Adjusts for changes across time in undetectable VL, health insurance, number of scheduled PC appointments, clinic

Appointment Adherence: Proportion of Scheduled PC Appts Kept

Mean Proportion of Scheduled PC Appts Kept

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

Overall .68 N=9,407

.70 N=10,344

3.0% < 0.001

Adjusts for changes across time in undetectable VL, age, health insurance, number of scheduled PC appointments, clinic

Mean Proportion of Scheduled PC Appts Kept by Number of Scheduled PC Appts

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

1 -3 .65N=4,142

.68N=5,215

4.5% < 0.001

4 - 6 .705N=3,589

.72N=3,600

2.1% 0.003

7 or more .67N=1,676

.68N=1,529

1.5% NS

Adjusts for changes across time in undetectable VL, age, health insurance, clinic

Mean Proportion of Scheduled PC Appts Kept by Viral Load Status of Patients

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

Detectable VL> 400 copies

.62N=3,265

.66 N=3,213

5.5% < 0.0001

Undetectable VL≤ 400 copies

.72N=6,142

.74N=7,131

2.0% 0.0004

Adjusts for changes across time in age, health insurance, number of scheduled appointments, clinic

Mean Proportion of Scheduled PC Appts Kept by CD4 Cell Count

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

CD4 cell count <350

.66N=3,719

.70N=3,922

5.1% < 0.0001

CD4 cell count≥ 350

.69N=5,558

.70N=6,115

1.9% < 0.002

*Adjusts for changes across time in undetectable VL, age, health insurance, number of scheduled appointments, clinic

Mean Proportion of Scheduled PC Appts Kept by New/Re-engaging vs. Active Patients

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

New orre-engaging patients

.65N=1,310

.70 N=1,371

7.6% < 0.001

Active patients

.68N=8,097

.694N=8,973

2.4% <0.0001

Adjusts for changes across time in undetectable VL, age, health insurance, number of scheduled PC appointments, clinic

Mean Proportion of Scheduled PC Appts Kept, by Patient Age

Pre-intervention period

Intervention period

% relative improvement

GEE-based p-value

16-29 .60N=526

.66N=638

9.6% 0.0002

30-39 .67N=1,667

.68N=1,749

2.7% 0.06

40-49 .69N=3,554

.71N=3,739

2.8% 0.001

50-85 .74N=3,660

.76N=4218

2.5% 0.003

Adjusts for changes across time in undetectable VL, health insurance, number of scheduled PC appointments, clinic

Limitations

•Pre-post comparison with no concurrent control group

•Patient exit surveys were not available during the pre-intervention period (no comparison)

Conclusions

• Low effort clinic-wide intervention contributed to a modest boost in attendance for PC

• Stronger for “next two” (short term boost)• Waning effect for “visit adherence” (proportion of all

appts kept in 12-month period)

• Some small effects “significant” due to large N

Conclusions

For both outcomes, effects stronger for some sub-groups:

•New/re-engaging •Detectable VL •CD4 cell count < 350•Younger patients (16-29)

Effect of # scheduled visits differed by outcome variable

Boston Medical CenterMari-Lynn Drainoni (PI)Cintia FerreiraLisa KoppelmanRoosevelt LewisMaya McDoomMichal NaisteterKarina OsellaGlory RuizMeg Sullivan (PI)

The Retention in Care Study TeamSUNY Downstate Medical CenterSophia Gibbs-CohenElana DesrivieresMayange FrederickKevin GravesandeSusan HolmanHarry JohnsonTonya TaylorTracey Wilson (PI)

FederalLaura Cheever, HRSAFaye Malitz, HRSARobert Mills, HRSAJason Craw, CDC/ICF-MacroLytt Gardner, CDCSonali Girde, CDC/ICF-MacroGary Marks, CDC

U. of Alabama-BirminghamScott BateyStephanie GaskinMichael Mugavero (PI)Jill MurphreeJim RaperMichael Saag (PI)Suneetha ThogaripallyJames WilligAnne Zinski

Baylor-Houston, TXMonisha AryaDavid BartholomewTawanna BiggsHina BudhwaniJessica DavilaTom Giordano (PI)Nancy MiertschinShapelle PayneWilliam Slaughter

Johns HopkinsMollie JenckesJeanne Keruly (PI)Angie McCrayMary McGannRichard Moore (PI)Melissa OtterbeinLiming Zhou

U. Of MiamiCarolyn GarzonJesline Jean-SimonKathy MercoglianoLisa Metsch (PI)Allan Rodriguez (PI)Gilbert Saint-JeanMarvin Shika

Mountain Plains AETCLucy Bradley-SpringerMarla Corwin

Questions and Discussion

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Time for Questions and Answers

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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET

• Upcoming Webinars: • Optimal Wellness | Dec. 13, 2012 2pm ET

• Sustaining Retention Projects in Unsure Funding Environments | Jan. 9, 2013 2pm ET

• Mental Health & Retention | Jan. 10, 2013 2pm ET

• How Can We Increase Initiation Of and Retention In Care Among Persons Living With HIV? | Jan. 30, 2013 2pm ET

• Data Collection Submission Deadline: February 1, 2013

• Improvement Update Submission Deadline: December 17, 2012

Upcoming Events and Deadlines

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