ARV MANAGEMENT: Is Anybody Home?

HIVQUAL Workshop

BRUCE AGINS MD MPHOctober 15th, 2003

The ARV Indicator

ARV Data

The Letter

The Responses

Next Steps

The ARV Indicator

What’s an Unstable Patient Anyways?

Stable Patient: Definition

Viral load is undetectable, or Viral load has dropped by at least one

log since last 4-month review period, or Viral load has increased by less than 3X

from the lowest value in last 12 months on that regimen and

A note in the patient record by the treating physician states that the patient is stable despite detectable viral load

Stable Patient: Considerations for the Reviewer

Viral load is dropping (but not yet undetectable) or

VL has increased by less than 3X from the lowest value in last 12 months, or

A note in the patient record by the treating physician states that the patient is stable despite detectable viral load

Stable Patient: Appropriate Management

Monitoring of viral load every 4 months

Unstable Patient: Definition

Viral load is increasing by more than 1 log and absolute value is over 1,000; or

CD4 is dropping by 50% since last 4-month review period or

Patient deemed unstable by physician or

OI in the last four month review period (new or recurrent); or

Unstable Patient: Appropriate Management

Three Options:– Regimen was changed and viral load assay

performed within 8 weeks of decision– Justification provided not to change therapy

• intercurrent illness, recent vaccination, adherence intervention documented, viral load reordered, resistance testing ordered, other and

• viral load assay performed within 8 weeks of decision

– Decision made to discontinue therapy and clinical follow-up plan noted in record

Unstable Patient: Appropriate Management

Ultimately, the decision about whether the patient is stable or unstable is made by the clinician

The Data

Data: AIDS Institute Response

Review of data raises concerns about appropriateness of care about management of ARV in unstable patients

Staff review medical records to assess validity of indicator and discover causes of poor performance

Review confirms that the data are accurate Concern raised to Advisory Committee which

recommends that we send letter to facilities to raise awareness

Data: Advisory Committee Suggestions

Send letters asking for explanation & to review systems of care for ARV management

Arrange individual meetings to discuss low scores Highlight below average results in reports Develop tracking forms with prompts to address

abnormal results Develop best practices to improve ARV

performance

Data: Advisory Committee Suggestions

Think about systems problems– Delays in lab results– Panic Value Systems– Direct transmission of results to medical

directors Correlate with HIV Specialist data Provider education focusing on management of

patients with high viral loads receiving antiretroviral therapy

Data: Mailing

Non-HIVQUAL sites:– 2001 data mailed to facilities

HIVQUAL sites:– Data entered and can be produced by

facility

The Letter

The Letter

Sent to facilities with performance of 70% or lower

Mailing date of January 8, 2003 Results in red and boxed Copies sent to Program Medical Director and

Program Administrator Asks facilities to review management of ARV in

their clinic as part of their HIV Quality Management Program focusing on systems

Respond to me via phone or email to discuss findings by early March, 2003

The Responses

Responses: Individual Factors

Physician not managing patients appropriately

Documentation poor by specific physicians

Responses: Indicator Issues

For patients with high viral loads, when the decision is made not to change therapy, VL does not need to be rechecked in 8 weeks

Inappropriate management for not ordering a resistance test?

Only one value is below threshold for ARV [should have been appropriate if documentation was provided since therapy was not offered]

Won’t pick up special case – no need for action or change [intercurrent illness diverting attention from ARV management and documentation]

Changes: Flow Sheets

Comprehensive flow sheets with key components of HIV care– HIV issues included now in routine visit sheet

Standardized forms covering the following areas: -CD4 and Viral load monitoring + trends -Triggers for VL>1000 -Adherence referrals -Defined follow-up intervals -Specific ARV management parameters -New medical visits Add HIV elements to standard medical visit sheet Medication flow sheet with documentation about

adherence

Changes: Provider Education

Review of guidelines and indicator definitions– Discuss concepts of stability/instability at physician meeting,

including management of ARV Integrate ARV management into routine provider meetings Specific education about ARV management to frontline

clinician staff Documentation requirements, including f/u of VL Adherence tools Meetings with HIV Specialist Preceptorships Increase number of HIV Specialists Attendance at IAS conferences Offer CME credits for HIV training

Changes: Provider Education (2)

Discuss when ARV should not be given Tighten resident supervision Train case workers about ARV management and

importance of routine monitoring Updates in HIV care at monthly provider meetings Weekly clinical conference for providers to

discuss complicated ARV decisions Attending review of fellows management

decisions Grand Rounds Case Presentations and seminars by HIV experts

Changes: Medical Director Involvement

Feedback to frontline practitioners Letter sent by medical director to medical staff

about guidelines for unstable patients Assign medical director as backup for complex

cases Designate clinician lead at each site Monitoring of clinical decisions by medical

director with random chart review Medical Director follow up on findings from

chart audits

Changes: Reminder Strategies

Follow-up calls by case manager or nurse Letters to no-shows Call no-shows Enhance outreach program Call before appointment Tickler file to send cards out for appointments Comprehensive no-show program – including

patient input into process for follow-up & checking in after visit - Montefiore

Changes: Self-Management

Patient Education/Empowerment Treatment readiness program, including importance of

keeping appts. Side effects education Information system with new appointment system to

easily track appointments Automated reminder system Database to track followup appointments and outcomes Incentives Patient diary to track labs, treatment, provide tips

about adherence and other educational materials Enhance role of CAB in reviewing data

Changes: Home Visits

COBRA Nursing staff VNS Adherence - ?DOT

Changes: Information Systems

Tracking databases QA database showing multiple

parameters Automated appointment tracking Scheduling database Use EMR data to monitor care

Changes: Tracking Systems

Logbooks Facilitate contact of no-shows Complete baseline assessments Create list of unstable patients, update

and use for tracking, referrals to multidisciplinary team

Routine updating of list of visits and missed appointments with direct feedback to medical providers

Changes: Documentation

Emphasize importance & general improvements Adherence counseling CM interventions included in record Reorganize medical records Clearly state in record whether patient is stable or

unstable Documentation of side-effects Incorporate pharmacy provider into adherence form

(Interfaith) Improve documentation of decision process about

ARV Hasten return of information and results to chart Information about no-shows

Changes: Documentation (2)

Stamp for progress note that includes criteria and stable/unstable status for use at every encounter (LICH)

Modify medical history and physical forms to improve documentation about ARV management

Patients sign that they are choosing not to take ARV (can reverse decision) [ENY]

Progress note developed to document & prompt providers at each visit to address & review CD4, VL, treatment plans, with prompt to document rationale for decisions & issues

leading to unstable status

Changes: QI Plans

Specific ARV QI Plan (Elmhurst, Scruggs) Unstable Patients Plan: (Middletown) -Review case with clinical coordinator -Contact case manager -use adherence information form -flag for resistance test or repeat VL -case conference Unstable Patients Plan -MD review -Team review -Tracking -Increase HIV Specialist involvement -Focused plans to facilitate adherence, expedite &

enhance access to multidisciplinary team services Monitor timeliness of viral loads

Changes: Lab Issues

Simplify review of results Shorten turnaround time for results Posting of results to computerized lab system,

including resistance testing Coordinate blood drawing with visit Staff drawing blood will ensure f/u clinic visit

scheduled in two weeks Loosen lab restrictions for processing

specimens Lab Error Plan (see next slide)

Responses: Lab Issues

Lab Error Plan (Scruggs)– Identify when blood not drawn or not picked up– Flag missing results for follow up– Nurse communicates routinely with lab staff– Lab log to track when labs were completed for checking

results within 14 d of draw– Immediate rescheduling if labs not obtained– CM and outreach staff to bring patient for labs– Coordinate with lab staff/address IS issues– Ongoing performance measurement

Changes: Case Conferencing

Focus on difficult cases Routine quarterly adherence

discussions Include as part of monthly provider

meeting in clinic

Changes: Adherence

Promote enrollment into adherence program Comprehensive treatment adherence services Increase referrals by physicians to adherence

counselors Increase appointment-keeping for labs Routine monitoring quarterly by case manager Pts who miss appts. meet with Medical

Director or administrator and may be referred elsewhere

Changes: Performance Measurement Routine medical record reviews: monthly, quarterly, Random ARV management reviews Independent reviewer Specific reviews of patients >1000 copies to

determine if unstable, and if so flag for special review Review of charts by medical director Modify indicators to incorporate indicators from

guidelines Develop new indicators to measure care of unstable

patients on ARV Review all unstable patients QA Database: shows values which can be flagged QOC review teams – multidisciplinary (Narco)

Changes: Staff & Visits

Hire new case managers

Special medication visit for unstable patients

Changes: Pharmacy Involvement

Delivery of medications onsite to ensure pickup whenever refills are due

Pharmacist onsite in clinic to discuss changes in regimen

Integrate pharmacy into adherence form

Responses: Systems Issues

Community Resources– Referral processes to CBOs documented

Other Responses

Patients who are non-adherent substance users and shouldn’t be counted in the sample

Patients don’t return for their lab tests or visits (“no shows”)

Results

Improvements have already been measured

Next Steps andSome Preliminary Observations

What Have We Learned So Far

Where’s the Data? Routine monitoring and QI that focuses

on ARV management is not occurring Minor tinkering with the indicator is

indicated Many providers pay attention to letters

flagging poor result

What Have We Learned So Far

Difficult issues to resolve include “no-shows” and complicated patients– Challenges of documentation– Complexity of management– Some innovative strategies!

Conclusions

Most people are home Lots of interesting innovations Some full-scale QI plans and programs Some are still stuck A handful are still not home

Next Steps

Responders– Encouragement– Ongoing follow-up– Some still need to provide QI information!– Follow up: compare subsequent results– Letter

Compilation of Best Practices and Innovative Solutions