the impact of integrated hiv care on patient health outcomes
DESCRIPTION
The Impact of Integrated HIV Care on Patient Health Outcomes. Tuyen Hoang, PhD Matthew B. Goetz, MD, Elizabeth Yano, PhD, Barbara Rossman, PhD, Henry D. Anaya, PhD, Herschel Knapp, PhD, Steven M. Asch, MD MPH. Background. The key factor to control HIV is adherence to HIV medications - PowerPoint PPT PresentationTRANSCRIPT
The Impact of Integrated HIV The Impact of Integrated HIV Care on Patient Health OutcomesCare on Patient Health Outcomes
Tuyen Hoang, PhDTuyen Hoang, PhD
Matthew B. Goetz, MD, Elizabeth Yano, PhD, Matthew B. Goetz, MD, Elizabeth Yano, PhD,
Barbara Rossman, PhD, Henry D. Anaya, PhD, Barbara Rossman, PhD, Henry D. Anaya, PhD,
Herschel Knapp, PhD, Steven M. Asch, MD MPHHerschel Knapp, PhD, Steven M. Asch, MD MPH
BackgroundBackground
• The key factor to control HIV is The key factor to control HIV is adherence to HIV medicationsadherence to HIV medications
• Co-morbidities impede adherenceCo-morbidities impede adherence
Mental disordersMental disorders
Substance abuseSubstance abuse
Hepatitis CHepatitis C
Integrated HIV Care in the VAIntegrated HIV Care in the VA
PHARMACISTPHARMACIST
HIV SPECIALISTHIV SPECIALIST
PSYCHIATRISTPSYCHIATRIST
SOCIAL WORKERSOCIAL WORKER
PSYCHOLOGISTPSYCHOLOGIST
Research QuestionsResearch Questions
• Would integrated HIV care enable Would integrated HIV care enable providers to manage co-morbidities more providers to manage co-morbidities more effectively?effectively?
• Would access to Would access to more comprehensivemore comprehensive integrated care lead tointegrated care lead to better control better control of of HIV?HIV?
Study DesignStudy Design
Study populationStudy population– Retrospective cohort of HIV-infected veteransRetrospective cohort of HIV-infected veterans– Five VA facilities in western U.S.Five VA facilities in western U.S.– Oct 2000 to April 2006Oct 2000 to April 2006
Eligibility criteriaEligibility criteria– Receiving HIV treatment in the VAReceiving HIV treatment in the VA– Sufficient baseline severity Sufficient baseline severity – 3+ months of follow-up3+ months of follow-up
Data SourcesData Sources
QuantitativeQuantitative– VA regional data warehouse: demographics, VA regional data warehouse: demographics,
visits, lab tests, diagnoses, pharmacy visits, lab tests, diagnoses, pharmacy prescriptions and refillsprescriptions and refills
QualitativeQualitative– Interviews with chiefs of the HIV clinics to Interviews with chiefs of the HIV clinics to
obtain descriptions of integrated servicesobtain descriptions of integrated services
Four Levels of ComprehensivenessFour Levels of Comprehensiveness
Components of HIV clinicsComponents of HIV clinics Comprehensive LevelComprehensive Level
44 33 22 11Physician assistant, nurse practitionersPhysician assistant, nurse practitioners xx xx xx xx
Clinical coordinatorClinical coordinator xx xx xx xx
HIV physician specialist HIV physician specialist xx xx xx
Dedicated pharmacist Dedicated pharmacist xx xx xx
PsychiatristPsychiatrist xx xx
Social worker Social worker xx xx
Psychologist Psychologist xx
Distribution of Integrated HIV Care Users Distribution of Integrated HIV Care Users (N=1,069)(N=1,069)
3%3%
I onlyI only
Multi-level usersMulti-level users
II onlyII only III onlyIII only IV onlyIV only
27%27%
5%5% 8%8%
57%57%
Single-level usersSingle-level users
Utilization IndexUtilization Index
PatientPatient ComprehensivenessComprehensiveness ScoreScore
Level 4Level 4 Level 3Level 3 Level 2Level 2 Level 1Level 1
AA 00 00 11 11 33
BB 00 11 00 11 44
CC 00 22 00 22 88
Survival AnalysesSurvival Analyses
First analysisFirst analysis (N=459 single-level users) (N=459 single-level users)
Time to viral suppression Time to viral suppression comprehensive levelscomprehensive levels
Second analysisSecond analysis (N=610 multi-level users) (N=610 multi-level users)
Time to viral suppression Time to viral suppression utilization indexutilization index
Demographics of Study PatientsDemographics of Study Patients
CharacteristicsCharacteristics Statistics Statistics
Eligible patients, N Eligible patients, N
1,0691,069
Age, mean (SD)Age, mean (SD) 51 (9.4)51 (9.4) Caucasian, African A. (%)Caucasian, African A. (%) 34, 2434, 24 Never married (%)Never married (%) 5757 Low income (%)Low income (%) 7676 Homeless (%)Homeless (%) 1818
Clinical characteristics of PatientsClinical characteristics of Patients
CharacteristicsCharacteristics Statistics Statistics
Had co-morbidities (%) Had co-morbidities (%)
9393
No. of co-morbidities per patientNo. of co-morbidities per patient 33 Mental disorders (%)Mental disorders (%) 5656 Hepatitis B (%)Hepatitis B (%) 4949 Hepatitis C (%)Hepatitis C (%) 3333 Drug use (%)Drug use (%) 3131
FactorsFactors Adjusted Hazard ratiosAdjusted Hazard ratios
Multi-level usersMulti-level users(n=610)(n=610)
Single-level usersSingle-level users(n=459)(n=459)
AgeAge 0.960.96 1.001.00
Marital status (Single)Marital status (Single) MarriedMarried Widow/divorced/separatedWidow/divorced/separated
1.211.211.331.33
1.121.12
1.351.35
Low incomeLow income 0.760.76 0.850.85HomelessHomeless 0.730.73 0.990.99
STDSTD 1.061.06 1.55 1.55
Number of co-morbiditiesNumber of co-morbidities 1.041.04 0.960.96
Baseline HIV viral loadBaseline HIV viral load 0.960.96 0.930.93
Baseline CD4Baseline CD4+ + countscounts 1.001.00 1.061.06
Factors Associated with Viral SuppressionFactors Associated with Viral Suppression
Factors Associated withFactors Associated with Viral SuppressionViral Suppression
FactorsFactors Adjusted Hazard ratiosAdjusted Hazard ratios
Multi-level usersMulti-level users(n=610)(n=610)
Single-level usersSingle-level users(n=459)(n=459)
Access to medicationAccess to medication 2.042.04 1.911.91
Utilization indexUtilization index 1.121.12 n/an/a
Compared to Level 2Compared to Level 2 Level 1Level 1 Level 3Level 3 Level 4Level 4
n/an/a0.940.94
1.621.62
2.632.63
Visit frequencyVisit frequency n/an/a 1.431.43
ConclusionsConclusions
HepatitisHepatitisPsychiatric Psychiatric
PsychologicalPsychologicalSocial services Social services
HIV HIV primary primary
carecare
ViralViralsuppressionsuppression
2.6 times2.6 timesmore likelymore likely++
ImplicationsImplications
• Resources should be allocated to Resources should be allocated to channel patients toward comprehensive channel patients toward comprehensive integrated HIV care clinicsintegrated HIV care clinics
• Findings may be relevant for other Findings may be relevant for other chronic conditions that require principle chronic conditions that require principle care in subspecialty clinicscare in subspecialty clinics