Transcript Lytt Gardner Intervention Slides 12.12.12

in+care Campaign
Meet 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
3
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
CDC
Lytt Gardner, lead CDC investigator
Gary Marks, Co-I
Jason Craw, Co-I/study coordinator
HRSA Investigators
Faye Malitz, Robert Mills, Laura Cheever
Mountain Plains AETC
Lucy Bradley-Springer, Marla Corwin
6 HIV Clinics
Investigators
Boston University Medical Center,
Center for Infectious Diseases
Meg Sullivan
Mari-Lynn Drainoni
STAR Health Center, SUNY
Downstate Medical Center,
Brooklyn, NY
Tracey Wilson
Moore HIV Clinic, Johns Hopkins
University, Baltimore, MD
Richard Moore
Jeanne Keruly
Jackson Memorial Hospital Adult
HIV Clinic, Miami, FL
Allan Rodriguez
Lisa Metsch
1917 HIV Clinic, University of
Alabama, Birmingham
Michael Mugavero
Michael Saag
Thomas Street Health Center,
Baylor College of Medicine,
Houston
Tom Giordano
Jessica 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,
• Provider messages, brochures, visual
low effort, clinic-wide intervention
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
▼
Intervention period
6/08
6/09
6/10
|---------------------|--------------------|--------------------|---------------------|
Pre-intervention period
Comparison strategy
Of patients exposed to intervention in first 6 months, looked at behavior after
exposure
Compared with behavior of patients in pre-intervention period after they had
an anchor visit in the first 6 months
Outcomes (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 Appts
Overall
Preintervention
period
Overall
49.3%
N=8,535
Intervention % relative
period
improvement
52.7%
N=9,227
7.0%
GEE-based
p-value
< 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
Preintervention
period
Intervention % relative
period
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 Appts
by Viral Load Status
Preintervention Intervention
period
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 Appts
by CD4 Cell Count
Preintervention Intervention
period
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
Preintervention
period
Intervention % relative
period
improvement
GEE-based
p-value
New or
re-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 Appts
by Patient Age
Preintervention
period
Intervention % relative
period
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
Preintervention
period
Overall
.68
N=9,407
Intervention % relative
period
improvement
.70
N=10,344
3.0%
GEE-based
p-value
< 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
Preintervention
period
Intervention % relative
period
improvement
GEE-based
p-value
1 -3
.65
N=4,142
.68
N=5,215
4.5%
< 0.001
4-6
.705
N=3,589
.72
N=3,600
2.1%
0.003
7 or more
.67
N=1,676
.68
N=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
Preintervention Intervention
period
period
% relative
improvement
GEE-based
p-value
Detectable VL
> 400 copies
.62
N=3,265
.66
N=3,213
5.5%
< 0.0001
Undetectable VL
≤ 400 copies
.72
N=6,142
.74
N=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
Preintervention Intervention
period
period
% relative
improvement
GEE-based
p-value
CD4 cell count
<350
.66
N=3,719
.70
N=3,922
5.1%
< 0.0001
CD4 cell count
≥ 350
.69
N=5,558
.70
N=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
Preintervention
period
Intervention % relative
period
improvement
GEE-based
p-value
New or
re-engaging
patients
.65
N=1,310
.70
N=1,371
7.6%
< 0.001
Active
patients
.68
N=8,097
.694
N=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
Preintervention
period
Intervention % relative
period
improvement
GEE-based
p-value
16-29
.60
N=526
.66
N=638
9.6%
0.0002
30-39
.67
N=1,667
.68
N=1,749
2.7%
0.06
40-49
.69
N=3,554
.71
N=3,739
2.8%
0.001
50-85
.74
N=3,660
.76
N=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 subgroups:
•
•
•
•
New/re-engaging
Detectable VL
CD4 cell count < 350
Younger patients (16-29)
Effect of # scheduled visits differed by outcome
variable
The Retention in Care Study Team
Boston Medical Center
Mari-Lynn Drainoni (PI)
Cintia Ferreira
Lisa Koppelman
Roosevelt Lewis
Maya McDoom
Michal Naisteter
Karina Osella
Glory Ruiz
Meg Sullivan (PI)
SUNY Downstate
Medical Center
Sophia Gibbs-Cohen
Elana Desrivieres
Mayange Frederick
Kevin Gravesande
Susan Holman
Harry Johnson
Tonya Taylor
Tracey Wilson (PI)
U. of AlabamaBirmingham
BaylorHouston, TX
Scott Batey
Stephanie Gaskin
Michael Mugavero (PI)
Jill Murphree
Jim Raper
Michael Saag (PI)
Suneetha Thogaripally
James Willig
Anne Zinski
Monisha Arya
David Bartholomew
Tawanna Biggs
Hina Budhwani
Jessica Davila
Tom Giordano (PI)
Nancy Miertschin
Shapelle Payne
William Slaughter
Federal
Laura Cheever, HRSA
Faye Malitz, HRSA
Robert Mills, HRSA
Jason Craw, CDC/ICF-Macro
Lytt Gardner, CDC
Sonali Girde, CDC/ICF-Macro
Gary Marks, CDC
Johns Hopkins
U. Of Miami
Mollie Jenckes
Jeanne Keruly (PI)
Angie McCray
Mary McGann
Richard Moore (PI)
Melissa Otterbein
Liming Zhou
Carolyn Garzon
Jesline Jean-Simon
Kathy Mercogliano
Lisa Metsch (PI)
Allan Rodriguez (PI)
Gilbert Saint-Jean
Marvin Shika
Mountain Plains AETC
Lucy Bradley-Springer
Marla Corwin
Questions and Discussion
Time for Questions
and Answers
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Optimal Wellness | Dec. 13, 2012 2pm ET
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Sustaining Retention Projects in Unsure Funding Environments | Jan. 9,
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Mental Health & Retention | Jan. 10, 2013 2pm ET
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How Can We Increase Initiation Of and Retention In Care Among Persons
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December 17, 2012
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