1 in+care Campaign Meet the Author December 12, 2012.
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Transcript of 1 in+care Campaign Meet the Author December 12, 2012.
1
in+care CampaignMeet the Author
December 12, 2012
2
Ground Rules for Webinar Participation
• Actively participate and write your questions into the chat area during the presentation(s)
• Do not put us on hold• Mute your line if you are not speaking
(press *6, to unmute your line press #6)• Slides and other resources are available
on our website at incareCampaign.org• All webinars are being recorded
3
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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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone [email protected]
incareCampaign.orgyoutube.com/incareCampaign