A popula(on-based evalua(on of the delivery of care for people - - PowerPoint PPT Presentation
A popula(on-based evalua(on of the delivery of care for people living with HIV in Ontario Claire Kendall OHTN Clinics Mee2ng February 25, 2016 much is unknown about current HIV care delivery, namely: (1) whether and how HIV providers
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Chu and Selwyn, 2011
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Mental health condi2on Myocardial infarc2on Conges2ve heart failure End stage renal disease Peripheral vascular disease Asthma Diabetes Hypertension Stroke Mental-physical comorbidity Mul2morbidty (>=2)
Standardized prevalence ra2o
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20000 40000 60000 80000 100000 low med high low med high low med high low med high Family Medicine Internal Medicine Infec2ous Disease Other specialist number of visits/3 years Provider experience by provider specialty
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20000 40000 60000 80000 100000 low med high low med high low med high low med high Family Medicine Internal Medicine Infec2ous Disease Other specialist number of visits/3 years Provider experience by provider specialty
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20000 40000 60000 80000 100000 low med high low med high low med high low med high Family Medicine Internal Medicine Infec2ous Disease Other specialist number of visits/3 years Provider experience by provider specialty
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50000 100000 150000 200000 250000 number of visits/3 years
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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%
Forrest, 2009
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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%
Forrest, 2009
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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%
Forrest, 2009
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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%
Forrest, 2009
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8.6% 52.7% 10.1% 30.7% 5.3% 0% 10% 20% 30% 40% 50% 60%
Forrest, 2009
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0% 10% 20% 30% 40% 50% 60%
Forrest, 2009
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1 2 3 4 5 6 Odds ra(o (reference = Exclusively specialist care)
Exclusively primary care Family physician dominant co- management Specialist dominant co- management
Colorectal cancer screening Cervical cancer screening Mammography Any receipt of ART
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1 2 3 4 5 6 Odds ra(o (reference = Exclusively specialist care)
Exclusively primary care Family physician dominant co- management Specialist dominant co- management
Colorectal cancer screening Cervical cancer screening Mammography Any receipt of ART
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1 2 3 4 5 6 Odds ra(o (reference = Exclusively specialist care) Exclusively primary care Family physician dominant co-management Specialist dominant co- management
Any low acuity ED visits Any ED visits Any hospital admissions Any HIV-specific hospital admissions
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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <=5 6-49 >=50 <=5 6-49 >=50 <=5 6-49 >=50 Exclusively primary care Family physician dominant co-management Specialist dominant co- management
Percentage of pa(ents prescriebed ART (95% CI)
Family physician HIV experience (number of HIV pa(ents)
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0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <=5 6-49 >=50 <=5 6-49 >=50 <=5 6-49 >=50 Exclusively primary care Family physician dominant co-management Specialist dominant co- management
Percentage of pa(ents prescriebed ART (95% CI)
Family physician HIV experience (number of HIV pa(ents)
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QUANTITIATIVE Administer HIV specialty clinics
akributes survey and analyze results Determine par2cipants to be interviewed and develop interview guide QUALITATIVE Conduct key informant interviews and analyze results Interpreta2on & meta-inference
Phase 1 Phase 2 Phase 3 Phase 4
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Province Sent Completed Response Rate ON 23 12 52% MB 2 2 100% NL 1 1 100% SK 3 2 67% AB 2 1 50% NB 3 3 100% NS 1 0% BC 5 0% QC 3 1 33% Overall 43 22 51%
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Clinic Total mean (SD) Example ques(on...and best response Part 1: Pa#ent Rostering 8.23 (2.31) Registry or pa2ent-level data…are assigned to specific providers and pa2ent data are rou2nely used for scheduling purposes and are con2nuously monitored to balance supply and demand. Part 2: Team-Based Rela#onships 9.21 (2.15) Non-physician prac2ce team members…perform key clinical service roles that match their abili2es and creden2als. Part 3: Pa#ent-Centered Interac#ons 7.89 (2.18) Involving pa2ents in decision-making and care…is systema2cally supported by prac2ce teams trained in decision making techniques. Part 4: Engaged Leadership 8.1 (2.30) The organiza2on’s hiring and training processes…support and sustain improvements in care through training and incen2ves focused on rewarding pa2ent-centered care. Part 5: Quality Improvement 7.19 (2.26) Performance measures…are comprehensive – including clinical, opera2onal, and pa2ent experience measures – and fed back to individual providers. Part 6: Enhanced Access 7.39 (2.45) Appointment systems…are flexible and can accommodate customized visit lengths, same day visits, scheduled follow-up and mul2ple provider visits. Part 7: Care Coordina#on 8.37 (1.69) Medical and surgical specialty services…are readily available from specialists who are members of the care team or who work in an organiza2on with which the prac2ce has a referral protocol or agreement. Part 8: Evidence-Based Care 8.09 (2.19) Comprehensive, guideline-based informa2on on preven2on or chronic illness treatment…guides the crea2on of tailored, individual-level data that is available at the 2me of the visit. Total mean (SD) 8.06 (1.53) Scoring Category 3
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Clinics (n=22) Variable n % Popula2on Served Any person living with HIV 14 64% Members of a specific HIV popula2on (i.e. women MSM) 1 5% Infected children under the age of 16 1 5% Service includes family members of persons living with HIV/AIDS 1 5% No restric2on based on popula2on 5 23% Number of pa2ents served 0-500 8 36% 501-1000 6 27% 1001-2000 4 18% 2001-6000 2 9% >6000 2 9% Number of pa2ents living with HIV served 0-100 5 23% 101-200 2 9% 201-500 5 23% 501-1000 3 14% >1000 7 32%
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Clinics (n=22) Variable n % Loca2on of clinic (n=21) City 19 90% Suburb 2 10% Small town 0% Rural 0% Type of loca2on In a building owned by the physicians or of which they are shareholders 0% In a rented office in a commercial building for health professionals 0% In a rented office in a commercial building for any type of business 5 23% In an establishment that is part of the publicly funded health network (hospital, etc.) or university 15 68% Other 2 9% Type of physical loca2on One physical loca2on 13 59% One physical loca2on but linked to affiliated or satellite sites 4 18% More than one loca2on, but each loca2on is managed independently 2 9% More than one loca2on with coordina2on of care and administra2ve ac2vi2es between sites 3 14% Payment model (n=21) Fee-for-service 8 38% Capita2on or roster 1 5% Salary (hourly rate, sessional payment, contract) 3 14% Blended model (mix of different payment models) 8 38% Other 1 5% Clinic receives other types of funding from Yes Targeted program/ac2vity funding or grants 9 43% Targeted staffing funding or grants 9 43% Performance-based financial incen2ves 3 14% Academic research grants 7 33% Other 1 5%
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Test/Procedure (n=22) Number of clinics offering test % Rou2ne HIV blood work 20 91% HIV resistance tes2ng 15 68% Rou2ne blood work 20 91% Cervical smear (pap test) 16 73% Rou2ne immuniza2ons 21 95% Influenza (seasonal flu) vaccina2on 22 100% Pregnancy test 22 100% Urinalysis 21 95% Mantoux (TB) skin tes2ng 22 100% Sexually transmiked infec2on tes2ng 20 91% Spot glucose tes2ng (glucoscan) 14 64% Needle exchange (n=21) 4 19% Suture/minor surgery (n=21) 9 43% Musculoskeletal injec2on/aspira2on (n=21) 11 52% IUD inser2on (n=21) 9 43% Chronic disease self-management program (n=21) 9 43% Rapid streptococcal test (strep test) 8 36% Established process and resources to follow up on pa2ents who miss appointments (n=19) 12 63%
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Type of Prac((oner (n=22) # clinics with this type of prac((oner (n, %) Mean FTE Specialist physician in Infec2ous Diseases 16 73% 1.79 Family physician 9 41% 2.20 Specialist physician in Psychiatry 7 32% 0.06 Specialist physician (other) 9 41% 0.225 Nurse prac22oner 9 41% 0.59 Registered nurse 20 91% 2.31 Physician assistant 1 5% 0.02 Psychologist 7 32% 0.31 Pharmacist 18 82% 0.92 Addic2ons counsellor 4 18% 0.22 Social worker 17 77% 0.86 Peer support worker 2 9% 0.19 Die22an 12 55% 0.31 Home care support person 0% 0.00 Dental care worker 0% 0.00 Occupa2onal therapist 2 9% 0.08 Physiotherapist 0% 0.00 Other rehabilita2on service worker 0% 0.00 Smoking cessa2on support 2 9% 0.02 Other 6 27% 1.77
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EMR system (n=22) Number of clinics % Yes 15 68% Planned, but not yet implemented 5 23% Not sure 0% No 2 9% Technological Resources (n=22) Yes n % Internet access for all staff 21 95% Computerized tools to aid medical decision-making 13 59% Electronic interface to diagnos2c imaging & labs 20 91% An electronic system to transmit prescrip2ons 4 18% Computer souware to manage appointments 18 82% Automated op2on to send appointment reminders 0% A web-based appointment system for pa2ents 1 5% Informa2on technology support (on site or on call) 22 100% Unique email addresses for the clinic (i.e. name@myclnic.ca) 8 36%
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