Robust short-term Stephanie effectiveness of a Chamberlin 1 - - PowerPoint PPT Presentation

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Robust short-term Stephanie effectiveness of a Chamberlin 1 - - PowerPoint PPT Presentation

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Mary Irvine 1 Robust short-term Stephanie effectiveness of a Chamberlin 1 Rebekkah comprehensive Care Robbins 1 Coordination Program (CCP) Julie Myers 1, 3 in New York City (NYC) Graham Harriman 1 Sarah 1 NEW YORK CITY DEPARTMENT OF HEALTH

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Mary Irvine1 Stephanie Chamberlin 1 Rebekkah Robbins1 Julie Myers1, 3 Graham Harriman 1 Sarah Braunstein1 Beau Mitts1 Sarah Gorrell‐Kulkarni2 Denis Nash2

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Robust short-term effectiveness of a comprehensive Care Coordination Program (CCP) in New York City (NYC)

1 NEW YORK CITY DEPARTMENT OF HEALTH AND

MENTAL HYGIENE, NEW YORK, NY

2 CUNY SCHOOL OF PUBLIC HEALTH, NEW YORK, NY 3 DIVISION OF INFECTIOUS DISEASES, DEPARTMENT OF

MEDICINE, COLUMBIA UNIVERSITY MEDICAL CENTER

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0% 20% 40% 60% 80% 100%

Estimated HIV- infected Ever HIV- diagnosed Ever linked to HIV care Retained in HIV care in 2012 Presumed ever started on ART Suppressed viral load (≤200 copies/mL) in 2012

Percentage

Engagement in HIV care

100% 86% of

infected

73% of

infected 85% of diagnosed

55% of

infected 74% of linked to care

51% of

infected 93% of retained in care

41% of

infected 82% of started on ART

133,635 114,926 97,940 72,918 67,624 55,453

Num umber ber and propor roportion tion of perso sons ns with h HIV in New York rk City y engag gaged d in select ected d stages ges of the e continuu ntinuum m of care e at the end d of 2012

As reported to the New York City Department of Health and Mental Hygiene by June 30, 2013.

Of all persons estimated to be infected with HIV in NYC, 41% have a suppressed viral load.

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  • Black or latino

race/ethnicity

  • Younger age
  • Lower income
  • Non-AIDS status
  • Mental health issues

BACKGROUND: PREDICTORS OF SUBOPTIMAL CARE OUTCOMES

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  • Substance use issues
  • Stigma
  • Low levels of social

support

  • Non-U.S. country of birth
  • Unstable housing

Torian LV, et. al., AIDS Patient Care STDS 2011. Hsu LC, AIDS Care 2011. Wohl AR, AIDS Behav 2011. Aidala AA, AIDS Behav 2007. Israelski D, Prev Med 2001.

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CCP Goal: Ensure that HIV+ Ryan White clients at risk for suboptimal health outcomes receive support to achieve full engagement in care and treatment through coordinated care strategies

BACKGROUND: NYC RYAN WHITE PART A CCP

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BACKGROUND: THERE ARE 28 CARE COORDINATION PROVIDER AGENCIES IN NEW YORK CITY

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CCP targets persons at high risk for suboptimal care outcomes:

  • newly diagnosed
  • previously lost to care/never in care
  • irregularly in care
  • initiating a new regimen
  • with incomplete medication adherence or

response to treatment

BACKGROUND: CCP ELIGIBILITY CRITERIA

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 CCP model provides:

  • case management
  • patient navigation, including accompaniment
  • adherence support, including directly observed

therapy (DOT)

  • health promotion in home visits
  • assistance with medical/social services

BACKGROUND: CCP INTERVENTION DESCRIPTION

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  • Assess the effectiveness of this large-scale,

multi-site HIV care coordination program in NYC

  • Compare engagement in care (EiC) and

viral load suppression (VLS) in 12 months before and after CCP enrollment

  • Examine subgroup differences in
  • utcomes*

*Subgroups defined based on characteristics at time of enrollment

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BACKGROUND: STUDY OBJECTIVES

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  • Matched CCP eSHARE with NYC HIV

Registry data

METHODS: DATA SOURCES

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Programmatic Data: Ryan White Service Provider Reporting (eSHARE=Electronic

System for HIV/AIDS Reporting and Evaluation)

HIV Surveillance Data: Registry of NYC HIV cases (laboratory VL and CD4 tests, HIV diagnostic events) Merge

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Clients Eligible for Analysis: enrolled by

March 2011, matched to Registry, and alive for ≥ 1 year of follow-up.

Key Te Terms:

  • Newly Diagnosed: HIV diagnosis date in 12

months before enrollment

  • Current to Care (Baseline): Any CD4 or VL test

date in 6 months before enrollment*

  • Out of Care (Baseline): No CD4 or VL test date

in 6 months before enrollment*

METHODS: ELIGIBLE SAMPLE AND CARE STATUS GROUPS

*Among the previously diagnosed

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METHODS: SAMPLE ELIGIBILITY

3,803 Clients enrolled on or before March 31, 2011 3,641 (96.5%) Clients living 12 months post- CCP enrollment 134 (3.5%) clients excluded: died within 12 months of CCP enrollment SAMPLE POPULATION 465 (12.8%) Newly diagnosed at CCP enrollment 2,682 (73.7%) Current to Care at CCP enrollment 494 (13.6%) Out of Care at CCP enrollment

Previously Diagnosed

28 (.7%) clients excluded: did not match to the Registry

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Outcome Measures:

  • Engagement in Care (EiC): ≥2 CD4 or VL

tests ≥90 days apart, with ≥1 in each half

  • f 12-month period
  • Viral Load Suppression (VLS): VL≤200

copies/mL on most recent test in second half of 12-month period*

Estimated post- vs. pre- CCP enrollment relative risks (RRs) using GEE

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METHODS: STATISTICAL MEASURES

* Missing VL in 2nd half of 12-month period considered equivalent to unsuppressed VL.

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METHODS: CCP FOLLOW-UP TIME FOR OUTCOME MEASURES

12 months post-enrollment 12 months pre-enrollment Baseline: EiC0; VLS0 Outcomes: EiC1; VLS1 Enrollment Date: Start

  • f follow-up

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≤ 200 500 Viral Load Lab Yes VLS CD4 Lab No VLS 100 days=Yes EiC 200 days=Yes EiC

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St Study dy Populat ation

  • n Charac

racteristi stics cs at CCP Enro rollme ment nt CCP Over veral all N % TOTAL 3,641 100.0 Sex Male 2,286 62.8 Female 1,355 37.2 Ra Race/ e/Ethn thnicity icity Black 1,936 53.2 Hispanic 1,393 38.3 White 204 5.6 Other/Unknown 108 3.0 Age e (year ars) s) ≤ 24 224 6.2 25 – 44 1,534 42.1 45 – 64 1,767 48.5 65+ 116 3.2 Primar ary y languag guage e English 2,717 74.6 Spanish 736 20.2 Other 188 5.2 Countr ntry of b birth th US/US dependency 2,403 66.0 Foreign country 828 22.7 Unknown 410 11.3 Insurance rance Insured 2,643 72.6 Uninsured 998 27.4

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St Study dy Populat ation

  • n Charac

racteristi stics cs at CCP Enro rollme ment CCP Over veral all N % Housing ng statu atus Homeless 820 22.5 Not Homeless 2,707 74.3 Unknown 114 3.1 Househo ehold d income me level vel < $9,000 1,403 38.5 ≥ $9,000 1,229 33.8 Missing 1,009 27.7 Taking ng ART Yes 2,562 70.4 No 1,079 29.6 Year of H HIV Diagno nosi sis <1995 690 19.0 1995 - 2004 1,732 47.6 2005 - 2011 1,219 33.5 Viral suppression (≤200 copies/m es/mL) ) Yes 1,072 29.4 No 2,324 63.8 Unknown 245 6.7 CD4 (cells/ s/μL) ) < 200 972 26.7 200 - 349 683 18.8 350 – 499 509 14.0 500+ 692 19.0 Unknown 785 21.6

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RESULTS: ENGAGEMENT IN CARE, PRE & POST

74% 0% 87% 91% 91% 83% 93% 0% 20% 40% 60% 80% 100% Newly diagnosed ALL previously diagnosed Out of care Current to care 12 months prior to CCP enrollment 12 months post CCP enrollment

RR=1.24 (95% CI 1.21 - 1.27) RR=1.06 ( 95% CI 1.05- 1.08)

% with h EiC Among ng previous viously diagnose gnosed N/A

  • Improvements were observed for EiC at 25 (89%) of

the 28 agencies

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0.8 1 1.2 1.4 1.6 1.8 Male le Female ≤ 44 44 > 45 Insured Unins nsur ured ed Homeless ess Not Homeless On ART Not on ART <1995 1995-2004 2005 2005-2011 2011 Yes VLS No No VLS

Engagement in Care (previously dx’d): Post- vs. Pre- Enrollment Change, Relative Risk

Housing Status Sex Insurance Status Age ART Rx Baseline VL Year of Dx

RR= Previously Dx’d 95% CI, Previously Dx’d

1.24

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RESULTS: VL SUPPRESSION PRE & POST

32% 0% 38% 66% 51% 50% 51% 0% 20% 40% 60% 80% 100% Newly diagnosed ALL previously diagnosed Out of care Current to care 12 months prior to CCP enrollment 12 months post CCP enrollment

RR=1.58 (95% CI 1.5 - 1.66) RR=1.34 (95% CI 1.27- 1.4)

% with h VLS Among ng previous viously diagnose gnosed N/A

  • Improvements were observed for VLS at 21 (75%) of

the 28 agencies

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Viral Load Suppression (previously dx): Post- vs. Pre- Enrollment Change, Relative Risk

0.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 ≤ 44 > 45 <1995 1995-2004 2005 2005-2011 2011 <200 <200 200-349 350-499 ≥ 500 Age Year of Dx Baseline CD4

RR= Previously Dx’d 95% CI, Previously Dx’d

1.58

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Labs are an imperfect proxy for primary care

  • May overstate care engagement to the extent that

some labs reflect acute care vs. primary care visits

  • Not all primary care visits produce lab data

Ceiling effects may explain some subgroup findings

  • Certain groups have very little room for improvement

Evolving HIV service and policy landscape

LIMITATIONS AND CONSIDERATIONS

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Short-term EiC and VLS improvements were robust across most subgroups examined

  • Especially among those previously diagnosed and
  • ut of care

Newly diagnosed also show promising

  • utcomes

CCP may substantially improve short-term adherence to care and treatment among persons at risk for sub-optimal outcomes

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CONCLUSIONS

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 Care Coordination Program Service Providers and Clients  Levi Waldron  Bisrat Abraham  Fabienne Laraque  PACT Staff and Consultants

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ACKNOWLEDGEMENTS

This work was supported through a grant from the Health Resources and Services Administration(H89HA00015) and a grant from NIMH ( 1R01MH101028) entitled “ HIV care coordination: comparative effectiveness,

  • utcome determinants and costs” (CHORDS study).