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 are mee2ng pa2ents’ primary care needs; and (2) how structures and models of care can be improved to combine HIV-specific exper2se with comprehensiveness, con2nuity, coordina2on, and accessibility—four key elements of primary care.” Chu and Selwyn, 2011 2
Ins2tute for Clinical Evalua2ve Sciences (ICES) Databases Special Popula(on & Care Health Popula(ons Geography Providers Services Study 1: Comorbidi(es Study 2: Physicians and visits Study 3: Developing a typology of care Study 4: Quality of care Study 5: Impact of physician HIV experience 3
Study 1 : Comorbidity is higher among people with HIV Mental health condi2on Myocardial infarc2on Conges2ve heart failure End stage renal disease Peripheral vascular disease Asthma Diabetes Stroke Hypertension Mental-physical comorbidity Mul2morbidty (>=2) Standardized prevalence ra2o 4 0 0.5 1 1.5 2 2.5 3 3.5 4
Study 2 : Family physicians provide a lot of care 100000 number of visits/3 years 80000 60000 40000 20000 0 low med high low med high low med high low med high Family Medicine Internal Medicine Infec2ous Disease Other specialist Provider experience by provider specialty 5
Study 2 : Family physicians provide a lot of care 100000 number of visits/3 years 80000 60000 40000 20000 0 low med high low med high low med high low med high Family Medicine Internal Medicine Infec2ous Disease Other specialist Provider experience by provider specialty 6
Study 2 : Family physicians provide a lot of care 100000 number of visits/3 years 80000 60000 40000 20000 0 low med high low med high low med high low med high Family Medicine Internal Medicine Infec2ous Disease Other specialist Provider experience by provider specialty 7
Study 2 : Other physicians provide a lot of care 250000 200000 number of visits/3 years 29% 150000 100000 50000 0 8
Study 3 : Ques2ons asked for typology development • Can the pa2ent be linked to a usual family physician? • Does the pa2ent have any HIV-related billings to an infec2ous disease or internal medicine specialist (HIV specialist)? • Does the family physician or the HIV specialist provide the most HIV-related care? 9
Study 3 : Typology assignment (n=13,417) Exclusively HIV specialist care 5.3% Co-manager (Specialist 30.7% principal HIV provider) Co-manager (FP principal HIV 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 10 Forrest, 2009
Study 3 : Typology assignment (n=13,417) Exclusively HIV specialist care 5.3% Co-manager (Specialist 30.7% principal HIV provider) Co-manager (FP principal HIV 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 11 Forrest, 2009
Study 3 : Typology assignment (n=13,417) Exclusively HIV specialist care 5.3% Co-manager (Specialist 30.7% principal HIV provider) Co-manager (FP principal HIV 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 12 Forrest, 2009
Study 3 : Typology assignment (n=13,417) Exclusively HIV specialist care 5.3% Co-manager (Specialist 30.7% principal HIV provider) Co-manager (FP principal HIV 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 13 Forrest, 2009
Study 3 : Typology assignment (n=13,417) Exclusively HIV specialist care 5.3% Co-manager (Specialist 30.7% principal HIV provider) Co-manager (FP principal HIV 10.1% provider) Exclusively primary care 52.7% Low engagement 8.6% 0% 10% 20% 30% 40% 50% 60% 14 Forrest, 2009
Study 3 : Typology assignment (n=13,417) Exclusively HIV specialist care Specialist Co-manager (Specialist principal HIV provider) Co-manager (FP principal HIV provider) Family Physician Exclusively primary care Low engagement 0% 10% 20% 30% 40% 50% 60% 15 Forrest, 2009
Study 4 : Delivery model is associated with quality of care Colorectal cancer screening Cervical cancer screening * Mammography Exclusively primary care Family physician dominant co- management Any receipt of ART Specialist dominant co- management 0 1 2 3 4 5 6 Odds ra(o (reference = Exclusively specialist care) 16
Study 4 : Delivery model is associated with quality of care Colorectal cancer screening Cervical cancer screening * Mammography Exclusively primary care Family physician dominant co- management Any receipt of ART Specialist dominant co- management 0 1 2 3 4 5 6 Odds ra(o (reference = Exclusively specialist care) 17
Study 4 : Delivery model is less associated with health care u2liza2on Any ED visits Exclusively primary care Any low acuity ED visits Family physician dominant co-management Any hospital admissions Specialist dominant co- management Any HIV-specific hospital admissions 18 Odds ra(o (reference = Exclusively specialist care) 0 1 2 3 4 5 6
Study 5: Family physician experience impacts receipt of ART 100% 90% Percentage of pa(ents prescriebed ART (95% CI) 80% 70% 60% 50% 40% 30% 20% 10% 0% <=5 6-49 >=50 <=5 6-49 >=50 <=5 6-49 >=50 Exclusively primary care Family physician dominant Specialist dominant co- co-management management Family physician HIV experience (number of HIV pa(ents) 19
Study 5: Family physician experience impacts receipt of ART 100% 90% Percentage of pa(ents prescriebed ART (95% CI) 80% 70% 60% 50% 40% 30% 20% 10% 0% <=5 6-49 >=50 <=5 6-49 >=50 <=5 6-49 >=50 Exclusively primary care Family physician dominant Specialist dominant co- co-management management Family physician HIV experience (number of HIV pa(ents) 20
Limita2ons 1. Only those in care 2. No HIV-specific measures 3. No structural/social determinants 21
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
Canadian HIV Clinic Survey LHIV Innovation Team Claire Kendall February 2016
PRIMARY RESEARCH QUESTION § What are the organizational attributes of HIV clinics in Canada? § Components of the survey: • Part 1: Patient-Centered Medical Home Assessment (PCMH-A), adapted for HIV clinic context • Part 2: Organization of Clinics, adapted in part from the Canadian Institute for Health Information’s Measuring Organizational Attributes of Primary Health Care Survey and the Primary Health Care indicator Framework developed by the LHIV Innovation Team (led by Dr. Sharon Johnston) 24
Mixed-Methods Study Plan QUANTITIATIVE QUALITATIVE Administer HIV Conduct key Determine specialty clinics informant Interpreta2on par2cipants to organiza2onal interviews & be interviewed akributes survey and meta-inference and develop and analyze results interview guide analyze results Phase 1 Phase 3 Phase 4 Phase 2 25
Current Response Rates Clinic Survey: Response Rate by Province 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 0% BC 5 0 0% QC 3 1 33% Overall 43 22 51% 26
Preliminary Results: PCMH Survey Clinic Total mean (SD) Example ques(on...and best response Registry or pa2ent-level data…are assigned to specific providers and pa2ent Part 1: Pa#ent Rostering 8.23 (2.31) data are rou2nely used for scheduling purposes and are con2nuously monitored to balance supply and demand. Non-physician prac2ce team members…perform key clinical service roles that 9.21 (2.15) Part 2: Team-Based Rela#onships match their abili2es and creden2als. Involving pa2ents in decision-making and care…is systema2cally supported by Part 3: Pa#ent-Centered Interac#ons 7.89 (2.18) prac2ce teams trained in decision making techniques. The organiza2on’s hiring and training processes…support and sustain 8.1 (2.30) improvements in care through training and incen2ves focused on rewarding Part 4: Engaged Leadership pa2ent-centered care. Performance measures…are comprehensive – including clinical, opera2onal, Part 5: Quality Improvement 7.19 (2.26) and pa2ent experience measures – and fed back to individual providers. Appointment systems…are flexible and can accommodate customized visit Part 6: Enhanced Access 7.39 (2.45) lengths, same day visits, scheduled follow-up and mul2ple provider visits. Medical and surgical specialty services…are readily available from specialists Part 7: Care Coordina#on 8.37 (1.69) who are members of the care team or who work in an organiza2on with which the prac2ce has a referral protocol or agreement. Comprehensive, guideline-based informa2on on preven2on or chronic illness Part 8: Evidence-Based Care 8.09 (2.19) 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 27
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