Physician-Delivered Interventions:
Download
1 / 74

Physician-Delivered Interventions: The Options Project NIMH grant 1R01 MH594378 Jeffrey D. Fisher, Ph.D., Director Cen - PowerPoint PPT Presentation


  • 212 Views
  • Uploaded on

Physician-Delivered Interventions: The Options Project (NIMH grant 1R01 MH594378) Jeffrey D. Fisher, Ph.D., Director Center for HIV Intervention and Prevention University of Connecticut (email: [email protected]). August 3, 2001

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Physician-Delivered Interventions: The Options Project NIMH grant 1R01 MH594378 Jeffrey D. Fisher, Ph.D., Director Cen' - arleen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Slide1 l.jpg

Physician-Delivered Interventions: The Options Project(NIMH grant 1R01 MH594378)Jeffrey D. Fisher, Ph.D., DirectorCenter for HIV Intervention and PreventionUniversity of Connecticut(email: [email protected])

August 3, 2001

Conference sponsored by the Center for Mental Health Research on AIDS, National Institute of Mental Health (NIMH)


Slide2 l.jpg

Project Staff

Jeffrey D. Fisher, Ph.D, Principal Investigator

University of Connecticut

William A. Fisher, Ph.D., Co-Principal Investigator

University of Western Ontario

Gerald Friedland, M.D., Co-Principal Investigator

Yale University

Deborah H. Cornman, Ph.D., Project Manager

University of Connecticut

Rivet Amico, Ph.D., Assistant Research Professor

University of Connecticut


Slide3 l.jpg

Project Staff (Continued)

Tim Evans, Health Educator

University of Connecticut

Liz Harmon, Health Educator

University of Connecticut

Christine Woolley, Health Educator

University of Connecticut

Stephen Arnold, Abby Levine, Ianita Zlateva

University of Connecticut

Jack Ross, M.D., Investigator

Hartford Hospital


Special thanks to participating health care providers l.jpg

Special Thanks to Participating Health Care Providers:

Ken Abriola, MD; Frederick Altice, MD;

Nancy Angoff, MD; Martha Buitrago, MD;

Elizabeth Cooney, MD; Steve Farber, PA;

Tim Hatcher, PA; Michael Kozal, MD;

Michael Lawlor, MD; Neil Olson, MD;

Phillip Pierce, MD; Tanya Schreibman, MD;

Lynn Sullivan, MD; Jonathan Tress, MD;

Holenarasipur Vikram, MD;

Ann Williams, PhD; Madeline Wilson, MD;

Hussein Zaioor, MD


Slide5 l.jpg

The Problem: HIV+ patients in clinical care may engage in risky behaviors that can adversely affect their own and others’ health.



Slide7 l.jpg

Demographics of our Clinical Care Sample Patients in Clinical Care


Gender ethnicity and age n 315 l.jpg
Gender, Ethnicity, and Age Patients in Clinical Care(N=315)

Mean Age: 43.92 (7.66), range 22.93 to 66.96


Modes of hiv transmission n 307 l.jpg
Modes of HIV Transmission Patients in Clinical Care(N=307)



Past and present injection drug use l.jpg
Past and Present CareInjection Drug Use

About 62% of participants who were questioned reported ever having used injection drugs, while 25% reported injection drug use in the past month.

  • Of those who used injection drugs in the past month, 28% borrowed or lent uncleaned works or needles during this interval.

61% of those who have ever used injection drugs have been in recovery for a year or more.


Sexual events in the preceding three months n 315 participants l.jpg
Sexual Events in the Preceding Three Months Care(N=315 participants)

49% (155) of the whole sample reported engaging in a vaginal and/or anal sexual event in the preceding three months.

42% (65) of these individuals reported some degree of risk (events with no condom use) during one or more of these events.


In the preceding three months 155 participants engaged in 3838 vaginal and or anal sex events l.jpg
In the preceding three months, 155 participants engaged in 3838 Vaginal and/or Anal Sex events

63%

2432 sex events were protected

37%

1406 sex events were unprotected


Of the 1406 unprotected sex events reported by the 65 participants reporting risky sexual behaviors l.jpg
Of the 1406 unprotected sex events reported by the 65 participants reporting risky sexual behaviors:

34%

(482 events) involved HIV Positive Partners

66%

(924 events) involved HIV Negative and/or Unknown Partners


Potential partners exposed to hiv l.jpg
Potential Partners participants reporting risky sexual behaviors:Exposed to HIV

Our estimates indicate that in the past three months, participants engaged in risky vaginal and/or anal sex with a minimum of 391 partners of negative or unknown HIV status.


Clearly there is substantial risk behavior in our clinical sample l.jpg
Clearly, there is participants reporting risky sexual behaviors:substantial risk behaviorin our clinical sample


Slide17 l.jpg
Given mounting evidence participants reporting risky sexual behaviors:of the transmissionof resistant strains of HIV, this is even more problematic than in the past


Slide18 l.jpg

Co-existing with this risk, substantial numbers of patients were in Prochaska’s maintenance stage of behavior change (consistently using condoms during sex for 6 months or more)


Slide19 l.jpg
55% of 174 participants reporting sex events over the last 3 months were in Prochaska’s maintenance stage of condom use behavior.


Slide20 l.jpg
Health care providers months were in Prochaska’s maintenance stage of condom use behavior.have an excellent opportunity to address risky and reinforce safer behaviors in their HIV+ patients

  • Many have a trusting relationship with their patients.

  • Many have repeated contacts with their patients over long periods of time.


Slide21 l.jpg

This affords the opportunity months were in Prochaska’s maintenance stage of condom use behavior.

for brief, repeated, provider-initiated interventions with

powerful cumulative

effects


Slide22 l.jpg

But health care providers’ interactions with patients about patients’ risky and safer behaviors are relatively infrequent


Slide23 l.jpg

  • Research reveals that sexually active HIV+ patients do about patients’ risky and safer behaviors are relatively infrequentnot receive adequate HIV prevention counseling (Janssen et al., 2001).

  • There is great variability between health care providers in the extent to which they initiate HIV prevention discussions with HIV+ patients (Wilson & Kaplan, 2000).


Slide24 l.jpg


Why health care providers do not discuss hiv prevention l.jpg
Why health care providers do not discuss HIV prevention rigorously evaluated, effective interventions involving health care providers attempting to assist HIV + patients with safer sex behavior (Janssen et al., 2001).

Information Factors

  • Many health care providers have minimal knowledge about risk reduction strategies (Epstein et al., 1999).

  • Most have not participated in educational programs to heighten their ability to perform such interventions (Epstein et al., 1999).

    Motivational Factors

  • Other issues involve lack of time, physician/patient discomfort, and confidentiality (Elford et al., 2000).

    • Some physicians are especially uncomfortable discussing sexual and drug related issues.


Reasons why health care providers do not discuss hiv prevention continued l.jpg
Reasons why health care providers do not discuss HIV prevention(continued)

Behavioral Skills Factors

  • Many health care providers lack the necessary skills to discuss HIV risk reduction (Elford et al., 2000).

  • Communication barriers to providers engaging in HIV risk reduction include: lack of a good “opening line,” vague language, and the provider-centered interview style (Epstein et al., 1999).


Slide27 l.jpg

The Options Project: prevention

A collaboration between health care providers, HIV+ patients, and researchersto assist HIV+ patients address risky behaviors


Specific aims of the options project l.jpg
Specific aims of preventionThe Options Project:

  • Conduct elicitation research:

    • To better understand the dynamics of HIV risk behaviors among HIV+ patients in clinical care.

    • To assess health care providers’ views about performing HIV prevention interventions.


Specific aims continued l.jpg
Specific aims (continued) prevention

(2) Work with health care providers and their

patients:

  • To elicit recommendations about effective provider-initiated HIV prevention interventions for HIV+ patients in clinical care.

  • To elicit recommendations about how best to integrate HIV prevention into the day-to-day clinical care routine.


Specific aims continued30 l.jpg
Specific aims (continued) prevention

(3)Based on elicitation findings:

  • Design and implement the Options Project, a theoretically and empirically based provider-initiated HIV prevention program.


Specific aims continued31 l.jpg
Specific aims (continued) prevention

(4) Conduct long-term intervention

outcome research comparing the

experimental intervention condition

with a standard of care control

condition.



Slide33 l.jpg

The Information - Motivation - Behavioral Skills Model of HIV Prevention

HIV Prevention Information

HIV Preventive Behavior

HIV Prevention Behavioral Skills

HIV Prevention Motivation

(J. Fisher & Fisher, 1992, 2000; W. Fisher & Fisher, 1993)


Slide34 l.jpg

Motivational Interviewing is used as a vehicle to deliver an Information-Motivation- Behavioral Skills intervention.



Step 1 setting the agenda to discuss safer sex and safer drug use l.jpg
Step 1: Setting the agenda to discuss safer sex and safer drug use

  • “There are a couple of things that I talk about with all of my patients – safer sex and safer drug use. I know that these are not easy issues to talk about, but I do think that they are important ones. So I would like to spend a few minutes talking with you about these issues, if that is okay with you.”


Step 2 assessing risk behavior l.jpg
Step 2: Assessing risk behavior drug use

  • “Many of my patients are finding it challenging to practice safer sex and safer needle use on a day to day basis…Now, I don’t know if these are issues for you, but if they are, I would appreciate it if you would help me to understand what this struggle is like for you. What works for you and what doesn’t, when it comes to safer sex?… [or clean needle use?]”


Step 3 summarize risky behaviors and ask the patient to choose one behavior on which to focus l.jpg
Step 3: Summarize risky behaviors, and ask the patient to choose one behavior on which to focus

  • “You said that you are doing [riskbehavior x] and [risk behavior y]. Let’s just focus on one of these areas for today. Which one would you prefer to talk about?”


Slide40 l.jpg

Step 4: Determine how to proceed by choose one behavior on which to focus first having patients rate the “importance” of changing the risk behavior they chose, and then their “confidence” that they could change it.


Slide41 l.jpg

Importance and confidence ratings inform the provider about how to proceed by reflecting the patient’s:

  • Stage of change

  • Level of Information, Motivation, and Behavioral Skills


Slide42 l.jpg

  • Assessing Importance and Confidence: how to proceed by reflecting the patient’s:

    I would like to better understand how you feel about [changing behavior x or y]. Can you help me by answering a couple of questions?…

    • (1) On a scale from 0 to 10 where 0 is ‘not at all important’ and 10 is ‘extremely important,’ how important is it to you to [change or maintain this behavior]?…

    • (2) On a scale from 0 to 10 where 0 is ‘not at all confident’ and 10 is ‘extremely confident,’ how confident are you that you can [change or maintain this behavior].


Slide43 l.jpg

Step 5: Based on Importance and Confidence scores and the Options algorithm, further explore either Importance OR Confidence


Slide44 l.jpg

IS RATING Options algorithm, further explore either Importance OR Confidence

FOR IMPORTANCE

< 7 ?

WHICH RATING IS LOWER?

IF SAME, CHOOSE IMPORTANCE

YES

LOW

IMPORTANCE

LOW

CONFIDENCE

YES

PROBLEM-SOLVE STRATEGIES FOR OVERCOMING BARRIERS

(OR PREVENTING RELAPSE)

START

HERE

Options/Opciones Project

Algorithm

ARE RATINGS FOR BOTH

IMPORTANCE AND CONFIDENCE

9 OR 10? (often true for maintenance)

NO

NO

DISCUSS BARRIERS TO CHANGING BEHAVIOR

(OR DO RELAPSE PREVENTION IF NOT ENAGING IN ANY

RISKY BEHAVIORS)

ASK:

(1) Why is importance that score and not lower? (elicits self-motivating statements)

(2) What would need to happen to raise that score? (directs provider on how to proceed)

ASK:

(1) Why is confidence that score and not lower? (elicits self-motivating statements)

(2) What would need to happen to raise that score? (directs provider on how to proceed)


Slide45 l.jpg

Step 6: Summarize the patient’s responses, and then elicit a menu of specific strategies from the patient for raising his or her score.

  • If the patient does not offer any strategies, ask permission to suggest some, and then provide a menu of strategies.


Slide46 l.jpg

Step 7: Negotiate a goal or action plan with the patient by having the patient select a goal for the next clinic visit from a menu of goals.

  • Allow the patient to choose a goal that is realistic and attainable in the context of his/her life.


Slide47 l.jpg

Step 8: Record the goal or action plan on the having the patient select a goal for the next clinic visit from a menu of goals.Options Prescription Pad and give the “behavioral prescription” the to patient.


Slide48 l.jpg

Prevention having the patient select a goal for the next clinic visit from a menu of goals.

Date:________________

Name:____________________________________

Plan:_____________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

____________________________

Prevention

Prescription

Date:________________

Name:____________________________________

Plan:_____________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

_________________________________________

____________________________

Signature


Subsequent options meetings l.jpg
Subsequent Options Meetings having the patient select a goal for the next clinic visit from a menu of goals.

  • Review documentation from last visit.

  • Explore what, if any, progress the patient made toward achieving the goal set on the last visit.

  • Reassess Importance and Confidence.

  • Negotiate an attainable, specific goal for the next visit.

  • Document the new goal on the Options Prescription Pad and give the new behavioral prescription to the patient.


Training providers in the options protocol l.jpg
Training Providers having the patient select a goal for the next clinic visit from a menu of goals. in the Options Protocol

  • We have used a four-hour didactic and interactive training (including substantial role-playing) with the following agenda:


Slide51 l.jpg

Provider Training Agenda having the patient select a goal for the next clinic visit from a menu of goals.

  • Overview of Training

  • Project History, Background, and Theory

  • Behavior Change Exercise

  • Introduction of Motivational Interviewing

  • Overview of Intervention Protocol

  • Video Demonstration of Protocol

  • Step-by-Step Practice of Protocol

  • Practice of Entire Protocol

  • Logistics of Implementation



Evaluating and ensuring intervention fidelity l.jpg
Evaluating and Ensuring Intervention Fidelity Fidelity

  • Intervention fidelity was ensured and evaluated with multiple methods, including…

    • Our assessment of provider delivery of the protocol with simulated patients during training and post-training booster sessions

      • training continues until our criterion is reached

    • In-vivo observation of actual protocol delivery

      • a trained observer documents provider performance with actual patients in terms of specific steps and global elements


Evaluating and ensuring intervention fidelity continued l.jpg
Evaluating and Ensuring Intervention Fidelity (continued) Fidelity

  • Patient Exit Questionnaires

    • document the patient’s perception of whether the provider enacted critical protocol elements

  • Patient Record Forms

    • document the provider’s perception of his or her implementation of critical protocol elements


Intervention fidelity l.jpg
Intervention Fidelity Fidelity

  • All 15 providers performed to criterion after the training and booster sessions.

  • The majority of Options/Opciones protocol implementations conform to the protocol steps.

    For example…

    • Importance and Confidence were assessed 86% of the time

    • A goal was agreed upon 88% of the time

    • A behavioral prescription was given 74% of the time


Preliminary options project intervention outcomes l.jpg

Preliminary FidelityOptions Project Intervention Outcomes


Feasibility of the intervention l.jpg
Feasibility of the Intervention Fidelity

  • The intervention was consistently implemented in the experimental arm, despite providers’ demanding schedules and time constraints

    • Thus far there have been 245 medical visits that have included the delivery of the Options/Opciones protocol. On average, an Options/Opciones patient received the intervention protocol on 80% (median) of his or her medical visits.

    • 88% (117) of baselined participants who have had a medical appointment since baseline have participated in one or more Options intervention protocol(s).


Slide58 l.jpg

Effects on Behavior Fidelity

  • As of July 2001, 157 completed pre-intervention baseline surveys had been collected in the experimental arm, while 158 baseline surveys had been collected in the control arm.

  • 6-month follow-up data was available for a total of 80 participants, 45 in the experimental arm and 35 in the control arm.


Effects on behavior l.jpg
Effects on Behavior Fidelity

Using the completed 6 month post-intervention surveys, we sought to provide a preliminary response to the question:

Did the intervention decrease criticalriskbehaviors reported at time II for participants who had a history of such behaviors pre-intervention (i.e., risky participants)?


Slide60 l.jpg

  • Critical Risk Behaviors Fidelityinvolve unprotected vaginal, anal, and/or oral sex with partners of unknown or negative serostatus.

  • Risky Participants are individuals who practiced critical risk behaviors pre-intervention.


Hypothesis l.jpg
Hypothesis Fidelity

  • Patients with critical risk behaviors at time I who receive the intervention (Risk Hx • Tx) will make greater gains in risk reduction than those with similar risk histories who do not receive the intervention (Risk Hx • No Tx).


Statistical methods l.jpg
Statistical Methods Fidelity

  • Analysis of Covariance was used to assess differences in mean critical risk behaviors at time II:

    • between the Experimental and Control arm

    • between those who had critical risk behaviors at baseline and those who did not (who were probably in maintenance)

    • and the interaction of these factors

  • Pre-intervention baseline critical risk behaviors were controlled for (covaried).


Statistical methods63 l.jpg
Statistical Methods Fidelity

  • This resulted in a 2x2 Analysis of Covariance


Statistical methods64 l.jpg
Statistical Methods Fidelity

  • For these analyses we operationalized critical risk behavior in two ways:

  • Total number of unprotected vaginal, anal, and/or oral risk behaviors at time II with partners of negative and/or unknown HIV status.

  • Total number of unprotected vaginal and/or anal risk behaviors at time II with partners of negative and/or unknown HIV status.


Results l.jpg
Results Fidelity

Marginal means of time II total critical risk behavior (including vaginal, anal, and/or oral events) with time I scores covaried showed:

A significant Intervention X Critical Risk History

interaction effect: F(1,75) = 8.763 p = .004


Results66 l.jpg
Results Fidelity

  • Those with a critical risk behavior history who received the intervention made greater gains in risk reduction than those with similar risk histories who did not receive the intervention.

  • For those who reported no history of critical risk behavior pre-intervention (most likely those in maintenance), the experimental and control groups were not different (both maintained a low base rate of risk behavior).


Results67 l.jpg
Results Fidelity

  • When oral events were removed and critical risk was defined as risky vaginal and anal events, the pattern of results were similar, though not significant (interaction term F(1,77) = 2.81, p = .098), possibly due to the low N.


Limitations l.jpg
Limitations Fidelity

  • With only 80 completed 6-month follow-up surveys, inferences based on this data are not advisable.

  • Follow-up assessments continue to accrue and more definitive longitudinal outcome evaluation is anticipated to begin in the next few months.

  • Ultimately, with three waves of follow-up data, evaluations of outcome will provide for reasonable confidence in any inferences made from the data.


Overall conclusions l.jpg
Overall Conclusions Fidelity

  • Patients in clinical care engage in substantial risky behaviors.

  • Although it is a complex environment, the health care setting offers an excellent context to address these behaviors over time, and in large numbers of patients.


Overall conclusions continued l.jpg
Overall Conclusions (continued) Fidelity

  • Providers can be trained quickly and effectively in how to practice the Options protocol.

  • Patients who practice critical risk behavior pre-intervention respond well to the Options protocol, showing a decrease in critical risk behavior at time II.


Prevention can and should be linked to treatment for hiv positive patients l.jpg
Prevention Fidelitycan and should be linked to treatment for HIV positive patients


Future data available from the options project l.jpg
Future Data Available from the Options Project Fidelity

  • Definitive behavioral intervention outcome data at three post-intervention intervals (over 18 months).

  • Data on:

    • Psychosocial predictors of pre-intervention risk behavior, and of HIV risk behavior change over time.

    • Psychosocial and other factors associated with the presence of antiretroviral resistance.

    • Risk behavior patterns of individuals with antiretroviral reistance.


Future data available from the options project73 l.jpg
Future data available from the Options Project Fidelity

  • Naturalistic cohort study (using the control group) of risk behavior in HIV+ patients as a function of subjective and objective health status, treatment, antiretroviral resistance, medication adherence, and time.


ad