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in + care Campaign Meet the Author May 30, 2013

in + care Campaign Meet the Author May 30, 2013. 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)

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in + care Campaign Meet the Author May 30, 2013

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  1. in+care CampaignMeet the Author May 30, 2013

  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. Welcome & Introductions Michael Hager, MPH MA NQC Manager, in+care Campaign Manager New York, NY Tim Minniear, MD Research Associate Infectious Diseases Department St. Jude Children’s Research Hospital Memphis, TN In the chat room, Enter your: 1. name, 2. agency, 3. city/state, and 4. professional role at agency

  4. Agenda • Welcome & Introductions, 5min • Delayed Entry Into and Failure to Remain In Care Among HIV-Infected Adolescents, 30min • Background • Population and Methods • Results • Conclusions • Translating Research into Practice • Updates & Reminders, 5min • Q & A Session, 20min

  5. Delayed Entry into and Failure to Remain in HIV Care AmongHIV-Infected Adolescents TD Minniear, AH Gaur, A Thridandapani, C Sinnock, EA Tolley, and PM Flynn. AIDS Research and Human Retroviruses. January 2013, 29(1): 99-104. doi:10.1089/aid.2012.0267

  6. Disclosures I have no conflicts of interest to disclose.

  7. BACKGROUND

  8. Four Components of Engagement Linkage Retention Learn of HIV Positive Status Enter Health Care Services Utilize HIV Care Services Adhere to Medical Instructions Cheever. CID 2007 Horstmann et al. CID 2010

  9. The HIV/AIDS Epidemic in the USA 1.2 Million People Living with HIV 25% Unaware of Diagnosis • Includes 20-30,000 adolescents • ~ 26,000 new infections annually 900,000 Aware of Diagnosis 33% Not Linked into Care 600,000 Linked to Care 33% Fall out of Care 400,000 Actively Engaged Del Rico et al. CROI 2001, Marks et al. AIDS 2006 Hall et al. JAMA 2008, Campsmith et al. JAIDS 2010

  10. The HIV/AIDS Epidemic in the USA 600,000 People Living with HIV Not Yet Engaged in Care 200,000 People Living with HIV Inadequately Engaged Take Home Point: 2/3rds of All People Living with HIV in the United States Are NOT Adequately Engaged in Care

  11. Primary Study Objectives • Identify factors associated with delaying entry into care (DEC) after diagnosis of HIV infection. • Identify factors associated with falling to remain in care (FRC) after initial engagement.

  12. POPULATION & METHODS

  13. Population & Methods • Adolescents (13-21 years of age) • Infected via High-Risk Behavior • Diagnosed between 1996 and 2010 • Exclusions: • Diagnosed during pregnancy • Transferred in from another clinic • Large, urban comprehensive HIV clinic • Memphis, Tennessee, USA • 650,000 people • 64% Minority (61% African-American, 3% Hispanic) • 21% live below the poverty level

  14. Definition of Outcomes Delayed Entry into HIV Care • Lag >60 days from diagnosis to first kept appointment at the adolescent HIV clinic • Centers for Disease Control & Prevention’s Strategic Plan • Standard of care for outreach at our institution Failing to Remain in HIV Care • Not returning to clinic ≥6 months and missing at least 1 scheduled visit • After engaging in care for at least 1 year (making 1 visit in each quarter)

  15. Definition of Outcomes Failing to Remain in HIV Care • Not returning to clinic ≥6 months and missing at least 1 scheduled visit S NS S OUT 3 Months 3 Months 3 Months 3 Months NS S NS S IN 3 Months 1 1 1 S S 6 Months 3 Months 3 Months IN S: Show; NS: No Show

  16. Statistical Analysis • Descriptive statistics • Univariate analysis • Student’s t-test, Wilcoxon rank sum, chi-square as appropriate • Multivariate log-linear regression • Analyses performed with SAS 9.1.3 (Cary, North Carolina, USA)

  17. Statistical Analysis • Multivariable Model • Analyzed each outcome separately • Included all factors with significance <0.15 • Forced gender into the FRC model in order to adjust for the greater likelihood of a female having custody of a child • Estimated adjusted relative risks (rather than odds ratios) using a log-linear regression and assuming a Poisson distribution (GENMOD)

  18. RESULTS

  19. Case Assignment

  20. No correlation between DEC & FRC 38% (76/202) delayed entry into care 30% (53/178) failed to remain engaged  coefficient = -0.01 (p=0.93)

  21. Baseline CharacteristicsDelayed Entry into Care (N = 202)

  22. Factors Associated withDelaying Entry into HIV Care a Relative risk was adjusted for unstable residence, living alone, education, and distance from clinic.

  23. Baseline CharacteristicsFailed to Remain in Care (N = 177)

  24. HIV Disease CharacteristicsFailed to Remain in Care (N = 177) Values Presented as Mean (sd)

  25. Factors Associated withFalling out of HIV Care (N = 177) a Relative risk was adjusted for insurance status, custody of a child, gender, and education.

  26. CONCLUSIONS

  27. Delay does not predict falling out • Adolescents who delayed entering care did not necessarily later fall out of care. • The only predictor in common between delayed entry and failing to remain in care was education (in opposite directions). • However, each had at least one possible surrogate for poor socioeconomic status.

  28. Free access and transportation do not guarantee attendance • Despite the close proximity to the HIV clinic and despite free, non-stigmatized transportation, adolescents and young adults living closest to the clinic were at greater risk for delaying entry into HIV care.

  29. Free access and transportation do not guarantee attendance • Despite the fact that our clinic does never charges a patient and we help obtain Ryan White assistance for qualifying patients, not having insurance was associated with failing to remain in care.

  30. Free access and transportation do not guarantee attendance • We did not have objective measures of socioeconomic status for our patients. • Both residing within 5 miles of the clinic and lack of insurance could be surrogates for low socioeconomic status. • Covering the costs of care and transportation is not sufficient to overcome the barriers intrinsic to living in a low socioeconomic strata.

  31. The perplexing effect of education • Youth in college were more likely to delay entry into HIV care than youth with any lower level of education. • In contrast, once finally engaged, youth in college were more likely to remain engaged in HIV care.

  32. The perplexing effect of education • One—and not the only—explanation for the flip in association is that the demands or lifestyle of attending college lead youth to procrastinate making contact with the HIV clinic. • Once at the clinic, they may better understand the risks of non-compliance or be more motivated to maintain their health.

  33. TRANSLATING RESEARCH FINDINGS INTO PRACTICE

  34. Lessons Learned • Devote resources to linking “high-risk” youth to HIV care • Meet the youth where they are (e.g. school health clinics) • Outreach to no shows sooner rather than later • Strong social work and outreach support are key to keeping youth engaged in care

  35. Improving Linkage to Care • As part of Connect to Protect, we have expanded our outreach and follow-up of newly diagnosed youth to include not only the health department but also the city school system, several community and faith based organizations, and university health clinics.

  36. Improving Retention • Initiated a home visit program for established patients to bring them back into care sooner. • Assisted in establishing community advisory boards.

  37. Infectious Diseases Patricia Flynn, MD Aditya Gaur, MD Biostatistics Elisabeth Tolley, PhD Data Managers Wally Bitar Anil Thridandipani Psychology & Social Work Patricia Garvie, PhD Christine Sinnock Melanie Copeland Funding & Support St. Jude Children’s Research Hospital & ALSAC Acknowledgements

  38. Questions?

  39. Announcements

  40. Upcoming Events and Deadlines • Upcoming Webinars: • Partners in+care | Spanish Language Webinar | June 24, 2013 2pm ET • in+care Campaign | Latinos & Retention | June 25, 2013 1pm ET • Partners in+care Webinar | Adolescents and Retention | To be Scheduled • Data Collection Submission Deadline: June 3, 2013 • Improvement Update Submission Deadline: June 17, 2013 Upcoming Monthly Topics • June – Latinos and Retention • July – Patient Navigation • August – Migrants, Refugees and Retention • September – Women and Retention

  41. Time for Questions and Answers

  42. Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floor New York, NY 10007Phone 212-417-4730 incare@NationalQualityCenter.orgincareCampaign.org youtube.com/incareCampaign

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