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Concordance of HIV surveillance and medical record data: What do CD4 and viral loads not tell us about linkage to HIV care ?. Charu Sabharwal, MD MPH Medical Director Epidemiology and Field Services Program Bureau of HIV/AIDS Prevention and Control NYC Department of Health.

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Charu Sabharwal, MD MPH Medical Director Epidemiology and Field Services Program

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Charu sabharwal md mph medical director epidemiology and field services program

Concordance of HIV surveillance and medical record data: What do CD4 and viral loads not tell us about linkage to HIV care?

Charu Sabharwal, MD MPH

Medical Director

Epidemiology and Field Services Program

Bureau of HIV/AIDS Prevention and Control

NYC Department of Health


Acknowledgements

Acknowledgements

  • Sarah Braunstein

  • Rebekkah Robbins

  • Colin Shepard

  • HIV Epidemiology and Field Services Program


Charu sabharwal md mph medical director epidemiology and field services program

Background


Charu sabharwal md mph medical director epidemiology and field services program

National HIV/AIDS Strategy

  • NHAS (July, 2010) - first comprehensive roadmap

  • Amore coordinated response to the HIV epidemic

  • Primary Goals for 2015:

    • Reduce infections

    • Increase access to care

    • Reduce health disparities


Charu sabharwal md mph medical director epidemiology and field services program

HIV Continuum of Care

Das, MoupaliPrevention of HIV Acquisition: Behavioral, Biomedical, and Other Interventions.

Medscape 2012


Monitoring hiv care cd4 vl

Monitoring HIV Care – CD4/VL

  • HIV Care = outpatient HIV visit with provider authorized to prescribe ART1

  • Clinical monitoring/treatment guidelines2

    • Traditionally, 1st CD4/VL at initial HIV care visit

    • CD4/VL: every 3-6 months;  frequency after ART initiation

  • CD4/VLs proxy for HIV care [HIV care visits not reported]

  • Since 2004, CSTE encouraged all states (59 jurisdictions) to report allCD4 and VLs3[New York2005]

  • Limited comprehensive evaluation of the validity of surveillance data as proxy of HIV care

  • 1Health Resources and Services Administration. The HIV/AIDS Program: HAB Performance Measures Group 1. In; 2009. 2DHHS Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. In; 2012. 3 CSTE Position statement 04-ID-07


    Measuring linkage to care

    Measuring linkage to care

    • Surveillance traditionally measures linkage by a single event: 1streported CD4/VL on/after HIV diagnosis date

    • Accuracy of 1st CD4/VL1,2 drawn prior to referral to HIV care. For example, at the time of

      • Confirmatory testing after + rapid/point-of-care test

      • Inpatient diagnosis: CD4 impacts treatment decision

      • In New York City: routinemedical record (MR) abstraction for linkage to care is not feasible

      • 3,500 diagnosing providers; 3,000+ HIV cases yearly

      • Timely linkage – entry into care within 3 months of diagnosis. Local3 and national measure

    1 BertolliA. et al The Open AIDS Journal 2012,6:131-141. 2Keller et al. J Acquir Immune DeficSyndr2013.

    3New York City HIV/AIDS Surveillance Slide Sets. http://www.nyc.gov/html/doh/html/data/epi-surveillance.shtml


    New york city s care validation study

    New York City’s Care Validation Study

    • Validate CD4 and VL tests for persons living with HIV (PLWH) in NYC as proxy measure for HIV care in the first year after diagnosis

      1° Objective – evaluate the correspondence between a patients 1st CD4/VL on/after HIV diagnosis and linkage HIV care


    Purpose

    Purpose

    Validate 1st lab test (CD4/VL) from the diagnosing facility as measure of timely linkage toHIV care

    • Hypothesis: early post-diagnostic lab tests within first 2 weeks arepart of diagnostic work-up and not an actual linkage event


    Methods

    Methods

    Methods


    Study population selection new york city hiv registry

    Study population selection: New York City HIV Registry

    • Selected high-volume HIV diagnosing sites with co-located care (n=24)

      • Patients with new, confirmed HIV diagnosis in 2009 reported the Registry

      • Patients who had to linked to care at the same diagnosing facility within 12 months as per the Registry

        • PLEASE NOTE – Even though Surveillance does not require linkage to care at the same site of diagnosis, we did in order to conduct this validation study


    Charu sabharwal md mph medical director epidemiology and field services program

    Figure 1: Final study population

    3,536 new, confirmed HIV diagnoses

    among > 13 years in NYC in 2009

    1,263 (36%) patients reported from high-volume

    (> 20 diagnoses) co-located HIV care sites

    947 (75%) patients had 1st CD4/VL reported

    from co-located site within 12 months of diagnosis eligible for medical record (MR) abstractions

    165 (17%) excluded: MR unavailable

    782 (83%) patients

    Registry (1st CD/VL) and MR (care visit) data


    Data analysis

    Data Analysis


    A nalytic population n 782

    Analytic population (n=782)

    Linkage within 12 months, per Registry

    NO

    YES

    HIV care visit confirmed by MR

    No medical visit group

    Medical visit group

    • Compared the subgroups based on:

    • Key demographic characteristics (age, gender, risk)

    • Proportion concurrently diagnosed with HIV/AIDS(AIDS within 31 days of HIV diagnosis – local definition)

    • Proportion diagnosed on inpatient service

    • Proportion that died within 12 months of diagnosis


    Timely linkage to hiv care

    Timely linkage to HIV care

    • Compared the proportion who linked to HIV care within 3 months of diagnosis (timely) by Registry (1st CD/VL) vs. MR (care visit)


    Do 1 st reported cd4 vls indicate timely linkage to hiv care

    Do 1st reported CD4/VLs indicate timely linkage to HIV care?

    • Compared subgroups:

      • Median time to 1st lab per the Registry

      • Proportion of 1st labs in 0-7 days and 0-14 days

    • Calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of Registry data in correctly classifying patients’ true timely linkage to care status based on the 1st CD/VL within:

      • 0-91 days (no labs excluded: National standard)

      • 8-91 days (excluded labs from 0-7 days)

      • 15-91 days (excluded labs from 0-14 days)


    Results

    RESULTS


    Figure 2 linkage to care n 782 registry vs mr

    Figure 2: Linkage to care (n=782)Registry vs. MR

    No Medical visit

    20% (n=157)

    1st CD4/VL

    100% (n=782)

    Medical visit

    80% (n=625)


    Charu sabharwal md mph medical director epidemiology and field services program

    Table 1: Demographics/clinical outcomes


    Figure 3 inpatient diagnoses

    Figure 3: Inpatient diagnoses

    No medical visit

    Medical visit


    Figure 4 mortality outcomes deaths within 12 months of hiv diagnosis

    Figure 4: Mortality outcomes:Deaths within 12 months of HIV diagnosis


    Charu sabharwal md mph medical director epidemiology and field services program

    Timely Linkage to Care


    Figure 5 timely linkage to care registry vs mr

    Figure 5: Timely linkage to careRegistry vs. MR

    97%

    1st CD4/VL

    (proxy measure):

    0-91 days

    75%

    True linkage event

    (HIV care visit):

    0-91 days


    Timely linkage

    Are labs within the early

    post-diagnostic period indicative of timely linkage to care?

    Timely linkage


    Figure 6 median time days to linkage based on 1 st cd4 vl by subgroups

    Figure 6: Median time (days) to linkage based on 1st CD4/VL, by subgroups

    No medical

    visit

    1 day (IQR 0-5 days)

    p <0.001

    Medical visit


    Figure 7 proportion of 1 st labs in the early post diagnostic period by subgroups

    Figure 7: Proportion of 1st labs in the early post-diagnostic period, by subgroups

    p <0.001

    p <0.001

    19%

    31%

    No

    medical

    visit

    No

    medical

    visit

    Medical

    visit

    Medical

    visit


    Charu sabharwal md mph medical director epidemiology and field services program

    Figure 8: Performance of Registry data

    99%

    0-91 days

    8-91 days

    15-91 days


    Charu sabharwal md mph medical director epidemiology and field services program

    Refinement of NYC’s timely linkage to care indicator


    Figure 9 final study population r efining timely linkage to care

    Figure 9: Final study population: Refining timely linkage to care

    No lag applied

    Lag applied


    Figure 10 new york city s refined timely linkage to care indicator

    Figure 10: New York City’s refined Timely linkage to care indicator

    No lag

    No lag

    Lag

    Lag


    Conclusions

    Conclusions

    • First population-based study to validate the use of HIV Surveillance’s proxy measure of timely linkage to care

    • Substantial misclassification of timely linkage in the early post-diagnostic period

    • NYC DOHMH implemented a refined definition of timely linkage to care (labs 8-91 days after diagnosis)

      • HIV labs in 1st 7 days  not indicative of linkage

    • Surveillance data overestimated linkage for older persons, non-traditional HIV risk transmission, and those who died soon after diagnosis


    Limitations

    Limitations

    • Selection of provider

      • A portion had a CD4/VL at an alternate provider which may be the linkage to care visit –DID NOT validate if these patients EVER linked

      • Oversampled the acute care setting

    • Selection of study population

      • Due to the complexities of HIV laboratory reporting, the 1st lab may have been misclassified to the incorrect provider


    Future directions

    Future directions

    • Exploration of surveillance-based retention in care measures vs. medical abstraction data

      • All care visits at diagnosing provider during first 12 months immediately following diagnosis

    • In depth exploration of mortality within 12 months of HIV diagnosis


    Cjain@health nyc gov

    Thank you!

    [email protected]


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