Identifying Treatment Challenges and Highlighting Collaborative Opportunities to Improve Care for Veterans with HIV/AIDS

1. Identifying Treatment Challenges and Highlighting Collaborative Opportunities to Improve Care for Veterans with HIV/AIDS or Hepatitis S. Randal Henry, DrPH, MPH Amy Justice, MD Steven Wright, PhD Susan Zickmund, PhD Hildi Hagedorn, PhD Henry Anaya, PhD

2. Agenda/Speakers • Speakers • Randal Henry, DrPH, MPH 10 Minutes • Amy Justice, MD 15 Minutes • Steven Wright, PhD 15 Minutes • Susan Zickmund, PhD 10 Minutes • Hildi Hagedorn, PhD 10 Minutes • Henry Anaya, PhD 10 Minutes • Question and Answer Session 20 Minutes

3. Objectives • This workshop will review: • (1) HIV and HCV related health disparities in the VA • (2) measures for monitoring health inequities • (3) treatment challenges • (4) identify opportunities for partnerships with Operations and other QUERI centers

4. Background • Vulnerable patients groups are particularly disadvantaged • No one entity can address the multiple needs of the vulnerable patient group

5. The Call • We seek partners to help address the needs of veterans at highest risk for impaired access • who, as a result, do not benefit from improvements in chronic illness identification, care, and treatment

6. The Goal • Identify collaborative opportunities to improve access to care and increase the equitable distribution of HIV, HCV and specialist care for veterans with co-morbid health conditions. • Our goal is that each attendee identify potential partners for collaboration to…

7. The Purpose • Our purpose is threefold: • Highlight the impact of growing disparities in HIV/AIDS and HCV upon racial and ethnic minorities • Discuss methods of assessing disparities • Identify opportunities for operations and research to collaborate in reducing health disparities.

8. The Challenge • Few programs or treatment models are designed to: • address the needs of low-income patients with HIV and/or HCV and housing problems • manage patients with multiple co-occurring medical, substance use, or psychiatric illnesses • Provide comprehensive, integrated care for patients that require multiple co-morbid conditions • Sylvestre D, et al, Co-occurring hepatitis C, substance use, and psychiatric illness: Treatment issues and developing integrated models of care, Journal of Urban Health 5.13.06

9. Highlighting The Challenge Co-Morbid Conditions % of Patients Low Income 74.5 Depression 47.6 Substance Use Disorder 33.2 Hepatitis C 31.9 Lack of Housing 31.8 STDs 24.8 Hepatitis B 23.0 PTSD 19.4 Schizophrenia 8.6 Henry, SR, et al, Disparities in HIV Clinic Appointment Attendance, Factors Associated With Missed HIV Clinic Appointments, QNM 2008 Poster

10. HIV/AIDS has become increasingly overrepresented in the African American and, Latino-American community. Among HCV patients, African Americans are more likely to be homeless and less like to receive anti-viral treatment than whites Disparities

12. Disproportionate Rates • The HIV prevalence rate for: • African American men was six times the rate for white men • Hispanic men was more than twice the rate for white men • African American women was nearly 18 times the rate for white women • Hispanic women was more than four times the rate for white women • African American women was greater than the rate for all other groups, except for black men • CDC.GOV

13. Disproportionate Rates • Disproportionate rates of HIV infection in racial and ethnic minority communities underscore the need for effective intervention efforts for prevention, treatment, and care.

14. Randal Henry

15. Racial and ethnic minorities are more likely to acquire HIV/AIDS, and more likely to die of HIV/AIDS once they acquire the infection. This is primarily because improved HIV outcomes and decreased mortality rates as a result of treatment with highly active antiretroviral therapy (HAART) have not benefited minorities to the same extent as whites. CDC.gocv Disparities

16. Disparities • Regardless of location (rural, urban, or suburban), racial and ethnic minorities are significantly impacted by HIV infection, • Poverty, unequal access to health care, racism, substance and alcohol abuse, limited infrastructure and capacity, social apathy, and homophobia all contribute to the transmission of HIV infection and the ramifications of this infection.

17. Amy Justice, MD Principal Investigator, Veterans Aging Cohort Study and Chief of General Internal Medicine (Yale)

18. Understanding Racial Disparities in HIV Using Data From the Veterans Aging Cohort 3-Site Study and VA Administrative Data Objectives: We identified race-associated differences in survival among HIV-positive US veterans to examine possible etiologies for these differences. Methods: We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients’ health status, clinical management, and adherence to medication by race. (Am J Public Health. 2003;93:1728–1733)

21. Why? • Minority veterans were • More likely to have comorbid disease • More likely to have more than one comorbid disease • More likely to have high viral load and low CD4 cell count • No significant differences found for • Proportion on HAART • Number of CD4 cell counts or viral loads • HAART adherence • Conclusions: Survival differences may derive from more comorbidities and severity of HIV disease at presentation for care. • Implication: Targeting interventions to optimize of care for chronic disease complicated by comorbidity and toxicity is a promising means of decreasing racial and ethnic disparities in health outcomes with VHA

22. How Can VACS Help? • (Observational data) Understand how people of differing race/ethnicity respond to health care for chronic disease • (Intervention research) Improve tailoring of health care to individual patient • Severity of HIV infection • Burden of comorbid disease • Health behaviors • Substance use • Risky sex • HAART adherence

23. Prevalence of HCV Infection Percent Veterans Aging Cohort Study, Baseline, lab or ICD-9 code

24. Steven Wright, PhD Director of Epidemiology, Office of Quality and Performance (OQP)

25. Steven Wright • Steven Wright is the Director of Epidemiology for the Office of Quality and Performance. He will discuss methods of assessing health disparities and opportunities for operations and research to collaborate in evaluating the effect of quality improvement efforts on reducing health disparities.

26. Disparities in the Quality of Care Steven M. Wright, PhD Director of Epidemiology Office of Quality and Performance

28. But…Health Disparities PersistResearch Findings & Current Investigations • Evidence synthesis summarizes VA research June 2006 (1981 - 2006 articles) • On objective health indicators, non-white veterans generally fare worse than whites • Reasons for disparities not clear but may relate to: • lifestyle • attitudes towards invasive procedures • communication styles of patients and providers • OQP operational focus on disparities: • Race/ethnicity • Technical process and intermediate outcome measures of Quality • Patient Satisfaction • Gender • Technical Quality • Patient Satisfaction

29. Ethnicity/RaceGlobal Measures of Technical Quality • Process Measures (e.g., preventive services, inpatient care metrics) show little difference • Intermediate outcomes (e.g. BP, LDL chol, Hgb A1c) are worse for black, Hispanic veterans Analyses adjusted for age, gender, income, Medicare, self-reported health status, depression, site of regular provider, geographic region

30. Ethnicity/RacePatient Perceptions of Quality • Hospital Quality Report Card in June 2008 and follow-up report examined veteran and system characteristics • Survey of Health Experiences of Patients (SHEP) • Overall Quality of Care (inpatient & outpatient) • Veterans Health Service Standards • Lots of data (FY2005 - FY2007) • Outpatients 748,681 responded • Inpatients 183,771 responded • Covariates – age, gender, health status, other demographics

33. Gender DisparitiesTechnical Quality of Care • Generally quality of care for women quite high • Significant and durable gaps in outpatient care for women in relationship to: • Management of cardiovascular risk factors including those with diabetes, HTN, IHD • Colorectal cancer screening • Immunization • Depression Screening • No association with presence of designated women’s health providers • Age an important effect modifier, variability by VISN and facility

34. VA Health Disparities Opportunities for Collaboration • OQP custodian of rich source of data for health disparities research (EPRP and/or SHEP). Many examples: • Chronic pain (race) • Alcohol Counseling (race) • Immunization (gender) • Quality of Care (mental health, MS, SCI, Chronic illness, rural/urban) • Understanding disparities important to VHACO; collaboration with subject experts is vital • HSR&D Centers of Excellence (eg, Center for the Study of Health Care Provider Behavior, CHERP)

35. Susan Zickmund, PhD Co-Chief Qualitative Research, Center for Health Equity Research and Promotion (CHERP)

36. Roadmap • HCV racial disparities and treatment challenges. • Measurement issues in capturing racial disparities. • And present an example of how researchers and VA Operations might effectively collaborate.

37. Prevalence of Hepatitis C (HCV) HCV affects 1.6% of the United States population. Is 5 times more prevalent than the human immunodeficiency virus(HIV) infection. 20% of patients progress to cirrhosis in 20 years. 10% succumb to liver cancer / end-stage liver disease. HCV is the primary reason for liver transplantation in the US.

38. Prevalence of HCV in the VA • HCV prevalence in the VA is 5.4%. • VA has more than 3 times the rate of HCV than that of the general US population. • Prevalence for whites in the VA is 3.2%, but is 11.0% for African Americans (AA).

39. VA HCV Treatment Disparities • Studies report low treatment rates within the VA, 8%-13%. • Bini et al. found AA significantly less likely to be considered candidates by GI clinicians. • Butt et al. found similar results with both monoinfected HCV veterans and HCV-HIV co-infected. • AAs were more likely to decline treatment when it was offered.

40. Inside the Black Box… • Reasons for treatment disparities are currently unknown. • One reason may be the lower cure (sustained viral clearance rate) for AA. • May be an association with communication with providers. • Retrospective chart review pilot study of patients initiating HCV treatment. • We found that providers in their CPRS notes told AA that they had a lower cure rate than whites. • We found that of those who withdrew/refused treatment, 76% were AA versus 56% were whites.

41. Potential Barrier: Communication and Trust • Our work outside the VA showed that nearly 40% of HCV patients reported conflict with providers* • A current interview study of methadone using veterans who rejected HCV treatment explained that a chief reason was a lack of trust in providers: • “They just don’t seem to think [treatment] is important.  I have to ask and ask and they still don’t suggest it.”  • “I’ve had this condition for a long time and no one before this suggested that I get treatment.  It’s like no one wanted me to get it.”  *Zickmund, et al. Hepatology (39) April 2004

42. Measuring Racial Disparities Challenges • Complex social factors. • A need exists for complex methods and for collaborations.

43. Mixed Methods • 50 AA & 50 whites: audiotape every HCV clinic, interview patients and providers. Outcome measure: patient dropout of treatment initiation process or starts treatment.

44. Opportunity to Partner with VA Operations • In closing, an example of how researchers and Operations can integrate their work to further research in health disparities. • Our opportunity drew on results of the SHEP report to fashion what is called in our CHERP model a 2nd generation study. designed to further our understanding of why disparities exist • Rapid turn around SHEP QI project* interviewing 30 AA & 30 whites at 3 major VA centers on satisfaction with VA care: *Preliminary Evaluation of Differences in Satisfaction with VA Health Care between African American and White Patients, An Internal VA Report Prepared for the Associate Deputy Under Secretary for Health, Quality and Safety, (S. Zickmund/M. Fine).

45. Results and Conclusion • Significant racial disparities in satisfaction with overall VA care and outpatient VA care (Likert scale). • African Americans reported lower levels of trust in their VA medical providers (69% of AA trusted vs. 90% of whites). • More African American patients expressed dissatisfaction with adequacy of pain management (48% vs. 15%). • Mixed methods and the combined efforts of research and Operations may be one critical way to understand the complexities of racial health disparities.

46. Hildi Hagedorn, PhD IRC, QUERI-Substance Use Disorders (SUD)

47. Challenges Facing SUD Patients with HIV/HCV • Missed opportunities for testing • If disease is identified, patient level barriers interfere with establishing a successful connection with a specialty clinic • For HCV, patients who attend an appointment in a specialty clinic encounter clinicians without training in management of SUD

48. Liver Health Initiative Preceptorship • Bring SUD and HCV clinicians together to plan for integration of care • Train SUD clinicians to implement hepatitis testing, education, and vaccination • Train HCV clinicians in standardized screening, brief interventions, and referral protocols for SUD • Develop expedited referral mechanisms between clinics

49. Collaborative Opportunities • How to expand LHI beyond volunteer clinics? • What is the best model for a similar program for HIV? • Partners: • VISN Leaders • HIV/HEP C QUERI • Public Health Strategic Healthcare Group • Office of Mental Health Services

50. Henry Anaya, PhD Investigator, QUERI-HIV/Hepatitis