evaluating hiv clinical care quality in massachusetts sites supported through the medical case...
TRANSCRIPT
Jeanne Day, MPH
Nancy Reinhalter, RN
Joseph Musolino
Joseph Rego
Amy Flynn
Katelyn Flaherty Dore
Ashley Hatcher
EVALUATING HIV CLINICAL CARE QUALITY
IN MASSACHUSETTS SITES SUPPORTED THROUGH
THE MEDICAL CASE MANAGEMENT SYSTEM
RESULTS FROM 2014 MEDICAL RECORD REVIEW
JSI Research & Training Institute, Inc.
Wednesday, March 2, 2016
Project Background
Review Data Collection and Analysis Procedures for
2014 chart review
Review of Aggregate Statewide Data for Clinical Care
Quality Indicators
PRESENTATION OVERVIEW
Table 1: Summary Data for All Clients Reviewed
Tables 2-8: Demographics and Clinical Care
Indicators, Clients >= 1 visit
Table 9: Clients with 0 visits, Reasons for 0 Visits
Table 10: Demographics, Clients with 0 Visits and
Determined to be Lost to Follow -up at the End of the
Review Year
TABLES IN SITE REPORT
Since 1998, through funding received from MDPH and BPHC, JSI has been evaluating quality of care through chart reviews in Massachusetts HIV clinics supported through Ryan White Part A and B funding.
8 “rounds” of chart review have been completed, providing data over a 15 year period (1999-2014)
The most recent round of chart reviews was conducted last year in 22 clinical sites and clinical care data was collected for calendar year 2014
BACKGROUND
CLINICAL QUALITY MANAGEMENT
Baystate Brightwood HC
Baystate Mason Square HC
Baystate High Street HC
Boston Medical Center
Brockton Neighborhood HC
Cambridge Health All iance
The Zinberg Clinic, Somerville PC
Dimock CHC
Dotwell
Codman Square/Dorchester House
East Boston Neighborhood HC
Edward M Kennedy CHC
Fenway CHC
Fitchburg CHC
Greater Lawrence Family HC
Greater New Bedford CHC
Holyoke HC
IDCS Hyannis
Lowell Community HC
Lynn Community HC
Outer Cape Health Services
SSTAR Family HC
Morton Hospital
UMass Memorial Health Care
MDPH AND BPHC SUPPORTED CLINICAL SITES
22 SITES REVIEWED IN 2014
DATA COLLECTION
2014 CHART REVIEW CYCLE
Target was to review 1200 medical records in the 22
clinical sites with the overall goal of collecting data
from a representative sample of HIV patients in care
in Massachusetts
Data collection focused on indicators from:
HRSA HIV/AIDS Bureau HIV performance measures
National Quality Center (NQC) supported in+care campaign
measures
Sites were asked to submit a list of patients who had
at least one clinical encounter in 2012 or 2013
Based on the lists we received, a total of 8619
patients were reported by the 22 sites
Number of charts reviewed per site was based on the
size of each site’s HIV/AIDS population
SAMPLING METHODOLOGY
SELECTION OF CHARTS FOR REVIEW
Site A had 250 HIV/AIDS patients with a clinical
encounter in either 2012 or 2013
Site % of total HIV/AIDS patients reported by 22 sites (n=8619)
250/8619 = .03 or 3%
Total number of charts to be reviewed at Site A
.03 x1200 = 36 charts
Across all sites, the number of charts selected for
review per site ranged from 24-264 charts
SAMPLING METHODOLOGY EXAMPLE
CHART SELECTION METHODOLOGY
Once the number of charts for each site was determined, patients were randomly selected from each site’s 2012 -2013 patient list
On-site medical record reviews were conducted by JSI trained chart abstractors and clinical care provided in 2014 was reviewed
If a patient did not have a visit in 2014, additional patient charts were supplemented to meet the targeted number of charts for each site
No. %
> 1 visits 1221 84%
0 visits 239 16%
Total charts reviewed 1460*
TOTAL NUMBER OF CHARTS REVIEWED
BY NUMBER OF VISITS, 2014
* 2 patients with HIV-2 only were reviewed and are not included in the statewide totals.
Did Our Method for Selecting Charts Result in a
Representative Sample of Patients Diagnosed
with HIV/AIDS in Massachusetts?
COMPARISON OF DEMOGRAPHICS CHARACTERISTICS
PEOPLE LIVING WITH HIV/AIDS IN MASSACHUSETTS VS.
PATIENTS RANDOMIZED AND SELECTED FOR CHART REVIEW
PLWHA as of
December 31, 2014
AIDS Surveillance Data
N=19,737*
Patients Randomized and
Selected for 2014
Chart Review
N=1460
Gender
Male 71% 69%
Female 29% 30%
Race/Ethnicity
White, non-Hispanic 43% 41%
Black, non-Hispanic 30% 27%
Hispanic/Latino 25% 29%
Asian/Pacific Islander 2% 1%
Other/Unknown 1% 3%
* Data from Massachusetts Department of Public Health HIV/STD Surveillance
COMPARISON OF DEMOGRAPHICS CHARACTERISTICS
PEOPLE L IV ING WITH HIV/AIDS IN MASSACHUSETTS VS.
PATIENTS RANDOMIZED AND SELECTED FOR 2014 CHART REVIEW
PLWHA as of
December 31, 2014
AIDS Surveillance Data
N= 19,737
Patients Randomized and
Selected for 2014
Chart Review
N=1460
Country of Birth
US 65% 56%
Puerto Rico/US Dependency 10% 14%
Other/Non-US 25% 24%
Not Documented 0% 5%
Current Age
0-19 1% 0%
20-29 5% 7%
30-39 11% 15%
40-49 26% 28%
50-59 38% 34%
60+ 19% 15%
COMPARISON OF DEMOGRAPHICS CHARACTERISTICS
PEOPLE L IV ING WITH HIV/AIDS IN MASSACHUSETTS VS.
PATIENTS RANDOMIZED AND SELECTED FOR 2014 CHART REVIEW
PLWHA as of
December 31, 2014
AIDS Surveillance Data
N= 19,737
Patients Randomized and
Selected for 2014
Chart Review
N=1460
HIV Risk Behavior
MSM 38% 40%
IDU 18% 18%
MSM/IDU 3% 3%
Heterosexual* 14% 35%
Blood Product < 1 % 1%
Pediatric/Perinatal 2% 2%
Undetermined/
Other/Unknown
24% 1%
* The chart review data collection form does not document heterosexual risk behavior in the same way as the AIDS
surveillance program .
RESULTS OF STATISTICAL TESTING COMPARING
THE DEMOGRAPHIC SUBGROUPS
Some statistically significant dif ferences were observed for some of the subgroups
Testing was done for all subgroups except heterosexual risk behavior
However, because the percentage dif ferences observed between most of the subgroups were small, between 1 -4 %, the statistically significant dif ferences observed for this analysis are not considered to be meaningful.
Exception is country of birth in the U.S. where a > 4 % percent difference was observed between the two groups (65% vs. 56%)
The patients randomly selected for the chart review are, in general, comparable to PLWHA in Massachusetts except for the country of birth in the US and heterosexual risk category
Retention in Care
HIV Care
Hepatitis and STD Screening
TB Screening
Other Screening Indicators
Cervical Cancer, Lipid, Mental Health and Substance Abuse
Screening
General Medical Care
Oral Screening, Influenza and Pneumococcal Vaccine
Counseling Indicators
HIV Risk and Tobacco Cessation
TYPES OF INDICATORS
Each performance indicator identifies who should be
included in the numerator and who should be
included in the denominator
Numerator includes the number of patients who received the
care or service
Denominator includes the number of patients who should have
received the care or service
HIV PERFORMANCE INDICATORS
RETENTION IN CARE INDICATORS MEDICAL VISITS, MEDICAL VISIT FREQUENCY,
VISIT GAP MEASURE
87% 89%
8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Medical Visits Medical Visit Frequency Visit Gap Measure
> 2 medical visits at least
3 months apart
Did not have medical visit in
last 6 months of
measurement year
>1 medical visit in each 6
months with 60 days
between first and last
medical visit
16% (n= 197) of patients missed more than 2 visits
during the review year
100% of these patients had some form of outreach
documented in the medical record
MISSED VISITS
DID NOT KEEP THEIR SCHEDULED APPOINTMENT
Telephone 93%
Face to Face* 68%
Letter 42%
Email outreach 13%
TYPES OF OUTREACH DOCUMENTED
* Includes visits with non-prescribing providers (RN, VNA, MCM, social worker)
HIV Care Indicators On ART During Measurement Year
All Patients and Pregnant Women
100%97%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
All Patients Pregnant Women
HIV/AIDS patients on ART during the
measurement year
Pregnant women with HIV diagnosis on
ART in the measurement year
HIV Care Indicators Monitoring CD4 Counts* and Viral Loads
60%68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CD4 monitoring Viral Load monitoring
> 2 CD4 T-cell counts performed at least 3
months apart during the measurement year
Viral load test performed at least once every
6 months during the measurement year
* 97% of patients had at least one CD4 count done in the review year
HIV Care Indicators Monitoring Viral Load Suppression Measures*
89% 92% 95%
85%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Last VL Suppressed1+ Medical Visits
All Patients
Last VL Suppressed2+ Medical VisitsPatients on ART
Any VL Suppressed2+ Medical VisitsPatients on ART
All VL Suppressed2+ Medical VisitsPatients on ART
*HIV viral suppression is defined as a viral load less than or equal to 200 copies/mL or BDL
81%
95%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PCP Prophylaxis TB Screening
HIV CARE PREVENTION INDICATORS PCP PROPHYLAXIS AND TB SCREENING
Patients with CD4 count < 200 cells/mm3
prescribed PCP prophylaxis in the
measurement year
Patients who were ever screened by
TST or IGRA since HIV diagnosis
99%96%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HBV Screening and/or
Documented Immunity
HBV Vaccination HCV Screening and/or
Documented Immunity
HEPATITIS HBV SCREENING, HBV VACCINATION, HCV SCREENING
Completed three vaccination
series for Hepatitis B
Hepatitis B screening
performed at least once
since HIV diagnosis
Hepatitis C screening
performed at least once since
HIV diagnosis
56%58% 57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Syphilis Screening Chlamydia Screening Gonorrhea Screening
STD SCREENING SYPHILIS, CHLAMYDIA, AND GONORRHEA SCREENING
Adult patients and sexually
active patients under age 18
who had a test for syphilis
performed within the
measurement year
Patients at risk for sexually
transmitted infections had a
test for chlamydia performed
within the measurement year
Patients at risk for sexually
transmitted infections had a
test for gonorrhea performed
within the measurement year
CERVICAL CANCER SCREENING PAP, PAP OR COLPOSCOPY
51%50%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PAP Only PAP or Colposcopy
HIV-infected women who had a PAP
screening in the measurement year,
cervical cancer screening appropriate*
HIV-infected women who had a PAP or
Colposcopy screening in the measurement
year, cervical cancer screening appropriate
*Patients excluded if ≤18 and not sexually active, or had a hysterectomy
97%98%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Mental Health Screening Substance Abuse Screening
SCREENING MENTAL HEALTH AND SUBSTANCE ABUSE SCREENING
Patient had a mental health screening
in the measurement year
Patient had a screening for substance
abuse in the measurement year
12%
60% 62%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Lipid Screening
Full lipid panel
Lipid Screening
Any lipid test
Oral Screening
GENERAL MEDICAL CARE FULL LIPID PANEL, ANY LIPID SCREENING, AND ORAL SCREENING
Patient on ART and had a
full lipid panel during the
measurement year
Patient on ART and had any
lipid screening test
(cholesterol, HDL, LDL, or
triglycerides) during the
measurement year
Patient received an oral
exam by a dentist at least
once during the
measurement year
80%
96%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Influenza vaccination Pneumococcal vaccine
GENERAL MEDICAL CARE - VACCINES INFLUENZA AND PNEUMOCOCCAL VACCINATION
Patient received influenza vaccination in the
seasonal flu period (10/1/2014 – 3/31/2015)
Patient received pneumococcal vaccination ever
94% 99%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HIV Risk Counseling Tobacco Cessation Counseling
COUNSELING HIV RISK AND TOBACCO CESSATION COUNSELING
Patient received HIV risk counseling within
the measurement year
Patient that used tobacco and received
cessation counseling within the
measurement year
Transferred care 32%
Lost to follow-up* 25%
Moved 23%
Deceased 10%
Visits with non-prescribing providers** 7%
Incarcerated 3%
No reason given*** 1%
REASONS FOR NO VISITS WITH A PRESCRIBING
PROVIDER IN THE REVIEW YEAR, N=239
*Documentation in the medical record that the patient was no longer receiving care at the site at the end of the
measurement year , n=59
**Includes visits with a RN, social worker, MCM visits
*** Last visit was in 2012, no documentation in EHR in 2014, n=2
The majority of indicators used were from HRSA/HAB
Do not ask “why” something was not done
Only information found in the medical record was
used to measure care
Case management records not reviewed
If not documented, we could not tell if done
LIMITATIONS
SUMMARY/CONCLUSIONS
STATEWIDE CHART REVIEW
84% of patients reviewed had at least 1 or more
visits in the review year
16% of patients had 0 visits in the review year
The majority of these patients were not lost to follow -up (74%)
100% of patients that missed more than 2 visits
during the review year had some form of outreach
documented in their medical record
A number of areas where high percentages of
patients met a particular measure:
ART
97% of patients were on ART during the measurement year
All pregnant women were on ART
Viral load suppression was high with 92% of patients on ART
having their last VL suppressed
Mental health and substance use screening
Hepatitis B and C screening
Pneumococcal vaccination
HIV risk and tobacco cessation counseling
SUMMARY/CONCLUSIONS
STATEWIDE CHART REVIEW
Some indicators where a lower percentage of patients
met a particular measure:
Viral load monitoring
Influenza vaccination
STD screening
Pap smears
Oral screening
SUMMARY/CONCLUSIONS
STATEWIDE CHART REVIEW
We will be reviewing charts for clinical care provided
in 2015
The same sampling approach will be used:
We will be asking for lists of patients who had a clinical visit in
2013 or 2014
Same method will be used to determine the number of charts
per site for review
The number of charts to be reviewed per site will be randomly
selected from each site’s list
JSI staff are in the process of contacting sites to discuss
obtaining patient lists
NEXT CHART REVIEW CYCLE
JSI QM team
Nancy Reinhalter, Jeanne Day, Joe Musolino, Joseph Rego,
Amy Flynn, Katelyn Flaherty Dore, Ashley Hatcher
Clinical site staff at participating MDPH and BPHC funded
sites
BPHC
Eric Thai, Ben Penningroth
MDPH
Liisa Randall, Sophie Lewis
ACKNOWLEDGEMENTS