ARV MANAGEMENT: Is Anybody Home

1
ARV MANAGEMENT Is Anybody Home?

• HIVQUAL Workshop
• BRUCE AGINS MD MPH
• October 15th, 2003

2
The ARV Indicator ARV Data The Letter The
Responses Next Steps
3
The ARV Indicator Whats an Unstable Patient
Anyways?
4
Stable Patient Definition

• Viral load is undetectable, or
• Viral load has dropped by at least one log since
  last 4-month review period, or
• Viral load has increased by less than 3X from the
  lowest value in last 12 months on that regimen
  and
• A note in the patient record by the treating
  physician states that the patient is stable
  despite detectable viral load

5
Stable Patient Considerations for the Reviewer

• Viral load is dropping (but not yet undetectable)
  or
• VL has increased by less than 3X from the lowest
  value in last 12 months, or
• A note in the patient record by the treating
  physician states that the patient is stable
  despite detectable viral load

6
Stable Patient Appropriate Management

• Monitoring of viral load every 4 months

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Unstable Patient Definition

• Viral load is increasing by more than 1 log and
  absolute value is over 1,000 or
• CD4 is dropping by 50 since last 4-month review
  period or
• Patient deemed unstable by physician or
• OI in the last four month review period (new or
  recurrent) or

8
Unstable Patient Appropriate Management

• Three Options
• Regimen was changed and viral load assay
  performed within 8 weeks of decision
• Justification provided not to change therapy
• intercurrent illness, recent vaccination,
  adherence intervention documented, viral load
  reordered, resistance testing ordered, other and
• viral load assay performed within 8 weeks of
  decision
• Decision made to discontinue therapy and clinical
  follow-up plan noted in record

9
Unstable Patient Appropriate Management

• Ultimately, the decision about whether the
  patient is stable or unstable is made by the
  clinician

10
The Data
11
Data AIDS Institute Response

• Review of data raises concerns about
  appropriateness of care about management of ARV
  in unstable patients
• Staff review medical records to assess validity
  of indicator and discover causes of poor
  performance
• Review confirms that the data are accurate
• Concern raised to Advisory Committee which
  recommends that we send letter to facilities to
  raise awareness

12
Data Advisory Committee Suggestions

• Send letters asking for explanation to review
  systems of care for ARV management
• Arrange individual meetings to discuss low scores
• Highlight below average results in reports
• Develop tracking forms with prompts to address
  abnormal results
• Develop best practices to improve ARV performance

13
Data Advisory Committee Suggestions

• Think about systems problems
• Delays in lab results
• Panic Value Systems
• Direct transmission of results to medical
  directors
• Correlate with HIV Specialist data
• Provider education focusing on management of
  patients with high viral loads receiving
  antiretroviral therapy

14
Data Mailing

• Non-HIVQUAL sites
• 2001 data mailed to facilities
• HIVQUAL sites
• Data entered and can be produced by facility

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The Letter
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The Letter

• Sent to facilities with performance of 70 or
  lower
• Mailing date of January 8, 2003
• Results in red and boxed
• Copies sent to Program Medical Director and
  Program Administrator
• Asks facilities to review management of ARV in
  their clinic as part of their HIV Quality
  Management Program focusing on systems
• Respond to me via phone or email to discuss
  findings by early March, 2003

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The Responses
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Responses Individual Factors

• Physician not managing patients appropriately
• Documentation poor by specific physicians

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Responses Indicator Issues

• For patients with high viral loads, when the
  decision is made not to change therapy, VL does
  not need to be rechecked in 8 weeks
• Inappropriate management for not ordering a
  resistance test?
• Only one value is below threshold for ARV should
  have been appropriate if documentation was
  provided since therapy was not offered
• Wont pick up special case no need for action
  or change intercurrent illness diverting
  attention from ARV management and documentation

20
Changes Flow Sheets

• Comprehensive flow sheets with key components of
  HIV care
• HIV issues included now in routine visit sheet
• Standardized forms covering the following areas
• -CD4 and Viral load monitoring trends
• -Triggers for VLgt1000
• -Adherence referrals
• -Defined follow-up intervals
• -Specific ARV management parameters
• -New medical visits
• Add HIV elements to standard medical visit sheet
• Medication flow sheet with documentation about
  adherence

21
Changes Provider Education

• Review of guidelines and indicator definitions
• Discuss concepts of stability/instability at
  physician meeting, including management of ARV
• Integrate ARV management into routine provider
  meetings
• Specific education about ARV management to
  frontline clinician staff
• Documentation requirements, including f/u of VL
• Adherence tools
• Meetings with HIV Specialist
• Preceptorships
• Increase number of HIV Specialists
• Attendance at IAS conferences
• Offer CME credits for HIV training

22
Changes Provider Education (2)

• Discuss when ARV should not be given
• Tighten resident supervision
• Train case workers about ARV management and
  importance of routine monitoring
• Updates in HIV care at monthly provider meetings
• Weekly clinical conference for providers to
  discuss complicated ARV decisions
• Attending review of fellows management decisions
• Grand Rounds
• Case Presentations and seminars by HIV experts

23
Changes Medical Director Involvement

• Feedback to frontline practitioners
• Letter sent by medical director to medical staff
  about guidelines for unstable patients
• Assign medical director as backup for complex
  cases
• Designate clinician lead at each site
• Monitoring of clinical decisions by medical
  director with random chart review
• Medical Director follow up on findings from chart
  audits

24
Changes Reminder Strategies

• Follow-up calls by case manager or nurse
• Letters to no-shows
• Call no-shows
• Enhance outreach program
• Call before appointment
• Tickler file to send cards out for appointments
• Comprehensive no-show program including patient
  input into process for follow-up checking in
  after visit - Montefiore

25
Changes Self-Management

• Patient Education/Empowerment
• Treatment readiness program, including importance
  of keeping appts.
• Side effects education
• Information system with new appointment system to
  easily track appointments
• Automated reminder system
• Database to track followup appointments and
  outcomes
• Incentives
• Patient diary to track labs, treatment, provide
  tips about adherence and other educational
  materials
• Enhance role of CAB in reviewing data

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Changes Home Visits

• COBRA
• Nursing staff
• VNS
• Adherence - ?DOT

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Changes Information Systems

• Tracking databases
• QA database showing multiple parameters
• Automated appointment tracking
• Scheduling database
• Use EMR data to monitor care

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Changes Tracking Systems

• Logbooks
• Facilitate contact of no-shows
• Complete baseline assessments
• Create list of unstable patients, update and use
  for tracking, referrals to multidisciplinary
  team
• Routine updating of list of visits and missed
  appointments with direct feedback to medical
  providers

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Changes Documentation

• Emphasize importance general improvements
• Adherence counseling
• CM interventions included in record
• Reorganize medical records
• Clearly state in record whether patient is stable
  or unstable
• Documentation of side-effects
• Incorporate pharmacy provider into adherence form
  (Interfaith)
• Improve documentation of decision process about
  ARV
• Hasten return of information and results to chart
• Information about no-shows

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Changes Documentation (2)

• Stamp for progress note that includes criteria
  and stable/unstable status for use at every
  encounter (LICH)
• Modify medical history and physical forms to
  improve documentation about ARV management
• Patients sign that they are choosing not to take
  ARV (can reverse decision) ENY
• Progress note developed to document prompt
  providers at each visit to address review CD4,
  VL, treatment plans, with prompt to document
  rationale for decisions issues leading to
  unstable status

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Changes QI Plans

• Specific ARV QI Plan (Elmhurst, Scruggs)
• Unstable Patients Plan (Middletown)
• -Review case with clinical coordinator
• -Contact case manager
• -use adherence information form
• -flag for resistance test or repeat VL
• -case conference
• Unstable Patients Plan
• -MD review
• -Team review
• -Tracking
• -Increase HIV Specialist involvement
• -Focused plans to facilitate adherence, expedite
  enhance access to multidisciplinary team
  services
• Monitor timeliness of viral loads

32
Changes Lab Issues

• Simplify review of results
• Shorten turnaround time for results
• Posting of results to computerized lab system,
  including resistance testing
• Coordinate blood drawing with visit
• Staff drawing blood will ensure f/u clinic visit
  scheduled in two weeks
• Loosen lab restrictions for processing specimens
• Lab Error Plan (see next slide)

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Responses Lab Issues

• Lab Error Plan (Scruggs)
• Identify when blood not drawn or not picked up
• Flag missing results for follow up
• Nurse communicates routinely with lab staff
• Lab log to track when labs were completed for
  checking results within 14 d of draw
• Immediate rescheduling if labs not obtained
• CM and outreach staff to bring patient for labs
• Coordinate with lab staff/address IS issues
• Ongoing performance measurement

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Changes Case Conferencing

• Focus on difficult cases
• Routine quarterly adherence discussions
• Include as part of monthly provider meeting in
  clinic

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Changes Adherence

• Promote enrollment into adherence program
• Comprehensive treatment adherence services
• Increase referrals by physicians to adherence
  counselors
• Increase appointment-keeping for labs
• Routine monitoring quarterly by case manager
• Pts who miss appts. meet with Medical Director or
  administrator and may be referred elsewhere

36
Changes Performance Measurement

• Routine medical record reviews monthly,
  quarterly,
• Random ARV management reviews
• Independent reviewer
• Specific reviews of patients gt1000 copies to
  determine if unstable, and if so flag for special
  review
• Review of charts by medical director
• Modify indicators to incorporate indicators from
  guidelines
• Develop new indicators to measure care of
  unstable patients on ARV
• Review all unstable patients
• QA Database shows values which can be flagged
• QOC review teams multidisciplinary (Narco)

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Changes Staff Visits

• Hire new case managers
• Special medication visit for unstable patients

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Changes Pharmacy Involvement

• Delivery of medications onsite to ensure pickup
  whenever refills are due
• Pharmacist onsite in clinic to discuss changes in
  regimen
• Integrate pharmacy into adherence form

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Responses Systems Issues

• Community Resources
• Referral processes to CBOs documented

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Other Responses

• Patients who are non-adherent substance users and
  shouldnt be counted in the sample
• Patients dont return for their lab tests or
  visits (no shows)

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Results

• Improvements have already been measured

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Next Steps and Some Preliminary Observations
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What Have We Learned So Far

• Wheres the Data?
• Routine monitoring and QI that focuses on ARV
  management is not occurring
• Minor tinkering with the indicator is indicated
• Many providers pay attention to letters flagging
  poor result

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What Have We Learned So Far

• Difficult issues to resolve include no-shows
  and complicated patients
• Challenges of documentation
• Complexity of management
• Some innovative strategies!

45
Conclusions

• Most people are home
• Lots of interesting innovations
• Some full-scale QI plans and programs
• Some are still stuck
• A handful are still not home

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Next Steps

• Responders
• Encouragement
• Ongoing follow-up
• Some still need to provide QI information!
• Follow up compare subsequent results
• Letter
• Compilation of Best Practices and Innovative
  Solutions