Quality Assessment: Primary medical services provided to HIV-infected persons

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Quality Assessment Primary medical services
provided to HIV-infected persons

• Shazia Kazi, MD, MPH.
• Baltimore City Health Department
• Ryan White Title I Office
• Shahdokht Boroumand, DMD, MPH.
• National Institutes of Health

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Background

• Maryland had the fourth highest annual AIDS case
  report rate of any state in 2004, 26.1 cases vs.
  14.9 cases per 100,000 population nationwide. 1
• Baltimore-Towson EMA had the fifth highest rate
  of any metropolitan area (32.8 cases per 100,000
  population) in 2004.1

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Ryan White CARE Act

• The Ryan White Comprehensive AIDS Resources
  Emergency (CARE) Act is Federal legislation that
  addresses the unmet health needs of persons
  living with HIV disease (PLWH) by funding primary
  medical care and support services.2

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Ryan White Care Act Title I

• Title I of the CARE Act provides resources to
  metropolitan areas most severely affected by
  HIV/AIDS. 51 Eligible Metropolitan Areas, or
  EMAs, receive assistance under Title I. EMAs are
  defined as areas with
• a population of at least 500,000 and
• at least 2,000 reported AIDS cases in the
  previous 5 years.3

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Quality Improvement Program- RW Title I mandate

• In accordance with the Ryan White CARE Act
  Reauthorization 2000, each EMA is mandated to use
  up to 5 of allocated funds to4
• Establish a quality management program that
  assesses the extent to which HIV health services
  are consistent with the most recent Public Health
  Service guidelines for the treatment of HIV
  disease and related opportunistic infections.
• Develop strategies that ensure such services are
  consistent with the guidelines for improvement in
  the access to and quality of HIV health services.

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Quality Improvement Program Baltimore-Towson
Eligible Metropolitan Area

• Baltimore City Health Department (Grantee)
  has implemented the Quality Improvement Program
  (QIP) since FY 2001.
• QIP assesses/documents the compliance of Ryan
  White Title I providers in Baltimore in terms of
  their adherence to Public Health Standards and
  local Standards of Care.
• QIP assesses the local Standards of Care, as
  established by the Greater Baltimore HIV Health
  Services Planning Council in accordance with the
  most recent Public Health Service Guidelines for
  the treatment of HIV disease.

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Quality Improvement Program Cycle

• The QIP Cycle for the Baltimore EMA is based on a
  four-year framework, the first year having been
  FY 2001.
• The Primary Medical Care service category was
  reviewed in FY 2001 and FY 2005, as a component
  of the four-year QIP cycle related to the
  continuum of care for PLWH/A.
• QIP assessment process includes following steps

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QIP Process

• Survey Instrument development
• Database Development
• Data Collection
• Data Entry
• Data Analysis
• Report Writing
• Technical Assistance/Capacity Building

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Objectives of the Study

• Assess the effectiveness of primary care programs
  serving HIV-infected clients within the Baltimore
  EMA for FY 2004.
• Evaluate the compliance of Title I medical
  providers with Public Health Guidelines and Local
  Standards of Care.
• Assess the association between frequency of
  visits by clients and quality of services.

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Baltimore (Towson) Eligible Metropolitan Area
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• Fourteen (14) providers (hospitals, community
  clinics, and federally qualified clinics)
  received Ryan White Title I funding to deliver
  primary medical care services in FY 2004.
• 6,269 HIV persons received primary medical care
  services through Ryan White Title I.5

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Primary Care Assessment Process

• Random sample was determined based on guidelines
  developed by the New York State Health
  Department, AIDS Institute.6 A total of 384
  primary medical care client charts were reviewed.
• A survey instrument was developed to collect
  demographic and medical information as well as to
  assess the documented compliance of providers to
  deliver services according to the local Standards
  of Care.

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Primary Care Assessment Process- Contd

• The primary source for the assessment was medical
  charts that were reviewed for documentation of
  adherence to minimum requirements.
• 10 measures were used to assess the quality of
  primary care.
• Numerical Scoring was used to code the 10 quality
  measures of primary care for each client.

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Minimal Data Variables Required By Primary Care
Standards

• CD4 Count (minimum of twice per year)
• Viral Load (minimum of twice per year)
• HAART (Highly Active Retroviral Therapy)
• Hepatitis B
• Hepatitis C

• PPD (Tuberculosis test)
• PCP- (Opportunistic Infection)
• MAC- (Opportunistic Infection)
• Syphilis- (Sexually transmitted infection)
• Safe-sex Education

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Definition - Quality Index

• A reverse scoring methodology was used to develop
  a numerical index for scoring the quality of care
  with the lower scores indicating the higher level
  of documented compliance. (See Table 1)

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Table 1 Reverse Scoring
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Scoring- Methodology

• Based on reverse scoring, a total score was
  calculated for each client based on 10 measures.
  Each client was placed in one of the three
  classes
• High-quality (0-1)
• Medium-quality (2 thru 4)
• Low-quality (5 thru 10)

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Results- Characteristics of Study Population
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Residential Distribution of Clients in Baltimore
EMA
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Results

• Only 32 of all client charts were in the high
  quality category, in which 9 or 10 measures were
  met and documented according to the minimum
  requirements of the local standards of care.
• 22 of total client charts were in the low
  quality category, in which only 5 or fewer of the
  10 measures were met and documented according to
  minimum requirements of local standards of care.

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Quality Categories
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Results

• The three quality classes were collapsed into two
  categories (high vs. non-high) to generate a
  binary variable. The moderate and low scoring
  classes were consolidated into the non-high
  category.
• No significant difference was found between the
  demographic characteristics of the study
  population and the quality of primary care
  services using Pearson Chi Square test Logistic
  Regression analysis.

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Results

• Number of visits is highly associated with
  quality of primary care services (using the
  binary quality variable)

Quality of Primary Care Services Quality of Primary Care Services
High (0-1) Non-High (2-10) Total
Number of Visits
1 0 (0) 56 (21.5) 56 (14.6)
2 37 (30.1) 78 (29.9) 115 (30)
3 86 (69.9) 127 (48.7) 213 (55.5)
Total 123 (100) 261 (100) 384 (100)
Pearson chi square p value lt 0.0001
Fishers exact p value lt 0.0001
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Boxplot showing number of visits vs. quality of
care
Quality of Care
Number of Visits
The box-plot graphs show the range of the quality
scores for clients. The box-plot shows 25, 50
75 percentile of clients having 1 , 2 3
visits. The median as well as maximum and minimum
scores can be seen for each visit category.
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Conclusion

• Proactive efforts should be made at the provider
  level to assess and remove the barriers that
  prevent the clients from seeking care on a
  regular basis.
• Emphasis should be made on complete documentation
  in the client charts per the minimum requirements
  of the Standards of Care.
• Ongoing Technical Assistance should be made
  available to providers to relate the minimum
  expectations for service delivery and
  documentation compliance.

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Acknowledgements

• This poster exhibition was possible with the
  support and contributions from my colleagues. I
  would like to thank them for their assistance.
• Richard Matens, M.Div.
• Ralph Brisueno.
• Jesse Ungard, MA.
• Alberta. Lin. Ferrari, MD.

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References

1. Centers of Disease Control and Prevention.
   HIV/AIDS Surveillance Report 20041627-3032-33.
2. HRSA (Health Resources and Services
   Administration) http//hab.hrsa.gov/history.htm
   accessed September 13,2006.
3. HRSA (Health Resources and Services
   Administration). The AIDS Epidemic and the Ryan
   White Care Act. Past successes future
   challenges. 2004.
4. The Ryan White Care Act A Compilation of The
   Ryan White Care Act of 1990 Pub.L.101-381, as
   amended by the Ryan White Care Act Amendments of
   1996 Pub.l.104-146 and The Ryan White Care Act
   amendments of 2000 Pub.L.106-345.
5. Associated Black Charities, Title I
   Administrative Agent, FY 2004 Unduplicated Client
   Level Data.
6. AETC (AIDS Education Training Centers) New York
   State Department of Health AIDS Institute.
   Measuring Clinical Performance A Guide for HIV
   Health Care Providers. 2002