Success and Challenges
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Success and Challenges

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Presented by Michael Horberg, MD, MAS, Executive Director Research and Community Benefit, Mid-Atlantic Permanente Medical Group Director of HIV/AIDS, Kaiser Permanente ...

Presented by Michael Horberg, MD, MAS, Executive Director Research and Community Benefit, Mid-Atlantic Permanente Medical Group Director of HIV/AIDS, Kaiser Permanente
Clinical Lead HIV/AIDS, Care Management Institute

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Success and Challenges Success and Challenges Presentation Transcript

  • Success and Challenges October 2, 2013 Michael Horberg, MD MAS FIDSA Executive Director Research and Community Benefit Mid-Atlantic Permanente Medical Group Director HIV/AIDS, Kaiser Permanente Chair, Board of Director, HIV Medicine Association
  • Disclosures  Employee of Kaiser Permanente  Ongoing research grants from: – Pfizer – Merck • Organizational • Chair, HIV Medicine Association • Member and committee chair, Presidential Advisory Council on HIV/AIDS  Please note that the opinions expressed in this presentation represent those of the presenter and do not necessarily reflect the view of Mid-Atlantic Permanente Medical Group or Kaiser Permanente.
  • Success is Possible Percent Patients with Any of 5 STDs also tested for HIV: all regions 100 2007* 2008 2009 2010 2011 80 60 55.2 57.7 55.2 49.7 43.1 61.5 56.4 54.0 52.2 50.6 44.8 59.9 57.3 48.5 40.8 40 20 0 Males and Females Females SC only and Hep B/C pos required prior neg *for 2007 data from GA, NC, NW, 3 November 19, 2013 The 5 STDs: GC/Chlamydia, HBV, HCV, Syphilis Males
  • Even Better: Percent Patients with Any of 3 STDs also tested for HIV: all regions 100 2007 2008 2009 2010 2011 80 60 55.4 59.3 61.7 68.0 63.3 64.9 52.4 55.3 57.6 58.6 60.5 70.3 72.9 74.1 61.8 40 20 0 Males and Females 4 November 19, 2013 Gonorrhea, Chlamydia, Syphilis Females Males
  • Improved KP HIV Care Cascade (compared to US) Reasons for success: • Multidisciplinary Care Team • Electronic Health Record • Quality Measurement and Quality Improvement • Continued Provider Education 5 November 19, 2013 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
  • KP Performance on Chlamydia Testing • Committed to it • (KP Georgia #1 nationally 2011—not just within KP) • US 90th Percentile performance: 53.4% (age 16-24) • KP Program wide performance: 65.8%* • All KP regions are above US 90th percentile • Also, all regions and KP nationally above US 90th percentile for ages 16-20 or 21-24 age groups • KP performance demonstrates that with commitment at multiple levels this is achievable • But even we can improve *--Commercial plans; similar results for Medicaid only patients 2011 data; probably has gotten better
  • But What That is NOT:  No evidence that we are capturing all STDs – But at least we are testing them for HIV  These are not rates: – STDs are increasing, not decreasing – So are we really doing the job?  Doesn’t reflect patient education  And are all doctors talking to their patients about prevention, sexual health, domestic violence? November 19, 2013 | ©7 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
  • HIV Disparities among Black MSM vs. White MSM, Black Community, and U.S. Population 90 72X HIV Prevelance Summary Odds Ratio 80 70 60 50 40 22X 30 20 10 3X 0 vs. White MSM (Millett et. al, The Lancet, 2012) vs. Black community vs. U.S. population
  • Disparities persist between black and other MSM throughout treatment cascade (24 comparative studies) Undiagnosed HIV OR, 6.38 (4.33-9.39) HIV Detection Diagnosed HIV+ OR, 3.00 (2.06-4.40) ART utilization/ access OR, 0.56 (0.41-0.76) >200 CD4 cells/mm3 before ART initiation OR, 0.40 (0.26-0.62) Healthcare visits OR, 0.61 (0.42-0.90) “To eliminate difference in viral suppression, an estimated additional 38,920 black MSM and 17,043 Latino MSM would need to be on treatment to raise viral suppression to levels on par with white MSM aware of their infection (56%).” (Hall, 2013) ART adherence OR, 0.50 (0.33-0.76) HIV suppression OR, 0.51 (0.31-0.83) Viral Suppression (Millett, 2012)
  • Physicians and Diagnosing Positives  1208 MSM (597 black, 611 Latino) not previously diagnosed with HIV – 105 black, 33 Latino MSM HIVpositive unaware  Black MSM who were HIV-positive unaware – 3x more likely than HIV- black MSM to have health insurance – 3x more likely to have disclosed sexuality their healthcare provider – 94% less likely to have more than 3 lifetime HIV test  Of 44 undiagnosed HIV+ black MSM who disclosed sexuality to provider – UIAI with 9 HIV- partners past 3 mos – URAI with 14 HIV- partners past 3 mos
  • US Preventive Services Guidelines for HIV Testing  Release Date: April 2013  The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Grade: “A” Recommendation.  The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. Grade: “A” Recommendation.  Now covered by Affordable Care Act (ACA).  Encourage all healthcare professionals to test their patients. 11 November 19, 2013 htp://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm
  • US Preventive Services Guidelines for HIV Testing  Release Date: April 2013  The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Grade: “A” Recommendation. This is an important innovation.  The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. Grade: “A” Recommendation.  Now covered by Affordable Care Act (ACA).  Encourage all healthcare professionals to test their patients. 12 November 19, 2013 htp://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm
  • However, next steps for the change: 1. Get eligible patients enrolled in the marketplace or enlarged Medicaid. 2. Get them to see their doctor. 3. Get the patient educated to ask the right questions. 4. Need to think of sub-populations: 1. Not just men/women, younger/older, gay/straight 2. Need to think about as young Black MSM, etc. 1. Each of these sub-groups may need a different strategy 13 November 19, 2013
  • Most Trusted on ACA: Doctors and Nurses, Federal and State Agencies, Pharmacists Percent who say they would trust information about the health care law from each of the following ‘a lot’: Your doctor or nurse Percent who say they have heard something about the law from each of the following in the past 30 days: 44% Federal agencies 34% State agencies 33% 22% Your local pharmacist 30% An employer 21% Non-profit or community organization 20% Friends and family NA 18% A health insurance company The news media* Social networking sites 15% 19% NA 12% 49% 15% 8% 3% Healthcare professionals are the most trusted. We must inform. 14% 21% Your local church or place of worship 16% 81% 23% NA = Item not asked for this question. *The news media includes cable TV news, national or local TV news, radio news or talk radio, online news sources, and newspapers/magazines. NOTE: Wording for some items abbreviated; item wording between questions varies. For full question wording see topline: http://www.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-august-2013/ SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted August 13-19, 2013)
  • States Health Insurance Marketplace Decisions, May 10, 2013 VT WA ND MT OR CA AZ CO PA IL KS TX WV KY VA DC SC AR AL CT NJ DE MD NC TN MS AK OH IN MO OK NM MI IA NE UT* NY WI WY NV NH MN SD ID ME GA LA FL HI State-based Marketplace (16 states and DC) Partnership Marketplace (7 states) Federally-facilitated Marketplace (27 states) • In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or SHOP, marketplace. MA RI
  • 16 November 19, 2013
  • This will need promotion. We’ll need your help. 17 November 19, 2013
  • Other Innovations  Pre-Exposure Prophylaxis (PrEP) to Prevent HIV  Post-Exposure Prophylaxis (PEP) – Likely Underutilized  STD testing as quality measures – This is what worked in Kaiser Permanente – Shouldn’t just be chlamydia screening of younger women  Making it a practice priority  NOT just the job of urgent care or primary care – It should be part of every healthcare worker’s evaluation and care of each patient. 18 November 19, 2013 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
  • Other Considerations  Testing needs resources. – Costs of labs – Costs of personnel – Need time to contact patients, get the right treatment, etc. – Partner notification, etc.  Testing is only one part of sexual health – Empowerment! – Safety! – Pride in one’s self  Homophobia is a health hazard. 19 November 19, 2013 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
  • All that’s (ideally)needed to provide HIV (STD) care Program Sustainability -Access to Care -Ryan White -Public & Private Coverage -Provider Reimbursement Patients -Adherence to Rx -Adherence to Care -Enhanced Quality of Life -Improved Immune Status -Risk/Harm Reduction -Virologic Control Healthcare Team Service Delivery & Integration -HIV Testing -Linkage to Care -Engagement & Retention in Care -Access to Rx -Medication Adherence Support -Medical Case Management -Co-located Social Services -Public Health & Community Agencies Quality Improvement Gallant, CID, 2012 -Performance Standards -Practice Guidelines -Electronic Health Records -HIV/Primary Care Provider -Specialty Medical Care -Clinical Pharmacist -Care Coordinator -Oral Health -Nursing Support Services -Alcohol and Drug Tx -Drug Assistance -Housing -Legal Services -Secondary Prevention Counseling -Nutrition Counseling -Pharmacy -Psychosocial -Mental Health