Assessing Linkage to Care by Linking Prescription  Filling Records from an AIDS Drug Assistance  Program to Laboratory Res...
Background The National AIDS Drug Assistance Program (ADAP) of  the Ryan White Comprehensive AIDS Resources  Emergency Ac...
ENROLLED CLIENTS VS SERVED CLIENTS                           2007 to 20113,000                             Total Enrolled ...
National HIV/AIDS Strategy               (NHAS)One of the primary goals:• Increase access to care and optimize health  out...
Objective The objective of this analysis was to assess  how well the Washington DC AIDS Drug  Assistance Program (ADAP) i...
DC DOH & CDC Collaboration In 2008, the Senior Deputy Director (Dr. Hader) of the  HIV/AIDS Administration of the Washing...
MethodsMicrosoft Access application that merged data  from three primary sources:   Service utilization database for clie...
Characterization of Laboratory Values   CD4 and Viral Load characterized in clinically relevant    strata.      CD4 cate...
Identified Clients ‘at Risk’ CD4 count < 350 cells/mm3 Viral load > 1,000 copies/ml or missing Not on antiretroviral th...
Results Identify Clients with Indication forAntiretroviral Therapy and Quantify       Time to Start Therapy
Washington DC Dept of Health ADAP       Volume of Laboratory Tests for AnalysisYear                                       ...
Quantify CD4 Counts among those in        ADAP – 2007 to 2010                      n = 394                          n = 79...
Identify those not on ART in ADAP and             ‘at Risk’ - 2010                          Viral Load Tests done while NO...
Patients in ADAP not on ART & ‘at Risk’              2007-2010                                CD4 cell count (cells/mm3)  ...
Time from CD4 Count until Initiation of ART in ADAP for ‘at Risk’ Patients - 2007-2010 Year      Eligible to    Started   ...
Strata of CD4 cell count who Initiated ARTin ADAP for ‘at Risk’ Patients - 2007-2010                     CD4 count        ...
‘At Risk’ Patients not Started on ART in           ADAP - 2007-2010   Year      Eligible to    Not Started        Pending2...
Limitations• Clients ‘not started on antiretroviral therapy  in ADAP’ may have received antiretroviral  therapy from other...
Conclusions• Between 2007 – 2010, many ADAP clients  eligible for antiretroviral therapy started  therapy in ADAP document...
Recommendation• To improve utilization of antiretroviral therapy  within ADAP, barriers to starting antiretroviral  therap...
AcknowledgementsWashington DC Department of Health   Centers for Disease Control and PrevenitonNnemdi Kamanu-Elias        ...
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Assessing Linkage to Care by Linking Prescription Filling Records from an AIDS Drug Assistance Program to Laboratory Results from HIV/AIDS Reporting System in Washington DC.

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Assessing Linkage to Care by Linking Prescription Filling Records from an AIDS Drug Assistance Program to Laboratory Results from HIV/AIDS Reporting System in Washington DC.

  1. 1. Assessing Linkage to Care by Linking Prescription Filling Records from an AIDS Drug Assistance Program to Laboratory Results from HIV/AIDS Reporting System in Washington DC.Gurung DK1, Bayone S1, Freehill G1, Griffin A1, Samala R1, Wu C1, Rangarajan S2,3, Hader S1, Kamanu Elias N1, Weidle PJ3 1HIV/AIDS, Hepatitis, STD & TB Administration (HAHSTA), District of Columbia Department of Health, Government of the District of Columbia, Washington, DC. 2 Satyam Computer Services Limited, Atlanta, GA. 3Division of HIV/AIDS Prevention, CDC, Atlanta, GA. Disclaimer: The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention or the DC Department of Health.
  2. 2. Background The National AIDS Drug Assistance Program (ADAP) of the Ryan White Comprehensive AIDS Resources Emergency Act.  Source of prescription drugs for people with HIV/AIDS with limited or no insurance.  More than one-third of all people with HIV in care.  Nationally: has grown from 183,299 persons in 2007 to 213,764 in 2010  Budget: ~$1.4 billion in 2007 - ~$1.8 billion in 2010 DC ADAP (2007-2010) enrolled about 2,500 clients and provided service to about 1,700 clients either by paying for all HIV drugs or with insurance help (Co-pay, Premium) NASTAD. National ADAP Monitoring Report. 2006-2011
  3. 3. ENROLLED CLIENTS VS SERVED CLIENTS 2007 to 20113,000 Total Enrolled Total Served2,5002,0001,5001,000 500 0 2007 2008 2009 2010 2011 AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  4. 4. National HIV/AIDS Strategy (NHAS)One of the primary goals:• Increase access to care and optimize health outcomes for people living with HIV. • “Clinical care providers should ensure that all eligible HIV-positive persons have access to antiretroviral therapy.” The White House, National HIV/AIDS Strategy for the United States 2010
  5. 5. Objective The objective of this analysis was to assess how well the Washington DC AIDS Drug Assistance Program (ADAP) identified clients in need of antiretroviral therapy and the rate and rapidity with which they started therapy.
  6. 6. DC DOH & CDC Collaboration In 2008, the Senior Deputy Director (Dr. Hader) of the HIV/AIDS Administration of the Washington DC Department of Health identified ADAP for review to better utilize routine information. CDC’s rapid analysis of program data determined feasibility of linking available databases with the goal to produce routine reports to improve performance of the ADAP program. 2008- 2009: DC DOH had more complete laboratory records and transitioned to E-HARS for HIV reporting. 2009-2010: CDC provided TA to develop a Microsoft Application that linked ADAP enrollment data, service utilization claims data and health outcome databases and generated ADAP program evaluation reports
  7. 7. MethodsMicrosoft Access application that merged data from three primary sources: Service utilization database for client characteristics  Data from Pharmacy Benefit Management System managed by Emdeon  Enrollment data managed by DC ADAP HIV/AIDS Reporting System (HARS) – laboratory values for viral load and CD4 cell count. Name-based since November 2006 Electronic HARS in 2009 which facilitated the transfer of laboratory values Prescription claims data from pharmacy benefit management system in the DC ADAP program.
  8. 8. Characterization of Laboratory Values CD4 and Viral Load characterized in clinically relevant strata.  CD4 categories (cells/µL):  0 – 49  50 – 199  200 – 349  350 – 499  > 500  Viral load categories (copies/ml):  < 400  401 – 999  1,000 – 9,999  10,000 – 99,999  > 100,000
  9. 9. Identified Clients ‘at Risk’ CD4 count < 350 cells/mm3 Viral load > 1,000 copies/ml or missing Not on antiretroviral therapy in ADAP at time of laboratory testing*US DHHS guidelines consistently recommended to start ART for clients with CD4 count <350 cells/mm3 between 2007 – 2010.*Clients not on antiretroviral therapy in ADAP with viral load <1,000 copies/ml considered to likely be taking therapy from another source.
  10. 10. Results Identify Clients with Indication forAntiretroviral Therapy and Quantify Time to Start Therapy
  11. 11. Washington DC Dept of Health ADAP Volume of Laboratory Tests for AnalysisYear 2007 2008 2009 2010ADAP Eligible Clients (n) 2022 2403 3212 3359Viral load test done at least once, n (%) 801 (40) 980 (41) 1298 (40) 2157 (64)CD4 test done at least once, n (%) 790 (39) 574 (24) 1212 (38) 2266 (67) *Laboratory tests reflect those available in the database. Other laboratory tests may have been completed, but not available to this analysis AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  12. 12. Quantify CD4 Counts among those in ADAP – 2007 to 2010 n = 394 n = 799100% 90% 80% 70% CD4 cells/mm3 60% >/=500 350-499 50% 200-349 50-199 40% 0-49 30% 20% 10% 0% 2007 2008 2009 2010 2007 2008 2009 2010 (n=552) (n=321) (n=837) (n=1719) (n=315) (n=286) (n=451) (n=1051) On ART in ADAP Not on ART in ADAPART = antiretroviral therapy AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  13. 13. Identify those not on ART in ADAP and ‘at Risk’ - 2010 Viral Load Tests done while NOT on ART in ADAP Viral Load Total At RiskCD4 count(cells/mm3) <= 400 401 - 999 1000 - 9999 10000 - 99999 >= 100000 Missing0 – 49 4 1 3 7 17 26 58 5350 – 199 75 2 16 25 12 34 164 87200 – 349 121 9 11 25 11 27 204 74350 – 499 133 2 13 30 5 34 217>= 500 305 9 21 20 2 51 408Missing 25 2 8 5 5 0 45Total 663 25 72 112 52 172 1096 214 ART = antiretroviral therapy AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  14. 14. Patients in ADAP not on ART & ‘at Risk’ 2007-2010 CD4 cell count (cells/mm3) Number of people at 0 – 49 50 – 199 200 – 349 Risk 2007 34 46 28 108 2008 45 61 17 123 2009 42 73 44 159 2010 53 87 74 214 Total 174 267 163 604 A person was considered ‘at risk’ if: •VL ≥ 1000 copies/ml •CD4+ <350 cells/mm3 •Not on ART prior to lab test AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  15. 15. Time from CD4 Count until Initiation of ART in ADAP for ‘at Risk’ Patients - 2007-2010 Year Eligible to Started start ART ART in Time from CD4 cell count until Started ART in ADAP (Days) ADAP N (%) Median IQR Range <30 31 – 60 > 60 2007 108 67 (62) 8 0-28.5 0-197 52 9 6 2008 123 47 (38) 14 5-46 0-309 31 7 9 2009 159 81 (51) 11 1-21.5 0-119 67 10 4 2010 214 106 (50) 10 0-21 0-167 96 4 6 Total 604 301 (50) 208 30 25 ART = antiretroviral therapy IQR = interquartile range AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  16. 16. Strata of CD4 cell count who Initiated ARTin ADAP for ‘at Risk’ Patients - 2007-2010 CD4 count Eligible to start Started ART in ADAP (cells/mm3) ART N (%) (n) 0 – 49 174 78 (45) 50 – 199 267 135 (51) 200 – 349 163 88 (54) Total 604 301 (50) P = 0.12 for comparison of starting ART if CD4 count 0 – 49 vs 50 – 349 ART = antiretroviral therapy AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  17. 17. ‘At Risk’ Patients not Started on ART in ADAP - 2007-2010 Year Eligible to Not Started Pending2 Time from CD4 cell count until end date start ART on ART in (<30 days) of eligibility in calendar year (Days) ADAP1 N (%) N (%) Median IQR Range 2007 108 35 (32) 6 (6) 102 52-193 32-278 2008 123 71 (58) 5 (4) 138 80.5-201 30-364 2009 159 58 (36) 20 (13) 112 68-218 30-360 2010 214 87 (41) 21 (10) 149 75.5-254 31-357 Total 604 251 (42) 52 (9) 1Clients‘not started on antiretroviral therapy in ADAP’ may have received antiretroviral therapy from other sources not captured in this analysis. 2Pending – Clients who had a CD4 cell count in December of the year, but had not started ART by December 31 of that year. ART = antiretroviral therapy IQR = interquartile range AIDS Drug Assistance Program, Washington DC Dept of Health, 2007 - 2010
  18. 18. Limitations• Clients ‘not started on antiretroviral therapy in ADAP’ may have received antiretroviral therapy from other sources not captured in this analysis.• Clients in ‘pending status’ to start ART may have started ART in the next year.• A small percentage of insurance clients who receive premium assistance only, not copay assistance, is unlikely to use DC ADAP network pharmacies and therefore, their claims do not exist in the claims data.
  19. 19. Conclusions• Between 2007 – 2010, many ADAP clients eligible for antiretroviral therapy started therapy in ADAP documenting the utility of this essential public drug assistance program (ADAP).
  20. 20. Recommendation• To improve utilization of antiretroviral therapy within ADAP, barriers to starting antiretroviral therapy for clients with low CD4 cell counts and effective means to overcome them, such as outreach services by case management services or providers for access and linkage to care, should be explored and programmatically addressed.
  21. 21. AcknowledgementsWashington DC Department of Health Centers for Disease Control and PrevenitonNnemdi Kamanu-Elias Paul J WeidleSonya Bayone David FlukerGunther Freehill A Danielle IulianoAngelique Griffin Siva RangarajanDamber Kumar Gurung Neha ShahTiffany Ojo-WestRowena SamalaCharles WuShannon Hader

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