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Trepka MJ, Gong Z, Ward MK, Fennie KP, Sheehan DM, Jean-Gilles M, Devieux J, Ibañez GE, Gwanzura T, Nawfal ES, Gray A, Beach MC, Ladner R, Yoo C. Using Causal Bayesian Networks to Assess the Role of Patient-Centered Care and Psychosocial Factors on Durable HIV Viral Suppression. AIDS Behav 2024; 28:2113-2130. [PMID: 38573473 PMCID: PMC11161314 DOI: 10.1007/s10461-024-04310-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/05/2024]
Abstract
We assessed the role of patient-centered care on durable viral suppression (i.e., all viral load test results < 200 copies per ml during 2019) by conducting a retrospective cohort study of clients medically case managed by the Miami-Dade County Ryan White Program (RWP). Summary measures of patient-centered care practices of RWP-affiliated providers were obtained from a survey of 1352 clients. Bayesian network models analyzed the complex relationship between psychosocial and patient-centered care factors. Of 5037 clients, 4135 (82.1%) had durable viral suppression. Household income was the factor most strongly associated with durable viral suppression. Further, mean healthcare relationship score and mean "provider knows patient as a person" score were both associated with durable viral suppression. Healthcare relationship score moderated the association between low household income and lack of durable viral suppression. Although patient-centered care supports patient HIV care success, wrap around support is also needed for people with unmet psychosocial needs.
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Affiliation(s)
- Mary Jo Trepka
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA.
- Research Center for Minority Institutions, Florida International University, Miami, FL, USA.
| | - Zhenghua Gong
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Melissa K Ward
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA
- Research Center for Minority Institutions, Florida International University, Miami, FL, USA
| | | | - Diana M Sheehan
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA
- Research Center for Minority Institutions, Florida International University, Miami, FL, USA
| | - Michele Jean-Gilles
- Department of Health Promotion and Disease Prevention, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Jessie Devieux
- Department of Health Promotion and Disease Prevention, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Gladys E Ibañez
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Tendai Gwanzura
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Ekpereka S Nawfal
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA
| | - Aaliyah Gray
- Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, University Park, AHC 5, 11200 SW 8th Street, Miami, FL, 33199, USA
| | | | - Robert Ladner
- Behavioral Science Research Corporation, Coral Gables, FL, USA
| | - Changwon Yoo
- Department of Biostatistics, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
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Engelmann P, Eilerskov N, Thilsing T, Bernardini F, Rasmussen S, Löwe B, Herrmann-Lingen C, Gostoli S, Andréasson F, Rafanelli C, Pedersen SS, Jaarsma T, Kohlmann S. Needs of multimorbid heart failure patients and their carers: a qualitative interview study and the creation of personas as a basis for a blended collaborative care intervention. Front Cardiovasc Med 2023; 10:1186390. [PMID: 38028443 PMCID: PMC10667702 DOI: 10.3389/fcvm.2023.1186390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Involving patients and carers in the development of blended collaborative care (BCC) interventions for multimorbid heart failure (HF) patients is recommended but rarely practised, and research on the patient perspective is scarce. The aim of this study is to investigate patients' and carers' care-related needs and preferences to better customize a novel international BCC intervention. Methods A qualitative study design using framework analysis was employed. The study was performed in accordance with the EQUATOR standards for reporting qualitative research (SRQR). Patients aged at least 65 years with HF and at least two other physical diseases as well as their carers completed semistructured interviews in Germany, Italy, and Denmark. Based on these interviews, personas (prototype profiles of patients and carers) were created. Results Data from interviews with 25 patients and 17 carers were analysed. Initially, seven country-specific personas were identified, which were iteratively narrowed down to a final set of 3 personas: (a) the one who needs and wants support, (b) the one who has accepted their situation with HF and reaches out when necessary, and (c) the one who feels neglected by the health care system. Carers identifying with the last persona showed high levels of psychological stress and a high need for support. Discussion This is the first international qualitative study on patients' and carers' needs regarding a BCC intervention using the creation of personas. Across three European countries, data from interviews were used to develop three contrasting personas. Instead of providing "one size fits all" interventions, the results indicate that BCC interventions should offer different approaches based on the needs of individual patients and carers. The personas will serve as a basis for the development of a novel BCC intervention as part of the EU project ESCAPE (Evaluation of a patient-centred biopSychosocial blended collaborative CAre Pathway for the treatment of multimorbid Elderly patients).
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Affiliation(s)
- Petra Engelmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Natasja Eilerskov
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Trine Thilsing
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Francesco Bernardini
- Department of Psychology “Renzo Canestrari”, University of Bologna, Bologna, Italy
| | - Sanne Rasmussen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense C, Denmark
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Herrmann-Lingen
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Centre, Göttingen, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Sara Gostoli
- Department of Psychology “Renzo Canestrari”, University of Bologna, Bologna, Italy
| | - Frida Andréasson
- Department of Health, Medicine and Caring Sciences (HMV), Linköping University, Linköping, Sweden
| | - Chiara Rafanelli
- Department of Psychology “Renzo Canestrari”, University of Bologna, Bologna, Italy
| | - Susanne S. Pedersen
- Department of Psychology, University of Southern Denmark, Odense M, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences (HMV), Linköping University, Linköping, Sweden
| | - Sebastian Kohlmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Li MJ, Chau B, Garland WH, Oksuzyan S, Weiss RE, Takada S, Kao U, Lee SJ, Shoptaw SJ. Racial, gender, and psychosocial disparities in viral suppression trends among people receiving coordinated HIV care in Los Angeles County. AIDS 2023; 37:1441-1449. [PMID: 37070545 PMCID: PMC10330081 DOI: 10.1097/qad.0000000000003578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVE To longitudinally evaluate differences in HIV viral suppression (<200 copies/ml) by intersections of race/ethnicity, gender, and psychosocial issues in people with HIV in the Los Angeles County Medical Care Coordination Program. DESIGN We analyzed 74 649 viral load measurements over 10 184 people with HIV enrolled in the Medical Care Coordination Program between January 1, 2013 and March 1, 2020.Methods: We fit Bayesian logistic hierarchical random effects models to test interactions between gender, race/ethnicity, and a psychosocial acuity score on viral suppression over time from 1 year prior to program enrollment to 24 months after enrollment. RESULTS The probability of viral suppression declined prior to enrollment, then increased and stabilized by 6 months after enrollment. Black/African American patients with low and moderate psychosocial acuity scores did not achieve the same increase in percentage of viral suppression as those in other racial/ethnic groups. Transgender women with high psychosocial acuity scores took longer (about 1 year) to achieve the same percentage of viral suppression as clients of other gender identities. CONCLUSIONS Some racial/ethnic and gender disparities in viral suppression persisted after enrollment in the Los Angeles County Medical Care Coordination Program while accounting for psychosocial acuity score, which may be explained by factors not assessed in the program.
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Affiliation(s)
- Michael J Li
- Center for HIV Identification, Prevention and Treatment Services
- Department of Family Medicine
| | - Brendon Chau
- Department of Family Medicine
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles
| | - Wendy H Garland
- Division of HIV and STD Programs, Los Angeles County Department of Public Health
| | - Sona Oksuzyan
- Division of HIV and STD Programs, Los Angeles County Department of Public Health
| | - Robert E Weiss
- Center for HIV Identification, Prevention and Treatment Services
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles
| | - Sae Takada
- Division of General Internal Medicine and Health Services Research
| | - Uyen Kao
- Center for HIV Identification, Prevention and Treatment Services
- Department of Family Medicine
| | - Sung-Jae Lee
- Center for HIV Identification, Prevention and Treatment Services
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, California, USA
| | - Steven J Shoptaw
- Center for HIV Identification, Prevention and Treatment Services
- Department of Family Medicine
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Schäfer I, Schulze J, Glassen K, Breckner A, Hansen H, Rakebrandt A, Berg J, Blozik E, Szecsenyi J, Lühmann D, Scherer M. Validation of patient- and GP-reported core sets of quality indicators for older adults with multimorbidity in primary care: results of the cross-sectional observational MULTIqual validation study. BMC Med 2023; 21:148. [PMID: 37069536 PMCID: PMC10111827 DOI: 10.1186/s12916-023-02856-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/30/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Older adults with multimorbidity represent a growing segment of the population. Metrics to assess quality, safety and effectiveness of care can support policy makers and healthcare providers in addressing patient needs. However, there is a lack of valid measures of quality of care for this population. In the MULTIqual project, 24 general practitioner (GP)-reported and 14 patient-reported quality indicators for the healthcare of older adults with multimorbidity were developed in Germany in a systematic approach. This study aimed to select, validate and pilot core sets of these indicators. METHODS In a cross-sectional observational study, we collected data in general practices (n = 35) and patients aged 65 years and older with three or more chronic conditions (n = 346). One-dimensional core sets for both perspectives were selected by stepwise backward selection based on corrected item-total correlations. We established structural validity, discriminative capacity, feasibility and patient-professional agreement for the selected indicators. Multilevel multivariable linear regression models adjusted for random effects at practice level were calculated to examine construct validity. RESULTS Twelve GP-reported and seven patient-reported indicators were selected, with item-total correlations ranging from 0.332 to 0.576. Fulfilment rates ranged from 24.6 to 89.0%. Between 0 and 12.7% of the values were missing. Seventeen indicators had agreement rates between patients and professionals of 24.1% to 75.9% and one had 90.7% positive and 5.1% negative agreement. Patients who were born abroad (- 1.04, 95% CI = - 2.00/ - 0.08, p = 0.033) and had higher health-related quality of life (- 1.37, 95% CI = - 2.39/ - 0.36, p = 0.008), fewer contacts with their GP (0.14, 95% CI = 0.04/0.23, p = 0.007) and lower willingness to use their GPs as coordinators of their care (0.13, 95% CI = 0.06/0.20, p < 0.001) were more likely to have lower GP-reported healthcare quality scores. Patients who had fewer GP contacts (0.12, 95% CI = 0.04/0.20, p = 0.002) and were less willing to use their GP to coordinate their care (0.16, 95% CI = 0.10/0.21, p < 0.001) were more likely to have lower patient-reported healthcare quality scores. CONCLUSIONS The quality indicator core sets are the first brief measurement tools specifically designed to assess quality of care for patients with multimorbidity. The indicators can facilitate implementation of treatment standards and offer viable alternatives to the current practice of combining disease-related metrics with poor applicability to patients with multimorbidity.
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Affiliation(s)
- Ingmar Schäfer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Josefine Schulze
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Katharina Glassen
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Amanda Breckner
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Heike Hansen
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Anja Rakebrandt
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jessica Berg
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Eva Blozik
- Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Dagmar Lühmann
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Grosso TM, Hernández-Sánchez D, Dragovic G, Vasylyev M, Saumoy M, Blanco JR, García D, Koval T, Loste C, Westerhof T, Clotet B, Sued O, Cahn P, Negredo E. Identifying the needs of older people living with HIV (≥ 50 years old) from multiple centres over the world: a descriptive analysis. AIDS Res Ther 2023; 20:10. [PMID: 36782210 PMCID: PMC9924192 DOI: 10.1186/s12981-022-00488-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/01/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Older People Living with HIV (OPWH) combine both aging and HIV-infection features, resulting in ageism, stigma, social isolation, and low quality of life. This context brings up new challenges for healthcare professionals, who now must aid patients with a significant comorbidity burden and polypharmacy treatments. OPWH opinion on their health management is hardly ever considered as a variable to study, though it would help to understand their needs on dissimilar settings. METHODS We performed a cross-sectional, comparative study including patients living with HIV aged ≥50 years old from multiple centers worldwide and gave them a survey addressing their perception on overall health issues, psychological problems, social activities, geriatric conditions, and opinions on healthcare. Data was analyzed through Chisquared tests sorting by geographical regions, age groups, or both. RESULTS We organized 680 participants data by location (Center and South America [CSA], Western Europe [WE], Africa, Eastern Europe and Israel [EEI]) and by age groups (50- 55, 56-65, 66-75, >75). In EEI, HIV serostatus socializing and reaching undetectable viral load were the main problems. CSA participants are the least satisfied regarding their healthcare, and a great part of them are not retired. Africans show the best health perception, have financial problems, and fancy their HIV doctors. WE is the most developed region studied and their participants report the best scores. Moreover, older age groups tend to live alone, have a lower perception of psychological problems, and reduced social life. CONCLUSIONS Patients' opinions outline region- and age-specific unmet needs. In EEI, socializing HIV and reaching undetectable viral load were the main concerns. CSA low satisfaction outcomes might reflect high expectations or profound inequities in the region. African participants results mirror a system where general health is hard to achieve, but HIV clinics are much more appealing to them. WE is the most satisfied region about their healthcare. In this context, age-specific information, education and counseling programs (i.e. Patient Reported Outcomes, Patient Centered Care, multidisciplinary teams) are needed to promote physical and mental health among older adults living with HIV/AIDS. This is crucial for improving health-related quality of life and patient's satisfaction.
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Affiliation(s)
- Tomás Martín Grosso
- grid.491017.a0000 0004 7664 5892Unidad de Ensayos Clínicos, Fundación Huésped, Buenos Aires, Argentina ,grid.26089.350000 0001 2228 6538Laboratorio de Inmunología, Universidad Nacional de Luján, Buenos Aires, Argentina
| | - Diana Hernández-Sánchez
- grid.411438.b0000 0004 1767 6330Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain ,grid.7080.f0000 0001 2296 0625Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gordana Dragovic
- grid.7149.b0000 0001 2166 9385Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - María Saumoy
- grid.411129.e0000 0000 8836 0780HIV and STD Unit, Hospital de Bellvitge, Barcelona, Spain
| | - José Ramón Blanco
- grid.428104.bInfectious Disease Department, Hospital Universitario San Pedro - CIBIR, Logroño, Spain
| | - Diego García
- Adhara HIV/AIDS Association, Sevilla Checkpoint, Seville, Spain
| | - Tetiana Koval
- grid.513024.1Department of Infectious Diseases, Poltava State Medical University, Poltava, Ukraine
| | - Cora Loste
- grid.411438.b0000 0004 1767 6330Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain ,grid.7080.f0000 0001 2296 0625Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tendayi Westerhof
- grid.411438.b0000 0004 1767 6330AIDS Research Institute-IRSICAIXA, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Bonaventura Clotet
- grid.7080.f0000 0001 2296 0625Universitat Autònoma de Barcelona, Barcelona, Spain ,grid.7080.f0000 0001 2296 0625AIDS Research Institute-IRSICAIXA, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain ,grid.440820.aUniversitat de Vic - Universidad Central de Catalunya (UVIC-UCC), Vic, Spain
| | - Omar Sued
- grid.491017.a0000 0004 7664 5892Unidad de Ensayos Clínicos, Fundación Huésped, Buenos Aires, Argentina
| | - Pedro Cahn
- grid.491017.a0000 0004 7664 5892Unidad de Ensayos Clínicos, Fundación Huésped, Buenos Aires, Argentina
| | - Eugènia Negredo
- Lluita contra les Infeccions, Hospital Universitari Germans Trias i Pujol, Badalona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain. .,Universitat de Vic - Universidad Central de Catalunya (UVIC-UCC), Vic, Spain.
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The Healthcare Experiences of African Americans with a Dual Diagnosis of HIV/AIDS and a Nutrition-Related Chronic Disease: A Pilot Study. Healthcare (Basel) 2022; 11:healthcare11010028. [PMID: 36611485 PMCID: PMC9818712 DOI: 10.3390/healthcare11010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
For HIV-positive African Americans, the mistrust of medical providers due to anticipation of unequal treatment care, prejudice, and bias can become a major deterrent to medication and treatment adherence. Although programs and services incorporate strategies to improve patient-provider relationships, a deeper understanding of their healthcare experiences, especially among those with a dual diagnosis of HIV/AIDS and a nutrition-related chronic disease, is lacking. This qualitative study aimed to address this gap by conducting focus groups with participants who identified themselves as being African American, and having a dual diagnosis of HIV/AIDS, and a chronic disease. Content analysis generated several major themes, highlighting the impact of a negative healthcare experience on their ability to self-manage their health. Factors such as lack of consistency in care team, negative interactions with doctors, feelings of stigma due to prejudice and bias from healthcare staff, loss of privacy, and the need for comprehensive services that targeted their physical, emotional, and nutritional health emerged as recurring sub-themes. These findings provide the foundation for the design of a comprehensive intervention model that helps participants to communicate their medical needs more effectively, thus optimizing their overall health outcomes and quality of life.
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The Management of HIV Care Services in Central and Eastern Europe: Data from the Euroguidelines in Central and Eastern Europe Network Group. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137595. [PMID: 35805250 PMCID: PMC9265352 DOI: 10.3390/ijerph19137595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/19/2022] [Accepted: 06/19/2022] [Indexed: 12/18/2022]
Abstract
Introduction: The COVID-19 pandemic has been challenging time for medical care, especially in the field of infectious diseases (ID), but it has also provided an opportunity to introduce new solutions in HIV management. Here, we investigated the changes in HIV service provision across Central and Eastern European (CEE) countries before and after the COVID-19 outbreak. Methods: The Euroguidelines in Central and Eastern Europe Network Group consists of experts in the field of ID from 24 countries within the CEE region. Between 11 September and 29 September 2021, the group produced an on-line survey, consisting of 32 questions on models of care among HIV clinics before and after the SARS-CoV-2 outbreak. Results: Twenty-three HIV centers from 19 countries (79.2% of all countries invited) participated in the survey. In 69.5% of the countries, there were more than four HIV centers, in three countries there were four centers (21%), and in four countries there was only one HIV center in each country. HIV care was based in ID hospitals plus out-patient clinics (52%), was centralized in big cities (52%), and was publicly financed (96%). Integrated services were available in 21 clinics (91%) with access to specialists other than ID, including psychologists in 71.5% of the centers, psychiatrists in 43%, gynecologists in 47.5%, dermatologists in 52.5%, and social workers in 62% of all clinics. Patient-centered care was provided in 17 centers (74%), allowing consultations and tests to be planned for the same day. Telehealth tools were used in 11 centers (47%) before the COVID-19 pandemic outbreak, and in 18 (78%) after (p = 0.36), but were represented mostly by consultations over the telephone or via e-mail. After the COVID-19 outbreak, telehealth was introduced as a new medical tool in nine centers (39%). In five centers (28%), no new services or tools were introduced. Conclusions: As a consequence of the COVID-19 pandemic, tools such as telehealth have become popularized in CEE countries, challenging the traditional approach to HIV care. These implications need to be further evaluated in order to ascertain the best adaptations, especially for HIV medicine.
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Felizzola J, Pinho V, Funk D, Del Río-González AM, Zea MC, Sol C, Barker S. Transforming Latinx HIV Care: Mixed-Methods Evaluation of a Patient-Centered HIV Practice Transformation. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2022; 34:131-141. [PMID: 35438539 DOI: 10.1521/aeap.2022.34.2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
We conducted a mixed-method longitudinal evaluation of an HIV primary care practice transformation project in Washington, D.C. The project aimed to enhance organizational capacity to deliver culturally appropriate and patient-centered care for Latinxs living with HIV. Quantitative and qualitative data were simultaneously collected to capture the complex interactions among care providers, staff, and patients as well as to monitor practice changes that occurred as a result of the project implementation. The practice transformation intervention consisted of core competency workforce training, workflow redesign, and data-driven quality improvement strategies utilized to guide the intervention and to gather data from providers and patients. The mixed-methods approach facilitated meaningful change within the clinic that resulted in improved patient outcomes, patient experiences of care, and increases in staff's perceived level of knowledge of patient-centered care and improved efficiencies in HIV health care service delivery.
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Affiliation(s)
| | | | - Danielle Funk
- The Fenway Institute, Fenway Health, Boston, Massachusetts
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Jin Y, Assanangkornchai S, Fang M, Guan W, Tian B, Yu M, Du Y. Measuring the uptake of continuous care among people living with HIV receiving antiretroviral therapy and social determinants of the uptake of continuous care in the southwest of China: a cross-sectional study. BMC Infect Dis 2021; 21:943. [PMID: 34511077 PMCID: PMC8436458 DOI: 10.1186/s12879-021-06644-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background Continuous care is essential for people living with HIV. This study aimed to measure continuous care uptake and investigate the association between higher uptake of continuous care and behavioral and social factors, including HIV-acquisition risk and socioeconomic characteristics. Methods A hospital-based cross-sectional study was conducted from April to November 2019 in an HIV treatment center of a specialized hospital in Kunming city, China. Fourteen service indicators were used to calculate composite care scores, which were classified into three levels (low, middle, and high), using principal component analysis. The Behavioral Model for Vulnerable Populations was employed to examine predisposing, enabling, and need factors associated with composite care scores among people living with HIV. Results A total of 702 participants living with HIV aged ≥ 18 years (median age: 41.0 years, 69.4% male) who had been on ART for 1–5 years were recruited. Based on ordinal logistic regression modeling, predisposing factors: being employed (adjusted odds ratio (AOR): 1.54, 95% confidence interval (CI): 1.13–2.11), heterosexuals (AOR: 1.58, 95% CI: 1.11–2.25) and men who have sex with men (AOR: 2.05, 95% CI: 1.39–3.02) and enabling factors: Urban Employee Basic Medical Insurance (AOR: 1.90, 95% CI: 1.03–3.54), middle socioeconomic status (SES) (AOR: 1.42, 95% CI: 1.01–2.01), were positively associated with the higher level of continuous care uptake, compared to the unemployed, people who inject drugs, those with no medical insurance and low SES, respectively. Conclusion There were large differences in continuous care uptake among people living with HIV. HIV-acquisition risk categories and socioeconomic factors were significant determinants of uptake of continuous care. Our findings could inform the development of evidence-based strategies that promote equitable healthcare for all people living with HIV.
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Affiliation(s)
- Yongmei Jin
- Department of Infectious Diseases, The Third People's Hospital of Kunming City, Kunming, Yunnan, People's Republic of China.,Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Sawitri Assanangkornchai
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
| | - Meiqin Fang
- Department of Infectious Diseases, The Third People's Hospital of Kunming City, Kunming, Yunnan, People's Republic of China
| | - Wei Guan
- Department of Infectious Diseases, The Third People's Hospital of Kunming City, Kunming, Yunnan, People's Republic of China
| | - Bo Tian
- Department of Infectious Diseases, The Third People's Hospital of Kunming City, Kunming, Yunnan, People's Republic of China
| | - Min Yu
- Department of Infectious Diseases, The Third People's Hospital of Kunming City, Kunming, Yunnan, People's Republic of China
| | - Yingrong Du
- Department of Infectious Diseases, The Third People's Hospital of Kunming City, Kunming, Yunnan, People's Republic of China
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Liu Y, Siddiqi KA, Cook RL, Bian J, Squires PJ, Shenkman EA, Prosperi M, Jayaweera DT. Optimizing Identification of People Living with HIV from Electronic Medical Records: Computable Phenotype Development and Validation. Methods Inf Med 2021; 60:84-94. [PMID: 34592777 PMCID: PMC8672443 DOI: 10.1055/s-0041-1735619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Electronic health record (EHR)-based computable phenotype algorithms allow researchers to efficiently identify a large virtual cohort of Human Immunodeficiency Virus (HIV) patients. Built upon existing algorithms, we refined, improved, and validated an HIV phenotype algorithm using data from the OneFlorida Data Trust, a repository of linked claims data and EHRs from its clinical partners, which provide care to over 15 million patients across all 67 counties in Florida. METHODS Our computable phenotype examined information from multiple EHR domains, including clinical encounters with diagnoses, prescription medications, and laboratory tests. To identify an HIV case, the algorithm requires the patient to have at least one diagnostic code for HIV and meet one of the following criteria: have 1+ positive HIV laboratory, have been prescribed with HIV medications, or have 3+ visits with HIV diagnostic codes. The computable phenotype was validated against a subset of clinical notes. RESULTS Among the 15+ million patients from OneFlorida, we identified 61,313 patients with confirmed HIV diagnosis. Among them, 8.05% met all four inclusion criteria, 69.7% met the 3+ HIV encounters criteria in addition to having HIV diagnostic code, and 8.1% met all criteria except for having positive laboratories. Our algorithm achieved higher sensitivity (98.9%) and comparable specificity (97.6%) relative to existing algorithms (77-83% sensitivity, 86-100% specificity). The mean age of the sample was 42.7 years, 58% male, and about half were Black African American. Patients' average follow-up period (the time between the first and last encounter in the EHRs) was approximately 4.6 years. The median number of all encounters and HIV-related encounters were 79 and 21, respectively. CONCLUSION By leveraging EHR data from multiple clinical partners and domains, with a considerably diverse population, our algorithm allows more flexible criteria for identifying patients with incomplete laboratory test results and medication prescribing history compared with prior studies.
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Affiliation(s)
- Yiyang Liu
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Khairul A. Siddiqi
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Robert L. Cook
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Patrick J. Squires
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, United States
| | - Elizabeth A. Shenkman
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Florida, United States
| | - Dushyantha T. Jayaweera
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, United States
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11
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Crawford D, Allan B, Cogle A, Brown G. Client-led care in HIV: perspectives from community and practice. HIV Med 2021; 22 Suppl 1:3-14. [PMID: 34296511 DOI: 10.1111/hiv.13133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES While current antiretroviral and care strategies can effectively suppress HIV, achieving optimal quality of life (QoL) requires a wider consideration of clients' well-being, the complexity of individuals' lives and social determinants of health. The objective of this commentary was to develop a definition of client-led care in the Australian context and its key supporting principles for people living with HIV (PLHIV). METHODS The authors used two sources of evidence to support their HIV community experience with client-led care: (1) a scoping review of the literature, and (2) consultations with colleagues who were PLHIV advocates or HIV specialist physicians. The findings from the scoping review and consultations were summarised and the key principles of client-led care compared with those identified by the authors. RESULTS Seven articles met the inclusion criteria for qualitative analysis in the scoping review. Five PLHIV advocates and three HIV specialist physicians were consulted. Key principles supporting client-led care identified by the authors based on their experience centred around the themes of: (1) clients and healthcare providers working in partnership, (2) information and communication, (3) coordinating access to care, (4) building trust, and (5) respect for client's needs and preferences. The principles identified by the authors were supported by those of the scoping review and colleague consultations. CONCLUSIONS A client-led approach can complement conventional HIV care strategies and enable empowerment and greater engagement with care, potentially improving the care continuum and overall QoL for individuals living with HIV who can, and want to, lead their own care.
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Affiliation(s)
- David Crawford
- Positive Life New South Wales, Surry Hills, NSW, Australia
| | - Brent Allan
- International AIDS Society and the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Melbourne, VIC, Australia
| | - Aaron Cogle
- National Association of People Living with HIV, Newtown, NSW, Australia
| | - Graham Brown
- Centre for Social Impact, University of New South Wales, Kensington, NSW, Australia.,Australian Research Centre in Sex Health and Society, La Trobe University, Bundoora, VIC, Australia
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12
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Pohontsch NJ, Schulze J, Hoeflich C, Glassen K, Breckner A, Szecsenyi J, Lühmann D, Scherer M. Quality of care for people with multimorbidity: a focus group study with patients and their relatives. BMJ Open 2021; 11:e047025. [PMID: 34130962 PMCID: PMC8208013 DOI: 10.1136/bmjopen-2020-047025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Prevalence of people with multimorbidity rises. Multimorbidity constitutes a challenge to the healthcare system, and treatment of patients with multimorbidity is prone to high-quality variations. Currently, no set of quality indicators (QIs) exists to assess quality of care, let alone incorporating the patient perspective. We therefore aim to identify aspects of quality of care relevant to the patients' perspective and match them to a literature-based set of QIs. METHODS We conducted eight focus groups with patients with multimorbidity and three focus groups with patients' relatives using a semistructured guide. Data were analysed using Kuckartz's qualitative content analysis. We derived deductive categories from the literature, added inductive categories (new quality aspects) and translated them into QI. RESULTS We created four new QIs based on the quality aspects relevant to patients/relatives. Two QIs (patient education/self-management, regular updates of medication plans) were consented by an expert panel, while two others were not (periodical check-ups, general practitioner-coordinated care). Half of the literature-based QIs, for example, assessment of biopsychosocial support needs, were supported by participants' accounts, while more technical domains regarding assessment and treatment regimens were not addressed in the focus groups. CONCLUSION We show that focus groups with patients and relatives adding relevant aspects in QI development should be incorporated by default in QI development processes and constitute a reasonable addition to traditional QI development. Our QI set constitutes a framework for assessing the quality of care in the German healthcare system. It will facilitate implementation of treatment standards and increase the use of existing guidelines, hereby helping to reduce overuse, underuse and misuse of healthcare resources in the treatment of patients with multimorbidity. TRIAL REGISTRATION NUMBER German clinical trials registry (DRKS00015718), Pre-Results.
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Affiliation(s)
- Nadine Janis Pohontsch
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Josefine Schulze
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Charlotte Hoeflich
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Katharina Glassen
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Amanda Breckner
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Dagmar Lühmann
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
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13
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Chau E, Rosella LC, Mondor L, Wodchis WP. Association between continuity of care and subsequent diagnosis of multimorbidity in Ontario, Canada from 2001-2015: A retrospective cohort study. PLoS One 2021; 16:e0245193. [PMID: 33705429 PMCID: PMC7951913 DOI: 10.1371/journal.pone.0245193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 12/23/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuity of care is a well-recognized principle of the primary care discipline owing to its medical, interpersonal, and cost-saving benefits. Relationship continuity or the ongoing therapeutic relationship between a patient and their physician is a particularly desirable goal, but its role in preventing the accumulation of chronic conditions diagnoses in individuals is unknown. The objective of this study was to investigate the effect of continuity of care with physicians on the rate of incident multimorbidity diagnoses in patients with existing conditions. METHODS This was a population-based, retrospective cohort study from 2001 to 2015 that focused on patients aged 18 to 105 years with at least one chronic condition (n = 166,665). Our primary exposure was relationship continuity of care with general practitioners and specialists measured using the Bice-Boxerman Continuity of Care Index (COCI). COCI was specified as a time-dependent exposure prior to the observation period. Our outcomes of interest were the time to diagnosis of a second, third, and fourth chronic condition estimated using cause-specific hazard regressions accounting for death as a competing risk. FINDINGS We observed that patients with a single chronic condition and high continuity of care (>0.50) were diagnosed with a second chronic condition or multimorbidity at an 8% lower rate compared to individuals with low continuity (cause-specific hazard ratio (HR) 0.92 (95% Confidence Interval 0.90-0.93; p<0.0001) after adjusting for age, sex, income, place of residence, primary care enrolment, and the annual number of physician visits. Continuity remained protective as the degree of multimorbidity increased. Among patients with two conditions, the risk of diagnosis of a third chronic condition was also 8% lower for individuals with high continuity (HR 0.92; CI 0.90-0.94; p<0.0001). Patients with three conditions and high continuity had a 9% lower risk of diagnosis with a fourth condition (HR 0.91; CI 0.89-0.93; p<0.0001). CONCLUSIONS Continuity of care is a potentially modifiable health system factor that reduces the rate at which diagnoses of chronic conditions are made over time in patients with multimorbidity. Additional research is needed to explain the underlying mechanisms through which continuity is related to a protective effect and the clinical sequalae.
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Affiliation(s)
- Edward Chau
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Laura C. Rosella
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
- ICES, Toronto, Canada
| | | | - Walter P. Wodchis
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Canada
- ICES, Toronto, Canada
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14
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Heid AR, Gerber AR, Kim DS, Gillen S, Schug S, Pruchno R. Timing of onset and self-management of multiple chronic conditions: A qualitative examination taking a lifespan perspective. Chronic Illn 2020; 16:173-189. [PMID: 30180778 DOI: 10.1177/1742395318792066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Over two-thirds of older individuals live with multiple chronic conditions, yet chronic diseases are often studied in silos. Taking a lifespan approach to understanding the development of multiple chronic conditions in the older population helps to further elucidate opportunities for targeted interventions that address the complexities of multiple chronic conditions. METHODS Semi-structured interviews were conducted with 38 older adults (age 64+) diagnosed with at least two chronic health conditions. Content analysis was used to build understanding of how older adults discuss the timing of diagnoses and subsequent self-management of multiple chronic conditions. RESULTS Findings highlight the complex process by which illnesses unfold in the context of individuals' lives and the subsequent engagement and/or disengagement in self-management behaviors. Two primary themes were evident regarding timing of illnesses: illnesses were experienced within the context of social life events and/or health events, and illnesses were not predominantly seen as connected to one another by patients. Self-management behaviors were described in response to onset of each illness. DISCUSSION Findings provide insight into how older adults understand their experience of multiple chronic conditions and change in self-management behaviors over time. In order for practitioners to ignite behavioral changes, a person's history and life experiences must be considered.
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Affiliation(s)
- Allison R Heid
- New Jersey Institute for Successful Aging, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Andrew R Gerber
- Department of Psychology, Rowan University, Glassboro, NJ, USA
| | - David S Kim
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Stefan Gillen
- Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Seran Schug
- Department of Sociology & Anthropology, Rowan University, Glassboro, NJ, USA
| | - Rachel Pruchno
- New Jersey Institute for Successful Aging, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
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15
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Back D, Marzolini C. The challenge of HIV treatment in an era of polypharmacy. J Int AIDS Soc 2020; 23:e25449. [PMID: 32011104 PMCID: PMC6996317 DOI: 10.1002/jia2.25449] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The availability of potent antiretroviral therapy has transformed HIV infection into a chronic disease such that people living with HIV (PLWH) have a near normal life expectancy. However, there are continuing challenges in managing HIV infection, particularly in older patients, who often experience age-related comorbidities resulting in complex polypharmacy and an increased risk for drug-drug interactions. Furthermore, age-related physiological changes may affect the pharmacokinetics and pharmacodynamics of both antiretrovirals and comedications thereby predisposing elderly to adverse drug reactions. This review provides an overview of the therapeutic challenges when treating elderly PLWH (i.e. >65 years). Particular emphasis is placed on drug-drug interactions and other common prescribing issues (i.e. inappropriate drug use, prescribing cascade, drug-disease interaction) encountered in elderly PLWH. DISCUSSION Prescribing issues are common in elderly PLWH due to the presence of age-related comorbidities, organ dysfunction and physiological changes leading to a higher risk for drug-drug interactions, drugs dosage errors and inappropriate drug use. CONCLUSIONS The high prevalence of prescribing issues in elderly PLWH highlights the need for ongoing education on prescribing principles and the optimal management of individual patients. The knowledge of adverse health outcomes associated with polypharmacy and inappropriate prescribing should ensure that there are interventions to prevent harm including medication reconciliation, medication review and medication prioritization according to the risks/benefits for each patient.
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Affiliation(s)
- David Back
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
| | - Catia Marzolini
- Department of Molecular and Clinical PharmacologyUniversity of LiverpoolLiverpoolUnited Kingdom
- Division of Infectious Diseases and Hospital EpidemiologyDepartments of Medicine and Clinical ResearchUniversity Hospital of Basel and University of BaselBaselSwitzerland
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16
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Livio F, Marzolini C. Prescribing issues in older adults living with HIV: thinking beyond drug-drug interactions with antiretroviral drugs. Ther Adv Drug Saf 2019; 10:2042098619880122. [PMID: 31620274 PMCID: PMC6777047 DOI: 10.1177/2042098619880122] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Françoise Livio
- Service of Clinical Pharmacology, Department of Laboratories, University Hospital of Lausanne, Switzerland
| | - Catia Marzolini
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research, University Hospital of Basel and University of Basel, CH-4031 Basel, Switzerland
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17
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Guilcher SJT, Everall AC, Patel T, Packer TL, Hitzig SL, Lofters AK. Medication adherence for persons with spinal cord injury and dysfunction from the perspectives of healthcare providers: A qualitative study. J Spinal Cord Med 2019; 42:215-225. [PMID: 31573463 PMCID: PMC6781202 DOI: 10.1080/10790268.2019.1637644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Context: People with spinal cord injury and dysfunction (SCI/D) often take multiple medications (i.e. polypharmacy) to manage secondary health complications and multiple chronic conditions. Numerous healthcare providers are often involved in clinical care, increasing the risk of fragmented care, problematic polypharmacy, and conflicting health advice. These providers can play a crucial role in assisting patients with medication self-management to improve medication adherence. Design: A qualitative study involving telephone interviews, following a semi-structured guide that explored healthcare providers' conceptualization of factors impacting medication adherence for persons with SCI/D. The interviews were transcribed and analyzed descriptively and interpretively using a constant comparative process with the assistance of data display matrices. Analysis was guided by an ecological model of medication adherence. Setting and participants: Thirty-two healthcare providers from Canada, with varying clinical expertise. Intervention: Not Applicable. Outcome measures: Not Applicable. Results: Providers identified several factors that impact medication adherence for persons with SCI/D, which were grouped into micro (medication and patient-related), meso- (provider-related) and macro- (health system-related) factors. Medication-related factors included side effects, effectiveness, safety, and regimen complexity. Patient-specific factors included medication knowledge, preferences/expectations/goals, severity and type of injury, cognitive function/mental health, time since injury, and caregiver support. Provider-related factors included knowledge/confidence and trust. Health system-related factors included access to healthcare and access to medications. While providers were able to identify several factors influencing medication adherence, micro-level factors were the most frequently discussed. Conclusion: Findings from this study indicate that strategies to optimize medication adherence for persons with SCI/D should be multi-faceted.
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Affiliation(s)
- Sara J. T. Guilcher
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada,Correspondence to: Sara J. T. Guilcher, Leslie Dan Faculty of Pharmacy, 144 College Street, Toronto, ON, Canada, M5S 3M2; Ph: 416-946-7020.
| | - Amanda C. Everall
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Tejal Patel
- School of Pharmacy, University of Waterloo, Kitchener, Canada,Department of Family Medicine, DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Tanya L. Packer
- School of Occupational Therapy and Health Administration, Dalhousie University, Halifax, Canada
| | - Sander L. Hitzig
- Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada,St. John’s Rehab Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada,Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Aisha K. Lofters
- Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, Canada
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How the delivery of HIV care in Canada aligns with the Chronic Care Model: A qualitative study. PLoS One 2019; 14:e0220516. [PMID: 31348801 PMCID: PMC6660092 DOI: 10.1371/journal.pone.0220516] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada.
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19
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Kiplagat J, Mwangi A, Chasela C, Huschke S. Challenges with seeking HIV care services: perspectives of older adults infected with HIV in western Kenya. BMC Public Health 2019; 19:929. [PMID: 31296195 PMCID: PMC6624873 DOI: 10.1186/s12889-019-7283-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 07/05/2019] [Indexed: 12/27/2022] Open
Abstract
Background While younger adults (15–49 years) form the majority of the population living with HIV, older adults (≥50 years) infected with HIV face multiple challenges related to the aging process and HIV. We explored the experiences of older persons infected with HIV at the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya to understand the challenges faced when seeking HIV care services. Methods Between November 2016 and April 2017, a total of 57 adults aged 50 years and above were recruited from two AMPATH facilities – one rural and one urban facility. A total of 25 in-depth interviews and four focus group discussions were conducted, audio-recorded, transcribed and thematic analysis performed. Results Study participants raised unique challenges with seeking HIV care that include visits to multiple healthcare providers to manage HIV and comorbidities and as a result impact on their adherence to medication and clinical visits. Challenges with inadequate quality of facilities and poor patient-provider communication were also raised. Participants’ preference for matched gender and older age for care providers that serve older patients were identified. Conclusion Results indicate multiple challenges faced by older adults that need attention in ensuring continuous engagement in HIV care. Targeted HIV care for older adults would, therefore, significantly improve their access to and experience of HIV care. Of key importance is the integration of other chronic diseases into HIV care and employing staff that matches the needs of older adults. Electronic supplementary material The online version of this article (10.1186/s12889-019-7283-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jepchirchir Kiplagat
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya. .,Academic Model Providing Access to Healthcare, Eldoret, Kenya. .,Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Ann Mwangi
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya.,Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Charles Chasela
- Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Right to Care, EQUIP, 1006 Lenchen North Avenue, Centurion, Pretoria, South Africa
| | - Susann Huschke
- Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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20
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Abstract
Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug-disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade. Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug-drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019. Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.
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Affiliation(s)
- Catia Marzolini
- a Division of Infectious Diseases and Hospital Epidemiology, Departments of Medicine and Clinical Research , University Hospital of Basel and University of Basel , Basel , Switzerland.,b Department of Molecular and Clinical Pharmacology , University of Liverpool , Liverpool , UK
| | - Françoise Livio
- c Service of Clinical Pharmacology, Department of Laboratories , University Hospital of Lausanne , Lausanne , Switzerland
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21
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Althoff KN, Gebo KA, Moore RD, Boyd CM, Justice AC, Wong C, Lucas GM, Klein MB, Kitahata MM, Crane H, Silverberg MJ, Gill MJ, Mathews WC, Dubrow R, Horberg MA, Rabkin CS, Klein DB, Lo Re V, Sterling TR, Desir FA, Lichtenstein K, Willig J, Rachlis AR, Kirk GD, Anastos K, Palella FJ, Thorne JE, Eron J, Jacobson LP, Napravnik S, Achenbach C, Mayor AM, Patel P, Buchacz K, Jing Y, Gange SJ. Contributions of traditional and HIV-related risk factors on non-AIDS-defining cancer, myocardial infarction, and end-stage liver and renal diseases in adults with HIV in the USA and Canada: a collaboration of cohort studies. Lancet HIV 2019; 6:e93-e104. [PMID: 30683625 DOI: 10.1016/s2352-3018(18)30295-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 09/03/2018] [Accepted: 10/19/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Adults with HIV have an increased burden of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease. The objective of this study was to estimate the population attributable fractions (PAFs) of preventable or modifiable HIV-related and traditional risk factors for non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes. METHODS We included participants receiving care in academic and community-based outpatient HIV clinical cohorts in the USA and Canada from Jan 1, 2000, to Dec 31, 2014, who contributed to the North American AIDS Cohort Collaboration on Research and Design and who had validated non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, or end-stage renal disease outcomes. Traditional risk factors were tobacco smoking, hypertension, elevated total cholesterol, type 2 diabetes, renal impairment (stage 4 chronic kidney disease), and hepatitis C virus and hepatitis B virus infections. HIV-related risk factors were low CD4 count (<200 cells per μL), detectable plasma HIV RNA (>400 copies per mL), and history of a clinical AIDS diagnosis. PAFs and 95% CIs were estimated to quantify the proportion of outcomes that could be avoided if the risk factor was prevented. FINDINGS In each of the study populations for the four outcomes (1405 of 61 500 had non-AIDS-defining cancer, 347 of 29 515 had myocardial infarctions, 387 of 35 044 had end-stage liver disease events, and 255 of 35 620 had end-stage renal disease events), about 17% were older than 50 years at study entry, about 50% were non-white, and about 80% were men. Preventing smoking would avoid 24% (95% CI 13-35) of these cancers and 37% (7-66) of the myocardial infarctions. Preventing elevated total cholesterol and hypertension would avoid the greatest proportion of myocardial infarctions: 44% (30-58) for cholesterol and 42% (28-56) for hypertension. For liver disease, the PAF was greatest for hepatitis C infection (33%; 95% CI 17-48). For renal disease, the PAF was greatest for hypertension (39%; 26-51) followed by elevated total cholesterol (22%; 13-31), detectable HIV RNA (19; 9-31), and low CD4 cell count (13%; 4-21). INTERPRETATION The substantial proportion of non-AIDS-defining cancers, myocardial infarction, end-stage liver disease, and end-stage renal disease outcomes that could be prevented with interventions on traditional risk factors elevates the importance of screening for these risk factors, improving the effectiveness of prevention (or modification) of these risk factors, and creating sustainable care models to implement such interventions during the decades of life of adults living with HIV who are receiving care. FUNDING National Institutes of Health, US Centers for Disease Control and Prevention, the US Agency for Healthcare Research and Quality, the US Health Resources and Services Administration, the Canadian Institutes of Health Research, the Ontario Ministry of Health and Long Term Care, and the Government of Alberta.
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Affiliation(s)
- Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Kelly A Gebo
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Richard D Moore
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Cynthia M Boyd
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Amy C Justice
- Yale School of Medicine, New Haven, CT, USA; Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Cherise Wong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory M Lucas
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | | | | | - Michael A Horberg
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, MD, USA
| | | | | | | | | | - Fidel A Desir
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Anita R Rachlis
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | - Jennifer E Thorne
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joseph Eron
- University of North Carolina, Chapel Hill, NC, USA
| | - Lisa P Jacobson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Pragna Patel
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kate Buchacz
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Yuezhou Jing
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stephen J Gange
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Poitras ME, Maltais ME, Bestard-Denommé L, Stewart M, Fortin M. What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC Health Serv Res 2018; 18:446. [PMID: 29898713 PMCID: PMC6001147 DOI: 10.1186/s12913-018-3213-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 05/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to improve patient-centered care for persons with multimorbidity are in constant growth. To date, the emphasis has been on two separate kinds of interventions, those based on a patient-centered care approach with persons with chronic disease and the other ones created specifically for persons with multimorbidity. Their effectiveness in primary healthcare is well documented. Currently, none of these interventions have synthesized a patient-centered care approach for care for multimorbidity. The objective of this project is to determine the particular elements of patient-centered interventions and interventions for persons with multimorbidity that are associated with positive health-related outcomes for patients. METHOD A scoping review was conducted as the method supports the rapid mapping of the key concepts underpinning a research area and the main sources and types of evidence available. A five-stage approach was adopted: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; and (5) collating, summarizing and reporting results. We searched for interventions for persons with multimorbidity or patient-centered care in primary care. Relevant studies were identified in four systematic reviews (Smith et al. (2012;2016), De Bruin et al. (2012), and Dwamena et al. (2012)). Inductive analysis was performed. RESULTS Four systematic reviews and 98 original studies were reviewed and analysed. Elements of interventions can be grouped into three main types and clustered into seven categories of interventions: 1) Supporting decision process and evidence-based practice; 2) Providing patient-centered approaches; 3) Supporting patient self-management; 4) Providing case/care management; 5) Enhancing interdisciplinary team approach; 6) Developing training for healthcare providers; and 7) Integrating information technology. Providing patient-oriented approaches, self-management support interventions and developing training for healthcare providers were the most frequent categories of interventions with the potential to result in positive impact for patients with chronic diseases. CONCLUSION This scoping review provides evidence for the adaption of patient-centered interventions for patients with multimorbidity. Findings from this scoping review will inform the development of a toolkit to assist chronic disease prevention and management programs in reorienting patient care.
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Affiliation(s)
- Marie-Eve Poitras
- Département des sciences de la santé, Université du Québec à Chicoutimi, 555 Boulevard Université, Chicoutimi, Québec, G7H 2B1, Canada.
| | - Marie-Eve Maltais
- Département de médecine de famille, Université de Sherbrooke, Sherbrooke, Canada
| | - Louisa Bestard-Denommé
- Centre for Studies in Family Medicine, The Western Centre for Public Health and Family Medicine, 2nd Floor, London, Canada
| | - Moira Stewart
- Centre for Studies in Family Medicine, The Western Centre for Public Health and Family Medicine, 2nd Floor, London, Canada
| | - Martin Fortin
- Département de médecine de famille, Université de Sherbrooke, Sherbrooke, Canada
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Schäfer I, Kaduszkiewicz H, Mellert C, Löffler C, Mortsiefer A, Ernst A, Stolzenbach CO, Wiese B, Abholz HH, Scherer M, van den Bussche H, Altiner A. Narrative medicine-based intervention in primary care to reduce polypharmacy: results from the cluster-randomised controlled trial MultiCare AGENDA. BMJ Open 2018; 8:e017653. [PMID: 29362248 PMCID: PMC5786138 DOI: 10.1136/bmjopen-2017-017653] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 11/03/2017] [Accepted: 12/19/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To determine if patient-centred communication leads to a reduction of the number of medications taken without reducing health-related quality of life. DESIGN Two-arm cluster-randomised controlled trial. SETTING 55 primary care practices in Hamburg, Düsseldorf and Rostock, Germany. PARTICIPANTS 604 patients 65 to 84 years of age with at least three chronic conditions. INTERVENTIONS Within the 12-month intervention, general practitioners (GPs) had three 30 min talks with each of their patients in addition to routine consultations. The first talk aimed at identifying treatment targets and priorities of the patient. During the second talk, the medication taken by the patient was discussed based on a 'brown bag' review of all the medications the patient had at home. The third talk served to discuss goal attainment and future treatment targets. GPs in the control group performed care as usual. PRIMARY OUTCOME MEASURES We assumed that the number of medications taken by the patient would be reduced by 1.5 substances in the intervention group and that the change in the intervention group's health-related quality of life would not be statistically significantly inferior to the control group. RESULTS The patients took a mean of 7.0±3.5 medications at baseline and 6.8±3.5 medications at follow-up. There was no difference between treatment and control group in the change of the number of medications taken (0.43; 95% CI -0.07 to 0.93; P=0.094) and no difference in health-related quality of life (0.03; -0.02 to 0.08; P=0.207). The likelihood of receiving a new prescription for analgesics was twice as high in the intervention group compared with the control group (risk ratio, 2.043; P=0.019), but the days spent in hospital were reduced by the intervention (-3.07; -5.25 to -0.89; P=0.006). CONCLUSIONS Intensifying the doctor-patient dialogue and discussing the patient's agenda and personal needs did not lead to a reduction of medication intake and did not alter health-related quality of life. TRIAL REGISTRATION NUMBER ISRCTN46272088; Pre-results.
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Affiliation(s)
- Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Kaduszkiewicz
- Medical Faculty, Institute of General Practice, University of Kiel, Kiel, Germany
| | - Christine Mellert
- Faculty of Medicine, Institute of General Practice, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Christin Löffler
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Achim Mortsiefer
- Faculty of Medicine, Institute of General Practice, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Annette Ernst
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carl-Otto Stolzenbach
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Heinz-Harald Abholz
- Faculty of Medicine, Institute of General Practice, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik van den Bussche
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Attila Altiner
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
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van der Heide I, Snoeijs S, Quattrini S, Struckmann V, Hujala A, Schellevis F, Rijken M. Patient-centeredness of integrated care programs for people with multimorbidity. Results from the European ICARE4EU project. Health Policy 2018; 122:36-43. [DOI: 10.1016/j.healthpol.2017.10.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
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Struckmann V, Leijten FRM, van Ginneken E, Kraus M, Reiss M, Spranger A, Boland MRS, Czypionka T, Busse R, Rutten-van Mölken M. Relevant models and elements of integrated care for multi-morbidity: Results of a scoping review. Health Policy 2017; 122:23-35. [PMID: 29031933 DOI: 10.1016/j.healthpol.2017.08.008] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 08/19/2017] [Accepted: 08/21/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND In order to provide adequate care for the growing group of persons with multi-morbidity, innovative integrated care programmes are appearing. The aims of the current scoping review were to i) identify relevant models and elements of integrated care for multi-morbidity and ii) to subsequently identify which of these models and elements are applied in integrated care programmes for multi-morbidity. METHODS A scoping review was conducted in the following scientific databases: Cochrane, Embase, PubMed, PsycInfo, Scopus, Sociological Abstracts, Social Services Abstracts, and Web of Science. A search strategy encompassing a) models, elements and programmes, b) integrated care, and c) multi-morbidity was used to identify both models and elements (aim 1) and implemented programmes of integrated care for multi-morbidity (aim 2). Data extraction was done by two independent reviewers. Besides general information on publications (e.g. publication year, geographical region, study design, and target group), data was extracted on models and elements that publications refer to, as well as which models and elements are applied in recently implemented programmes in the EU and US. RESULTS In the review 11,641 articles were identified. After title and abstract screening, 272 articles remained. Full text screening resulted in the inclusion of 92 articles on models and elements, and 50 articles on programmes, of which 16 were unique programmes in the EU (n=11) and US (n=5). Wagner's Chronic Care Model (CCM) and the Guided Care Model (GCM) were most often referred to (CCM n=31; GCM n=6); the majority of the other models found were only referred to once (aim 1). Both the CCM and GCM focus on integrated care in general and do not explicitly focus on multi-morbidity. Identified elements of integrated care were clustered according to the WHO health system building blocks. Most elements pertained to 'service delivery'. Across all components, the five elements referred to most often are person-centred care, holistic or needs assessment, integration and coordination of care services and/or professionals, collaboration, and self-management (aim 1). Most (n=10) of the 16 identified implemented programmes for multi-morbidity referred to the CCM (aim 2). Of all identified programmes, the elements most often included were self-management, comprehensive assessment, interdisciplinary care or collaboration, person-centred care and electronic information system (aim 2). CONCLUSION Most models and elements found in the literature focus on integrated care in general and do not explicitly focus on multi-morbidity. In line with this, most programmes identified in the literature build on the CCM. A comprehensive framework that better accounts for the complexities resulting from multi-morbidity is needed.
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Affiliation(s)
- Verena Struckmann
- Berlin University of Technology, Department of Health Care Management, Germany.
| | - Fenna R M Leijten
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | - Ewout van Ginneken
- WHO Observatory on Health Systems and Policies, Berlin University of Technology, Department of Health Care Management, Germany
| | | | | | - Anne Spranger
- Berlin University of Technology, Department of Health Care Management, Germany
| | - Melinde R S Boland
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | | | - Reinhard Busse
- Berlin University of Technology, Department of Health Care Management, Germany
| | - Maureen Rutten-van Mölken
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, The Netherlands
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Muche-Borowski C, Lühmann D, Schäfer I, Mundt R, Wagner HO, Scherer M. Development of a meta-algorithm for guiding primary care encounters for patients with multimorbidity using evidence-based and case-based guideline development methodology. BMJ Open 2017; 7:e015478. [PMID: 28645968 PMCID: PMC5734311 DOI: 10.1136/bmjopen-2016-015478] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The study aimed to develop a comprehensive algorithm (meta-algorithm) for primary care encounters of patients with multimorbidity. We used a novel, case-based and evidence-based procedure to overcome methodological difficulties in guideline development for patients with complex care needs. STUDY DESIGN Systematic guideline development methodology including systematic evidence retrieval (guideline synopses), expert opinions and informal and formal consensus procedures. SETTING Primary care. INTERVENTION The meta-algorithm was developed in six steps:1. Designing 10 case vignettes of patients with multimorbidity (common, epidemiologically confirmed disease patterns and/or particularly challenging health care needs) in a multidisciplinary workshop.2. Based on the main diagnoses, a systematic guideline synopsis of evidence-based and consensus-based clinical practice guidelines was prepared. The recommendations were prioritised according to the clinical and psychosocial characteristics of the case vignettes.3. Case vignettes along with the respective guideline recommendations were validated and specifically commented on by an external panel of practicing general practitioners (GPs).4. Guideline recommendations and experts' opinions were summarised as case specific management recommendations (N-of-one guidelines).5. Healthcare preferences of patients with multimorbidity were elicited from a systematic literature review and supplemented with information from qualitative interviews.6. All N-of-one guidelines were analysed using pattern recognition to identify common decision nodes and care elements. These elements were put together to form a generic meta-algorithm. RESULTS The resulting meta-algorithm reflects the logic of a GP's encounter of a patient with multimorbidity regarding decision-making situations, communication needs and priorities. It can be filled with the complex problems of individual patients and hereby offer guidance to the practitioner. Contrary to simple, symptom-oriented algorithms, the meta-algorithm illustrates a superordinate process that permanently keeps the entire patient in view. CONCLUSION The meta-algorithm represents the back bone of the multimorbidity guideline of the German College of General Practitioners and Family Physicians. This article presents solely the development phase; the meta-algorithm needs to be piloted before it can be implemented.
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Affiliation(s)
- Cathleen Muche-Borowski
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Dagmar Lühmann
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Ingmar Schäfer
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Rebekka Mundt
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Hans-Otto Wagner
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Martin Scherer
- Institute for Primary Care and Family Medicine, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Rhodes CM, Chang Y, Regan S, Singer DE, Triant VA. Human Immunodeficiency Virus (HIV) Quality Indicators Are Similar Across HIV Care Delivery Models. Open Forum Infect Dis 2017; 4:ofw240. [PMID: 28480238 DOI: 10.1093/ofid/ofw240] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 10/31/2016] [Accepted: 11/09/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There are limited data on human immunodeficiency virus (HIV) quality indicators according to model of HIV care delivery. Comparing HIV quality indicators by HIV care model could help inform best practices because patients achieving higher levels of quality indicators may have a mortality benefit. METHODS Using the Partners HIV Cohort, we categorized 1565 patients into 3 HIV care models: infectious disease provider only (ID), generalist only (generalist), or infectious disease provider and generalist (ID plus generalist). We examined 12 HIV quality indicators used by 5 major medical and quality associations and grouped them into 4 domains: process, screening, immunization, and HIV management. We used generalized estimating equations to account for most common provider and multivariable analyses adjusted for prespecified covariates to compare composite rates of HIV quality indicator completion. RESULTS We found significant differences between HIV care models, with the ID plus generalists group achieving significantly higher quality measures than the ID group in HIV management (94.4% vs 91.7%, P = .03) and higher quality measures than generalists in immunization (87.8% vs 80.6%, P = .03) in multivariable adjusted analyses. All models achieved rates that equaled or surpassed previously reported quality indicator rates. The absolute differences between groups were small and ranged from 2% to 7%. CONCLUSIONS Our results suggest that multiple HIV care models are effective with respect to HIV quality metrics. Factors to consider when determining HIV care model include healthcare setting, feasibility, and physician and patient preference.
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Affiliation(s)
- Corinne M Rhodes
- University of Pennsylvania, Division of General Internal Medicine, Philadelphia, Pennsylvania; Massachusetts General Hospital, Divisions of
| | - Yuchiao Chang
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Susan Regan
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Daniel E Singer
- General Internal Medicine.,Harvard Medical School, Boston, Massachusetts
| | - Virginia A Triant
- General Internal Medicine.,Infectious Diseases, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
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Rhodes CM, Chang Y, Regan S, Triant VA. Non-Communicable Disease Preventive Screening by HIV Care Model. PLoS One 2017; 12:e0169246. [PMID: 28060868 PMCID: PMC5218477 DOI: 10.1371/journal.pone.0169246] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 12/14/2016] [Indexed: 12/30/2022] Open
Abstract
Importance The Human Immunodeficiency Virus (HIV) epidemic has evolved, with an increasing non-communicable disease (NCD) burden emerging and need for long-term management, yet there are limited data to help delineate the optimal care model to screen for NCDs for this patient population. Objective The primary aim was to compare rates of NCD preventive screening in persons living with HIV/AIDS (PLWHA) by type of HIV care model, focusing on metabolic/cardiovascular disease (CVD) and cancer screening. We hypothesized that primary care models that included generalists would have higher preventive screening rates. Design Prospective observational cohort study. Setting Partners HealthCare System (PHS) encompassing Brigham & Women’s Hospital, Massachusetts General Hospital, and affiliated community health centers. Participants PLWHA age >18 engaged in active primary care at PHS. Exposure HIV care model categorized as infectious disease (ID) providers only, generalist providers only, or ID plus generalist providers. Main Outcome(s) and Measures(s) Odds of screening for metabolic/CVD outcomes including hypertension (HTN), obesity, hyperlipidemia (HL), and diabetes (DM) and cancer including colorectal cancer (CRC), cervical cancer, and breast cancer. Results In a cohort of 1565 PLWHA, distribution by HIV care model was 875 ID (56%), 90 generalists (6%), and 600 ID plus generalists (38%). Patients in the generalist group had lower odds of viral suppression but similar CD4 counts and ART exposure as compared with ID and ID plus generalist groups. In analyses adjusting for sociodemographic and clinical covariates and clustering within provider, there were no significant differences in metabolic/CVD or cancer screening rates among the three HIV care models. Conclusions There were no notable differences in metabolic/CVD or cancer screening rates by HIV care model after adjusting for sociodemographic and clinical factors. These findings suggest that HIV patients receive similar preventive health care for NCDs independent of HIV care model.
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Affiliation(s)
- Corinne M. Rhodes
- Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
- * E-mail:
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Susan Regan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Virginia A. Triant
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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Kendall CE, Manuel DG, Younger J, Hogg W, Glazier RH, Taljaard M. A population-based study evaluating family physicians' HIV experience and care of people living with HIV in Ontario. Ann Fam Med 2015; 13:436-45. [PMID: 26371264 PMCID: PMC4569451 DOI: 10.1370/afm.1822] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV. METHODS We retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period). RESULTS The majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients (mean levels of adherence [95% CIs] were 0.34 [0.30-0.39] and 0.40 [0.34-0.45], respectively, vs 0.77 [0.74-0.80]). Patients' receipt of cancer screenings and health care use were unrelated to family physician HIV experience. CONCLUSIONS Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings.
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Affiliation(s)
- Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Douglas G Manuel
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jaime Younger
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - William Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard H Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Monica Taljaard
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Affiliation(s)
- Amy Justice
- aDepartment of Internal Medicine, Yale University and the Veterans Affairs Healthcare System, West Haven, CT 06516, USA bChronic Viral Illness Service and Division of Geriatrics, McGill University Health Center, Montreal, Quebec, Canada
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