Activation of persons living with HIV for treatment, the great study

Physical and psychosocial impact on peers with HIV co-leading an HIV intervention: A pilot theory-guided case-study

Objective

To examine longitudinal changes in activation, HIV health outcomes, and social and psychological determinants of adherence to antiretroviral therapy (ART) among peer trainers with HIV.

Methods

A multi-method case study. The study population included peers (n = 4) from a randomized controlled trial about peers training patients with HIV (n = 359) to better manage their health. Each peer completed a semi-structured interview that we analyzed using Social Learning Theory (SLT) as a guiding framework. The peers also completed longitudinal surveys about their health after each training cohort (n = 5) over 3-years.

Results

Peers reported personal benefits from training others with HIV in self-management. Their self-reported activation, self-efficacy and some health outcomes increased overtime. The peers mentioned SLT principles during their interviews. Generally, the peers enjoyed and benefited from training others with HIV in a group-based learning environment.

Conclusion

Our findings suggest peer leadership can serve as a means for empowerment that is effective at both supporting improvements in health outcomes for patients and for themselves, which may be both scalable and sustainable.

Innovation

To our knowledge, this is the first mixed-methods study to show reciprocal long-term improvement in health behaviors in a diverse group of peers training others with HIV to self-manage their care.

Adaptive leadership in clinical encounters with women living with HIV

BACKGROUND

Women living with HIV (WLWH) report low engagement in health care, missed office visits, and less engagement in the clinical encounter. Strengthening the clinical encounter for WLWH may improve health outcomes and quality of life. The Adaptive Leadership Framework for Chronic Illness offers specific adaptive leadership strategies for providers to improve patient-provider interactions. The purpose of this study was to examine adaptive leadership behaviors that contribute to the development of effective patient-provider communication from the perspectives of WLWH.

METHODS

The descriptive, cross-sectional and qualitative study conducted interviews with 22 WLWH to assess perceptions of the clinical encounter related to HIV-related stigma, engagement in care, medical distrust, and experiences with discrimination and quality of life. Members of the study team using a set of a priori codes analyzed data using NVivo 12.0.

RESULTS

Participants described two primary themes and subthemes of each for adaptive leadership behaviors. The primary theme for adaptive leadership of providers was "my provider cares about me"; subthemes were communication, trust building takes time, and supportive providers are trusted. The primary theme for adaptive leadership of WLWH themselves was "I care about me; subthemes were self-advocacy and self-empowerment.

CONCLUSIONS

Providers can use adaptive leadership behaviors during clinical encounters to support WLWH, improve patient-provider communication, enhance trust, and improve patient outcomes.

The Mediating Role of Social Support and Resilience Between HIV-Related Stigmas and Patient Activation Among Young Black Women Living With HIV in the Southern United States: A Cross-sectional Study

ABSTRACT

Little is known about the construct of patient activation for engaging in favorable self-management behaviors in people with HIV. We conducted a cross-sectional study among young Black women with HIV (n = 84) to examine the association between stigma and patient activation and the mediating role of social support and resilience. Social support mediated the relationship between the following dimensions of stigma and patient activation: internalized (β = -0.20, SE = 0.08, CI [-0.369 to -0.071]) and anticipated in health care settings (β = -0.06, SE = 0.04, CI [-0.177 to -0.001]). Resilience mediated the relationship between the following dimensions of stigma and patient activation: anticipated in health care (β = -0.20, SE = 0.08, CI [-0.387 to -0.057]) and community settings (β = -0.15, SE = 0.08, CI [-0.318 to -0.017]), and enacted in community settings (β = -0.14, SE = 0.09, CI [-0.332 to -0.001]). Our findings suggest intrapersonal and interpersonal mechanisms by which various dimensions of stigma contribute to patient activation, thus identifying social support, resilience, and patient activation as potential intervention targets.

Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review

BACKGROUND

Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities.

OBJECTIVE

This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities.

METHODS

A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study.

RESULTS

PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information.

CONCLUSIONS

Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

A framework for patient-centered telemedicine: Application and lessons learned from vulnerable populations

Virtual technologies can facilitate clinical monitoring, clinician-patient interactions, and enhance patient-centered approaches to healthcare delivery. Telemedicine, two-way communication between a healthcare provider and a patient not in the same physical location, emphasizes patient preference and convenience by substituting the transportation of patients with information transfer. We present a framework for implementation of a comprehensive, dynamic, patient-centered telemedicine network deployed in 12 opioid treatment programs (OTP) located throughout New York State (NYS). The program aims to effectively manage hepatitis C virus (HCV) infection via telemedicine with co-administration of HCV and substance use medications. We have found that the Sociotechnical System model with emphasis on patient-centered factors provides a framework for telemedicine deployment and implementation to a vulnerable population. The issue of interoperability between the telemedicine platform and the electronic health record (EHR) system as well as clinical information retrieval for medical decision-making are challenges with implementation of a comprehensive, dynamic telemedicine system. Targeting telemedicine to a vulnerable population requires additional consideration of trust in the security and confidentiality of the telemedicine system. Our contribution is the valuable lessons learned from implementing a comprehensive, dynamic, patient-centered telemedicine system among an OTP network throughout NYS as applied to a vulnerable population that can be generalized to other difficult-to-reach populations.

ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (the PRECluDE consortium): Combatting chronic disease comorbidities in HIV populations through implementation research

Antiretroviral therapy (ART) prevented premature mortality and improved the quality of life among people living with the human immunodeficiency virus (PLWH), such that now more than half of PLWH in the United States are 50 years of age and older. Increased longevity among PLWH has resulted in a significant rise in chronic, comorbid diseases. However, the implementation of guideline-based interventions for preventing, treating, and managing such age-related, chronic conditions among the HIV population is lacking. The PRECluDE consortium supported by the Center for Translation Research and Implementation Science at the National Heart, Lung, and Blood Institute catalyzes implementation research on proven-effective interventions for co-occurring heart, lung, blood, and sleep diseases and conditions among PLWH. These collaborative research studies use novel implementation frameworks with HIV, mental health, cardiovascular, and pulmonary care to advance comprehensive HIV and chronic disease healthcare in a variety of settings and among diverse populations.

"Get Ready and Empowered About Treatment" (GREAT) Study: a Pragmatic Randomized Controlled Trial of Activation in Persons Living with HIV

BACKGROUND

Little is known about strategies to improve patient activation, particularly among persons living with HIV (PLWH).

OBJECTIVE

To assess the impact of a group intervention and individual coaching on patient activation for PLWH.

DESIGN

Pragmatic randomized controlled trial.

SITES

Eight practices in New York and two in New Jersey serving PLWH.

PARTICIPANTS

Three hundred sixty PLWH who received care at participating practices and had at least limited English proficiency and basic literacy.

INTERVENTION

Six 90-min group training sessions covering use of an ePersonal Health Record loaded onto a handheld mobile device and a single 20-30 min individual pre-visit coaching session.

MAIN MEASURES

The primary outcome was change in Patient Activation Measure (PAM). Secondary outcomes were changes in eHealth literacy (eHEALS), Decision Self-efficacy (DSES), Perceived Involvement in Care Scale (PICS), health (SF-12), receipt of HIV-related care, and change in HIV viral load (VL).

KEY RESULTS

The intervention group showed significantly greater improvement than the control group in the primary outcome, the PAM (difference 2.82: 95% confidence interval [CI] 0.32-5.32). Effects were largest among participants with lowest quartile PAM at baseline (p < 0.05). The intervention doubled the odds of improving one level on the PAM (odds ratio 1.96; 95% CI 1.16-3.31). The intervention group also had significantly greater improvement in eHEALS (difference 2.67: 95% CI 1.38-3.9) and PICS (1.27: 95% CI 0.41-2.13) than the control group. Intervention effects were similar by race/ethnicity and low education with the exception of eHealth literacy where effects were stronger for minority participants. No statistically significant effects were observed for decision self-efficacy, health status, adherence, receipt of HIV relevant care, or HIV viral load.

CONCLUSIONS

The patient activation intervention modestly improved several domains related to patient empowerment; effects on patient activation were largest among those with the lowest levels of baseline patient activation.

TRIAL REGISTRATION

This study is registered at Clinical Trials.Gov (NCT02165735).

A Critical Review and Commentary on the Challenges in Engaging HIV-Infected Latinos in the Continuum of HIV Care

Antiretroviral therapy for treatment of HIV infection has become increasingly effective. Persistent poor HIV outcomes in racial and ethnic minority populations in the US call for a closer examination into why Latinos are at significant risk for acquiring and dying from HIV. To improve clinical outcomes and achieve an AIDS-free generation, HIV research must address disparities in HIV outcomes in Latinos, the largest ethnic/racial minority population in the US. Immigrant status as well as cultural factors influence HIV care utilization and are essential to highlight for effective intervention development in Latinos. A better understanding of these individual and contextual factors is critical to developing tailored approaches to engaging Latinos in HIV care. Based on a comprehensive literature review, we offer a framework for understanding what is needed from clinical practice and research to improve engagement in HIV care for US-based Latinos. These findings may have implications for other minority populations.

Patient activation among people living with HIV: a cross-sectional comparative analysis with people living with diabetes mellitus

Standardized self-management supports are an integral part of care delivery for many chronic conditions. We used the validated Patient Activation Measure (PAM®) to assess level of engagement for self-management from a sample of 165 people living with HIV (PLWH) and 163 people with diabetes. We conducted multivariable logistic regression to assess associations between demographics and PAM® scores. PLWH had high levels of activation that were no different from those of people with diabetes (mean score = 67.2, SD = 14.2 versus 65.0, SD = 14.9, p = 0.183). After adjusting for patient characteristics, only being on disability compared to being employed or a student was associated with being less activated (AOR = 0.276, 95%CI = 0.103-0.742). Our findings highlight the potential for the implementation of existing standardized chronic disease self-management programs to enhance the care delivery for PLWH, with people on disability as potential target populations.

Shared decision-making using personal health record technology: a scoping review at the crossroads

Objective

This scoping review aims to determine the size and scope of the published literature on shared decision-making (SDM) using personal health record (PHR) technology and to map the literature in terms of system design and outcomes.

Materials and Methods

Literature from Medline, Google Scholar, Cumulative Index to Nursing and Allied Health Literature, Engineering Village, and Web of Science (2005-2015) using the search terms "personal health records," "shared decision making," "patient-provider communication," "decision aid," and "decision support" was included. Articles ( n  = 38) addressed the efficacy or effectiveness of PHRs for SDM in engaging patients in self-care and decision-making or ways patients can be supported in SDM via PHR.

Results

Analysis resulted in an integrated SDM-PHR conceptual framework. An increased interest in SDM via PHR is apparent, with 55% of articles published within last 3 years. Sixty percent of the literature originates from the United States. Twenty-six articles address a particular clinical condition, with 10 focused on diabetes, and one-third offer empirical evidence of patient outcomes. The tethered and standalone PHR architectural types were most studied, while the interconnected PHR type was the focus of more recently published methodological approaches and discussion articles.

Discussion

The study reveals a scarcity of rigorous research on SDM via PHR. Research has focused on one or a few of the SDM elements and not on the intended complete process.

Conclusion

Just as PHR technology designed on an interconnected architecture has the potential to facilitate SDM, integrating the SDM process into PHR technology has the potential to drive PHR value.

Racial Differences and Disparities in Osteoporosis-related Bone Health: Results From the PAADRN Randomized Controlled Trial

BACKGROUND

Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care.

DESIGN, SUBJECTS, AND MEASURES

We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors.

RESULTS

Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation.

CONCLUSIONS

Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.

Information and communication technologies for adherence to antiretroviral treatment in adults with HIV/AIDS

INTRODUCTION

Information and communication technologies support interventions directed at the prevention of HIV transmission and patient monitoring by promoting improved accessibility and quality of care.

OBJECTIVE

To evaluate the efficacy of information and communication technologies in the adherence to antiretroviral treatment in adults with HIV/AIDS.

METHODOLOGY

Systematic review conducted from March to May of 2015 in three databases-the Cumulative Index to Nursing and Allied Health Literature (CINAHL); the Latin-American and Caribbean Literature in Health Sciences (LILACS/BIREME) and SCOPUS; and the Cochrane library and the Medical Literature Analysis and Retrieval System Online portal (MEDLINE/PubMed). The sample consisted of nine randomized clinical trials based on the use of information and communication technologies for adherence to antiretroviral treatment in adults with HIV/AIDS.

RESULTS

Three studies analysed the use of a short message service - SMS - two phone calls, two alarm devices, one web-enabled Hand-held device and one web electronic intervention. Improvements in the levels of adherence in the group subjected to the intervention were identified in seven studies. The phone was the type of information and communication technology with proven efficacy with respect to adherence. It was used to make calls, as well as to send alert messages and reminders about taking medications. Pagers were not considered to be effective regarding adherence to antiretroviral therapy.

CONCLUSION

The integrated use of information and communication technologies with standard care promotes increased access to care, strengthening the relationship between patients and health services, with the possibility of mitigating the difficulties experienced by people with HIV in achieving optimal levels of adherence to drug therapy.