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Presentation on theme: "S ATISFACTION WITH MEDICAL CARE AMONG HIV- INFECTED WOMEN IN RURAL C ALIFORNIA Erin Moix Grieb, MA, Clea Sarnquist, DrPH, MPH, Yvonne Maldonado, MD Stanford."— Presentation transcript:

1 S ATISFACTION WITH MEDICAL CARE AMONG HIV- INFECTED WOMEN IN RURAL C ALIFORNIA Erin Moix Grieb, MA, Clea Sarnquist, DrPH, MPH, Yvonne Maldonado, MD Stanford University

2 P RESENTER D ISCLOSURES : C LEA S ARNQUIST The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3 I NTRODUCTION AIDS has increased among women nationally: 8% in 1985, 27% in 2006 The HIV epidemic has increasingly spread throughout rural areas: Only 1 California county does not have currently living HIV/AIDS cases. Minimal research exists on rural women living with HIV in the Western U.S. HIV-infected women in rural areas have less access to care, and may have worse outcomes, than their urban counterparts.

4 O BJECTIVES For this population of HIV-infected women in rural areas of California: (1) Evaluate satisfaction with medical care, (2) Evaluate quality of life, and (3) Discuss solutions for improvements.

5 M ETHODS Retrospective cohort 11 randomly-selected facilities serving rural areas Face-to-face interviews and medical chart abstractions Eligibility: HIV-infected, female patients in care Jan. 1 – Apr. 31, 2007 (4 months) Women asked to confirm they lived in a rural area Response rate: 24.7% (64/259) Confidentiality requirements limited recruitment efforts Statistical Analysis Frequencies


7 R ESULTS : S OCIO - ECONOMIC S TATUS Age: Median 47.5 years Health Insurance: 75% Medicare/Medicaid >90% covered Marital Status: 84.4% single 15.6% married or with partner Economic Status: 45% below Federal Poverty level 33% sole providers for minor(s) <18 70% currently unemployed


9 R ESULTS : C O - MORBIDITIES Hepatitis: 26.4% Hep A 7.1% Hep B 22.6% Hep C Tuberculosis: 10.9% Mental Health: 56.2% Depression 23.4% Anxiety 14.1% Bipolar disorder 12.5% Other

10 R ESULTS : S ATISFACTION WITH C ARE 96.9% rated services at their facility as ‘good’ or better. 89.1% would ‘definitely’ recommend their facility to friends

11 R ESULTS : S ATISFACTION WITH C ARE BUT, only: 28.1% are told in advance most/all of the time about treatment procedures they should have. 20.4% said staff understood the treatment needs of women most/all of the time. 17.2% said the staff answered their questions most/all of the time. 17.2% reported feeling ‘like an individual with unique needs and concerns’ most/all of the time. 6.2% said staff respected their privacy most/all of the time.

12 R ESULTS : Q UALITY OF L IFE 47.5% said their health limited their daily activities For example, walking several blocks. Women reported accomplishing less than they would like due to their: physical health (49.2%) and emotional problems (50.8%). 44.3% said they ‘felt so down in the dumps that nothing could cheer them up’ some or most of the time.

13 Q UALITY OF CARE AND L IFE : A GUIDELINES - BASED PERSPECTIVE Understanding quality of care received, compared to national guidelines, might help explain women’s satisfaction with care and quality of life. Statistics based on chart-review data

14 Q UALITY OF C ARE : A NTIRETROVIRAL (ARV) U SE 94% ever took ARVs 89% were taking ARVs at time of interview Half of those not taking ARVs cited high CD4 counts as reason Only 20% on combination therapy (ex. Truvada, Combivir, and Trizivir)

15 Q UALITY OF CARE : CD4 C OUNTS & V IRAL L OAD T ESTING Initial CD4 counts were 27% 500. Most recent CD4 were 5% 500. 84.4% undetectable at most recent test CD4 CountsViral Loads 85.9% had a CD4 and viral load test within the past 6 months (guidelines are every 3-6 months)

16 Q UALITY OF C ARE : S CREENING AND I MMUNIZATIONS Hepatitis Hep B: 85.9% Hep C: 79.7% Tuberculosis: 89.1% Pap smear: 87.5% Influenza: 88.9% Pneumococcus: 84.4% Hepatitis B: 73.5% ScreeningsImmunizations

17 Q UALITY OF L IFE : A DHERENCE o 8.8% reported missing a dose in the last 48 hours o 18.6% reported missing a dose in last 30 days For optimal health, adherence needs to be >=95% of medications

18 B ARRIERS TO C ARE /U NMET NEEDS Understanding barriers to care may help clarify both satisfaction with care and quality of life.

19 R ESULTS : B ARRIERS TO C ARE Your physical health has not allowed you to get to the service32.8% Transportation31.2% Your ability to find your way through the system25.0%

20 R ESULTS : U NMET SERVICE NEEDS Service % unmet need Assistance in finding a doctor for ongoing medical care62% Chore or homemaker services (paid or volunteer)50% Assistance in finding shelter or housing44% Local volunteer support services designed to assist persons with HIV44%

21 L IMITATIONS Likely biased sample: o Low response rate (24.7%) o Recruitment procedures likely a major cause o Opt-in approach probably selected for healthier individuals o Recall bias Only looked at in-care women. No multivariable analysis due to small sample size. Incomplete medical charts. Defining ‘rurality’ difficult.

22 D ISCUSSION : S ATISFACTION WITH CARE Despite the majority being satisfied with their care overall, issues remain: Staff do not respect privacy of patients, Staff unable to answer questions, Patients not informed of needed procedures, Patients do not feel like individuals, Staff may not understand treatment needs of women.

23 D ISCUSSION : F ACTORS RELATED TO SATISFACTION Care quality shortcomings, compared to national guidelines, may contribute to lower satisfaction: Regular CD4 and viral load testing ARV access and adherence Screenings/IZs, etc. Barriers to care and service needs may contribute to women reporting poor care or quality of life: Barriers: Physical Health, Transportation Needs: Medical home, Chore assistance, Housing

24 D ISCUSSION : P ATIENT R IGHTS Healthcare staff and patients may benefit from education on patient rights: Right to accurate information, Right to make decisions, Right to confidentiality.

25 D ISCUSSION : D UAL R ELATIONSHIPS Healthcare providers may interact with patients outside of the healthcare setting. Common in rural areas. Can complicate the patient-provider interaction: Providers may feel it is acceptable to share information outside of clinic, Patients may perceive a lack of confidentiality.

26 D ISCUSSION : P ROVIDER K NOWLEDGE, T RAINING, R ESOURCES Several reported issues (inability to answer questions, lack of knowledge about HIV issues in women) speak to lack of training and resources. Rural practices may only see a few HIV-infected individuals, especially women. Thus, time and resources are minimally expended to understand such sub-group needs. Even in larger practices, training and evaluation resources are frequently more limited in rural areas.

27 R ECOMMENDATIONS : P ROVIDER SUPPORT AND T RAINING Utilize existing resources such as AIDS Education and Training Centers (AETCs), partnerships with referral centers, telemedicine, etc. Ensure that: Providers have training opportunities and are encouraged to utilize them Training regarding HIV emphasizes privacy issues and patient rights Adress ‘Dual role’ of physicians in rural settings Example: PAETC’s Perinatal Summit 2011 in Fresno Example: NCCC National Perinatal HIV Hotline and HIV Clinical Consultation Warmline

28 R ECOMMENDATIONS : P ATIENT SUPPORT Education on rights and responsibilities. Mobile clinics. Transportation provision and reimbursement. Electronic reminders: Text messaging, etc. Case managers providing more linkages to services. Virtual support groups. Assess clients on a regular basis to understand needs and shortcomings.

29 A CKNOWLEDGEMENTS Stanford University interview team: Helen Hwang, MPH, Ariadna Gomez, MBA, Alma Gonzalez, MPH, Salima Mutima, MD, MPH, and Neal Patel. Survey assistance: Shayna Cunningham, PhD Facilities & subjects for their participation For further information, please contact: Clea Sarnquist:

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