1. Optimized Multidisciplinary Care Teams Enhance Antiretroviral Therapy Adherence --What We Know Michael Horberg, MD MAS FACP Director, HIV/AIDS Kaiser Permanente Executive Director Research, Mid-Atlantic Permanente Medical Group Clinical Lead, HIV/AIDS, Care Management Institute Vice-Chair, HIV Medicine Association HIVI HIV Initiative of Kaiser Permanente and Care Management Institute

2. Why The Care Team as Necessary? Doctors don’t always discuss adherence with the patient or don’t emphasize it enough  Nachega, IAPAC/NIMH 2011; Golin, JGIM, 2004 Patient treatment adherence is not static over time  Leading to changes in viral control over time (Mugavero, IAPAC/NIMH 2011) Care necessities evolve over time  drug-drug interactions, co-morbidities do too  These impact adherence also Structural issues can impact adherence  Including transportation, ease of refills Slide 2

3. HIV Demographics—for purposes of reference United StatesVA Kaiser Permanente (KP) + Group Health Year 200620082010 Number HIV+ 1,100,000 (est.)23,46320,180 % Female 25%3%*16% % Black 50% *18% % Latino 20%7%*15-25% % >50 years of age 27%64%42% Sources: CDC, KFF, VA, KP *--Varies significantly by state Slide 3 KP and GHC operate in 9 states plus DC. KP HIV population rising annually; VA remains steady.

4. KP Non-NQF HIV Quality Measures

5. Our Non-NQF HIV Quality Measures Care coordination key here. Many person effort necessary—not just the physician!

6. Our NQF/NCQA HIV Quality Performance Many team efforts here also. Outcomes are a team effort.

7. (Re-)New Interest in “Medical Home” Emphasis on integrated, multi-disciplinary care (MDCT)  HIV Specialist (ID or primary care) as “specialty leader”  Case manager and care management  Can be physically in one place or connected by technology  Linkage to inpatient and outpatient care, lab, pharmacy services, consults Has been an element in HIV care  Essentially, how KP practices HIV medicine  Ryan White C clinics, VA also Not much research  Some research but pre-combination ART (Le, 1998, Sherer, 2002)  HIV specialist improved outcomes (Kitahata 2000, Delgado 2003)  HIV clinical pharmacist (Horberg 2007) Slide 7

8. Multidisciplinary Care Team Components (1) Potential Components:  NOTE: Need for local considerations always HIV Specialist  Can be Infectious Disease Specialist  Or Primary Care with extended experience with HIV Care Care Coordination  Often an RN, but not necessarily  Consider PA, clinical pharmacist, other HIV Clinical Pharmacist Nurse Case Manager Slide 8

9. Multidisciplinary Care Team Components (2) Social Work  Benefits Coordination  Access to outside services  ?Housing  ?Legal Health Educator Nutrition Service Transportation Specialist Identified Specialists in other disciplines  Oncology  Gastroenterology Mental Health Slide 9

10. KP: Provider Experience and Outcomes IF antiretroviral naïve:  ↑ panel size has modest effect on adherence and odds BLQ at 12 month  Years of provider experience or specialty no association  Significant association with ARV class (NNRTI) and year started greatest impact IF antiretroviral experienced:  ↑ years provider experience associated with ↑ adherence and odds BLQ  No association with panel size or specialty  Significant association with older age, Caucasian, MSM, initiation after 2000 Horberg, Hurley, Towner, Allerton, Tang, Catz, Silverberg, Quesenberry, IDSA Abstract 1131, 2010; IAS Abstract MOPE464, 2011 Observational cohort data Slide 10

11. Clinical Pharmacists: Roles Can have many roles  Adherence and adverse effect counseling  Manage adverse effects and drug-drug interactions  Ombudsman with dispense pharmacies  Research staff  Potentially case management Physicians average 13 minutes entire course of a patient’s care discussing adherence while pharmacists spend 0.5-1.5 hours per visit discussing adherence  Older data, need to update  And this was adherence to antiretroviral medications only Golin, JGIM, 2004; Geletko, Am J Hlth Sys Pharm, 2002; Rathbun, Clin Ther, 2005

12. HIV Clinical Pharmacists Study ARV NaïveARV Experienced 12 Month --Continuous Outcome +6.5% (.06) [NOTE: Far greater impact on poorer subpopulation] +3.1% (.34) -- OR ≥90%1.23 (.47)1.02 (.92) 24 Month --Continuous Outcomes+8.7% (.01)+3.0% (.40)/ +10.6% (.001)* --OR ≥90%3.88 (<.0001)1.39 (.29)/ 2.49 (.002)* *--1st value is 0-50 patients; 2nd value is 51+ patients 3538 patients evaluated—1571 antiretroviral naïve and 1967 experienced patients3538 patients evaluated—1571 antiretroviral naïve and 1967 experienced patients Adherence Results (multivariate analysis, p value): Horberg, Hurley, Silverberg, Quesenberry, Kinsman, JAIDS, 2007; 44:531-539

13. HIV Clinical Pharmacists Study (2) ARV Na ï ve ARV Experienced Hospital Days↑67% (<.0001) [NOTE: Far greater impact on poorer subpopulation] / ↑10% (.36)* ↓14% (.008)/ ↓38% (<.0001)* ER Visits↓2% (.89)↓18% (.05) Office Visits↓12% (<.0001) [NOTE: Far greater impact on poorer subpopulation] / ↓1% (.71)* ↓22% (<.0001) / ↑3% (.16)* *--1st value is 0-50 patients; 2nd value is 51+ patients Utilization Results: Slide 13

14. HIV Multidisciplinary Care Team Study (1) Research Question:  What components of the HIV MDCT in combination are associated with the greatest increases in adherence? Retrospective analysis of HIV+ patients in KP California (11,411) initiating a new ART regimen from 1996-2006.  ARV Naïve:7,597 patients  ARV Experienced:3,814 patients Measured 12 month adherence to ART regimen using pharmacy dispense/refill records Horberg, Hurley, Towner, Allerton, Tang, Catz, Silverberg, Quesenberry, Treatment Adherence Conference, 2011

15. HIV Multidisciplinary Care Team Study (2) Primary Predictor—Exposure to MDCT component by medical center (26): HIV Specialist (y/n) Nurse Case Manager Non-Nurse Care Coordinator Clinical Pharmacist Social Work/Benefits Counselor Dietician Mental Health Other Predictor Variables Age Gender Race/Ethnicity (White, Black, Latino, Other) HIV Risk (MSM, IDU, Heterosexual) HCV+ ART Regimen Class ARV Experienced Year this ART regimen was initiated (temporal trend) Medical Center (cluster variable) Provider (cluster variable) Slide 15

16. HIV Multidisciplinary Care Team Study (3) Classification and regression tree approach (recursive partitioning) to ascertain potential MDCT compositions associated with maximal mean ART adherence (CART Pro 6.0 ®, Salford Systems, San Diego, CA) From above, potential combinations tested in adjusted* mixed linear regression to determine which associated with maximal ART adherence *--Clustering by medical center, provider, patient. Adjusted for ART experience, age, gender, race/ethnicity, HIV risk, HCV+, ART regimen class, temporal trend

17. HIV MDCT Study (4) : Recursive Partitioning * p < 0.05 Multiple team combinations possible with significant effect. First branch is clinical pharmacist.

18. HIV MDCT Study (5) : Teams Determined from RP MDCT below not significantly different between them Team Composition Mean Adjusted Percent Increase Adherence95% Confidence Intervalp Value Specialist Only74.4%72.2-76.8% Clinical Pharmacist Only+3.3%+0.1 to +5.8%0.01 Pharmacist + non- RN care coordinator+8.1%+2.7 to +13.4%0.003 Nurse + Social Work/Benefits+7.5%+5.4 to+9.7%<0.001 HIV Specialist + Mental Health+6.5%+2.6 to +10.4%0.001 Pharmacist + Social Work/Benefits+5.7%+4.0 to +7.4%<0.001 Slide 18

19. CC only p<0.05 RX=clinical pharmacist RNCCCM=nurse case manager CC=non-RN case coordinator SWBC=social work/benefits counselor MH=mental health worker Reference group is HIV specialist only Ref. RNCCM only RNCCM + SWBC RX + SWBC RX only p<0.05 RX + MH RX + CC This Can Be Applied to Other Outcomes– Odds Maximal Viral Control Horberg, Hurley, Towner, Allerton, Tang, Catz, Silverberg, Quesenberry, IAS Abstract MOPE422, 2011

20. CC only p<0.05 RX=clinical pharmacist RNCCCM=nurse case manager CC=non-RN case coordinator SWBC=social work/benefits counselor MH=mental health worker Reference group is HIV specialist only Ref. RNCCM only RNCCM + SWBC RX + SWBC RX only p<0.05 RX + MH RX + CC This Can Be Applied to Other Outcomes– Odds Maximal Viral Control First branch is clinical pharmacist. Different results when stratified by ARV status.

21. Discussion of MDCT Study Results First study to consider all elements of HIV MDCT interactively Clinical pharmacist is significantly associated with adherence improvement  Confirms prior study Multiple combinations (5) are associated with significantly improved adherence  Compared to HIV specialist only Likely some confounding by indication Slide 21

22. Next Research Questions/Steps Test MDCT optimized teams in prospective study  Also in different healthcare systems Do these teams also improve other outcomes?  Accessing Care  Retention in Care  Mortality Who are the key personnel for linkage to care?  Especially in non-integrated care systems What services are not addressed by these teams? Slide 22

23. Thank you! The great work continues. (Paraphrased from Angels in America)