1. Quality Assessment: Primary medical services provided to HIV- infected persons Shazia Kazi, MD, MPH. Baltimore City Health Department Ryan White Title I Office Shahdokht Boroumand, DMD, MPH. National Institutes of Health

2. Background Maryland had the fourth highest annual AIDS case report rate of any state in 2004, 26.1 cases vs. 14.9 cases per 100,000 population nationwide. 1 Baltimore-Towson EMA had the fifth highest rate of any metropolitan area (32.8 cases per 100,000 population) in 2004. 1

3. Ryan White CARE Act The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act is Federal legislation that addresses the unmet health needs of persons living with HIV disease (PLWH) by funding primary medical care and support services. 2

4. Ryan White Care Act Title I Title I of the CARE Act provides resources to metropolitan areas most severely affected by HIV/AIDS. 51 Eligible Metropolitan Areas, or EMAs, receive assistance under Title I. EMAs are defined as areas with: a population of at least 500,000 and at least 2,000 reported AIDS cases in the previous 5 years. 3

5. Quality Improvement Program- RW Title I mandate In accordance with the Ryan White CARE Act Reauthorization 2000, each EMA is mandated to use up to 5% of allocated funds to: 4 Establish a quality management program that assesses the extent to which HIV health services are consistent with the most recent Public Health Service guidelines for the treatment of HIV disease and related opportunistic infections. Develop strategies that ensure such services are consistent with the guidelines for improvement in the access to and quality of HIV health services.

6. Quality Improvement Program Baltimore- Towson Eligible Metropolitan Area Baltimore City Health Department (Grantee) has implemented the Quality Improvement Program (QIP) since FY 2001. QIP assesses/documents the compliance of Ryan White Title I providers in Baltimore in terms of their adherence to Public Health Standards and local Standards of Care. QIP assesses the local Standards of Care, as established by the Greater Baltimore HIV Health Services Planning Council in accordance with the most recent Public Health Service Guidelines for the treatment of HIV disease.

7. Quality Improvement Program Cycle The QIP Cycle for the Baltimore EMA is based on a four-year framework, the first year having been FY 2001. The Primary Medical Care service category was reviewed in FY 2001 and FY 2005, as a component of the four-year QIP cycle related to the continuum of care for PLWH/A. QIP assessment process includes following steps;

8. QIP Process Survey Instrument development Database Development Data Collection Data Entry Data Analysis Report Writing Technical Assistance/Capacity Building

9. Objectives of the Study Assess the effectiveness of primary care programs serving HIV-infected clients within the Baltimore EMA for FY 2004. Evaluate the compliance of Title I medical providers with Public Health Guidelines and Local Standards of Care. Assess the association between frequency of visits by clients and quality of services.

10. Baltimore (Towson) Eligible Metropolitan Area

11. Fourteen (14) providers (hospitals, community clinics, and federally qualified clinics) received Ryan White Title I funding to deliver primary medical care services in FY 2004. 6,269 HIV+ persons received primary medical care services through Ryan White Title I. 5

12. Primary Care Assessment Process Random sample was determined based on guidelines developed by the New York State Health Department, AIDS Institute. 6 A total of 384 primary medical care client charts were reviewed. A survey instrument was developed to collect demographic and medical information as well as to assess the documented compliance of providers to deliver services according to the local Standards of Care.

13. Primary Care Assessment Process- Contd The primary source for the assessment was medical charts that were reviewed for documentation of adherence to minimum requirements. 10 measures were used to assess the quality of primary care. Numerical Scoring was used to code the 10 quality measures of primary care for each client.

14. Minimal Data Variables Required By Primary Care Standards CD4 Count (minimum of twice per year) Viral Load (minimum of twice per year) HAART (Highly Active Retroviral Therapy) Hepatitis B Hepatitis C PPD (Tuberculosis test) PCP- (Opportunistic Infection) MAC- (Opportunistic Infection) Syphilis- (Sexually transmitted infection) Safe-sex Education

15. Definition - Quality Index A reverse scoring methodology was used to develop a numerical index for scoring the quality of care with the lower scores indicating the higher level of documented compliance. ( See Table 1)

16. Table 1: Reverse Scoring ConditionsNumerical Coding If measure met minimum Standard of Care. 0 If measure did not meet minimum Standard of Care. 1 If measure assessed did not meet the minimum Standard of Care due to non-applicability to the client (e.g. client previously treated for TB did not require any TB screening). 0

17. Scoring- Methodology Based on reverse scoring, a total score was calculated for each client based on 10 measures. Each client was placed in one of the three classes:  High-quality (0-1)  Medium-quality (2 thru 4)  Low-quality (5 thru 10)

18. Results- Characteristics of Study Population Mean Age (SD) Min Age Max age 40.7 yrs (9.8) 14.6 yrs 63.1 yrs Gender Male Female 58.9 % 41.1 % Race African-American White Other 80.2% 12% 7.8% Risk Factor Hetrosexual IDU MSM Heterosexual & IDU 36.6% 24% 16.4% 5.2%

19. Residential Distribution of Clients in Baltimore EMA

20. Results Only 32% of all client charts were in the high quality category, in which 9 or 10 measures were met and documented according to the minimum requirements of the local standards of care. 22% of total client charts were in the low quality category, in which only 5 or fewer of the 10 measures were met and documented according to minimum requirements of local standards of care.

21. Quality Categories

22. Results The three quality classes were collapsed into two categories (high vs. non-high) to generate a binary variable. The moderate and low scoring classes were consolidated into the “non-high” category. No significant difference was found between the demographic characteristics of the study population and the quality of primary care services using Pearson Chi Square test & Logistic Regression analysis.

23. Results Number of visits is highly associated with quality of primary care services (using the binary quality variable) Quality of Primary Care Services High (0-1)Non-High (2-10)Total Number of Visits 10 (0%)56 (21.5%)56 (14.6%) 237 (30.1%)78 (29.9%)115 (30%) 386 (69.9%)127 (48.7%)213 (55.5%) Total123 (100%)261 (100%)384 (100%) Fisher’s exact p value < 0.0001 Pearson chi square p value < 0.0001

24. Boxplot showing number of visits vs. quality of care 0 10 123 The box-plot graphs show the range of the quality scores for clients. The box-plot shows 25, 50 & 75 percentile of clients having 1, 2 & 3 visits. The median as well as maximum and minimum scores can be seen for each visit category. Quality of Care Number of Visits

25. Conclusion Proactive efforts should be made at the provider level to assess and remove the barriers that prevent the clients from seeking care on a regular basis. Emphasis should be made on complete documentation in the client charts per the minimum requirements of the Standards of Care. Ongoing Technical Assistance should be made available to providers to relate the minimum expectations for service delivery and documentation compliance.

26. Acknowledgements This poster exhibition was possible with the support and contributions from my colleagues. I would like to thank them for their assistance. Richard Matens, M.Div. Ralph Brisueno. Jesse Ungard, MA. Alberta. Lin. Ferrari, MD.

27. References 1. Centers of Disease Control and Prevention. HIV/AIDS Surveillance Report 2004;16:27-30;32-33. 2. HRSA (Health Resources and Services Administration) http://hab.hrsa.gov/history.htm [accessed September 13,2006]. http://hab.hrsa.gov/history.htm 3. HRSA (Health Resources and Services Administration). The AIDS Epidemic and the Ryan White Care Act. Past successes + future challenges. 2004. 4. The Ryan White Care Act: A Compilation of The Ryan White Care Act of 1990 [Pub.L.101-381], as amended by the Ryan White Care Act Amendments of 1996 [Pub.l.104-146] and The Ryan White Care Act amendments of 2000 [Pub.L.106-345]. 5. Associated Black Charities, Title I Administrative Agent, FY 2004 Unduplicated Client Level Data. 6. AETC (AIDS Education Training Centers) New York State Department of Health AIDS Institute. Measuring Clinical Performance: A Guide for HIV Health Care Providers. 2002