Barbara McInnis House
461 Walnut Avenue
Boston, Massachusetts 02130
Contact: Joan Lebow, MD (617) 625-8900
x2424
or Catherine Graziani (617) 522-7080
x163
Key words: HIV/AIDS; antiretrovirals;
PCP prophylaxis; adherence
This
study describes a homeless population
with HIV in Boston, the patterns of
treatment with Antiretrovirals treatment
and Pneumocystis Carinii Pneumonia (PCP)
prophylaxis and the resultant values
of the CD4 and HIV Ribonucleic Acid
(RNA) viral load (HVL) using the electronic
medical record (EMR) as a tool. In addition,
a determination of the number of clinic
visits and levels of charting preventive
health measures was done to help in
evaluating the system of care for this
population.
METHODS
Study Sample A retrospective review
of the encounters of 5,976 unique individuals
entered in the EMR from May 1, 1996
through May 31, 1997 was done to determine
the number of individuals with HIV infection
seen by the Boston Health Care for the
Homeless Program (BHCHP). One hundred
and eighty-eight patients had one of
four possible HIV related diagnoses:
AIDS, HIV+ symptomatic, HIV+ asymptomatic,
or HIV positive. A description of the
demographics and benefits was done on
the total group and a comparison made
between those getting primary care from
BHCHP versus a provider outside the
BHCHP network. Clinical data such as
stage of infection, associated co-morbidities,
Antiretrovirals treatment, CD4 counts
and HVL testing was only obtained on
the 84 patients for which BHCHP was
the primary care provider (BHCHP/PCP
cohort). Antiretrovirals Treatment and
Laboratory tests --CD4 and HIV RNA Viral
Load (HVL) All Antiretrovirals medications
and the date that they were started
were recorded for the BHCHP/PCP cohort.
Baseline CD4 counts and HVL were recorded
and defined as the counts prior to starting
medications or the first CD4 count recorded
during the observation period. The follow-up
CD4 counts and HVL were obtained and
defined as the count that occurred after
a change in a medication regimen. The
comparison and follow-up CD4 counts
were compared for three groups: those
who were treated with three medications,
those treated with one or two, and those
who were not started on any medications.
Not all patients had both CD4 and HVL
baseline and follow-up data. This evaluation
was done only on the patients who had
all four data points. Length of Follow-up
and Number of Visits A comparison was
made of the length of follow-up, number
of visits per patient, location of visits
between the BHCHP/PCP outreach sites
for the other homeless cohort.
Process Indicators
There was wide variability on the documentation
rates of the following preventive health
measures not documented in the EMR:
syphilis testing (36 percent); PPD_s
(46 percent); PAP smears (28 percent);
and adult vaccinations, specifically
Pneumovax and influenza (56 percent),
and Hepatitis B or C (37 percent). Eighty-two
percent of patients with CD4 counts
less than 200/Fl, were placed on either
Bactrim, Dapsone, Aerolized Pentamindine,
or atovaquone.
Client Level Outcomes
Of the 84 HIV positive homeless patients
whom BHCHP clinicians managed, 30 were
treated with combination therapy that
included three drugs. In the triple
drug group there was an increase in
CD4 count of 69 cells/Fl and decrease
in HVL of 0.72 log10 in the 25 who had
both baseline and follow-up labs recorded.
The suppression of viral load lasted
an average of 210 days and 52 percent
had complete suppression with HVL levels
undetectable. Improvement was also noted
in those treated with one or two medications,
all of which were nucleoside reverse
transcriptase inhibitors, but not to
the same degree (CD4 increase of 37
cells/Fl and HVL decrease 0.55 log10).
Twenty-nine patients under the care
of BHCHP were not treated with any antiretrovirals.
Some of these patients were in a category
where it is clinically appropriate to
monitor without initiation of medications
cohort and those followed by another
primary care provider, and those with
no designated PCP. For analysis of visit
history, the total group was divided
into three subgroups: the BHCHP/PCP
cohort, other PCP Homeless cohort (n=88),
and unknown PCP Homeless cohort(n=18).
Evaluation was done to determine the
frequency and sites where patients were
seen. Preventive Health Measures An
assessment of the quality of data entered
into the EMR was done by determining
the rate of documentation of tests or
procedures that included rapid plasma
reagent (RPR), TB skin test and influenza
vaccination annually, PAP biannually,
and Pnuemovax and antibody screen for
hepatitis B and C once. If there was
not any entry in these fields in the
database, the result was recorded as
_not documented._ The PCP is recommended
for those with CD4 count < 200/Fl,
unexplained fever for greater than 2
weeks, or a history of oropharyngeal
candidiasis. For purposed of this study
we looked at only those with CD4 counts
< 200/Fl.
Demographics
Of the 188 homeless persons (total group),
84 had a physician or nurse practitioner
from BHCHP identified as their primary
care provider (BHCHP/PCP cohort), 86
had a physician from another practice
or hospital, and 18 had no provider
identified (other homeless cohort).
There was no significant difference
between the sex or race of the BHCHP/PCP
cohort and all others, but there was
a difference in the age (p<0.01),
with the BHCHP/PCP cohort older evidenced
by 92 percent greater than 41 years,
whereas the other homeless cohort having
only 38 percent in this range. Nearly
70 percent of the BHCHP/PCP cohort had
Medicaid. There were 20 persons in the
BHCHP/PCP cohort who had either no insurance
or had no documentation. Of this group,
11 were placed on Antiretrovirals medications
which were either paid for by Medicaid
or via the HIV Drug Assistance Program
(HDAP). Patient Characteristics The
BHCHP/PCP cohort had 57 percent with
an AIDS diagnosis. Of the 48 persons
with AIDS, 52 percent was based on the
CD4 count being less than 200, the rest
had either an opportunistic infection
(40 percent), cancer (4 percent), and/or
dementia (2 percent). Over 80 percent
of the BHCHP/PCP cohort had a history
of substance abuse, and 44 percent had
a DSM-4 Axis I diagnosis. Dual diagnosis
of both substance abuse and mental illness
occurred in 40 percent. All but four
of the persons with a mental illness
had a history of substance abuse. Three
persons died during the 17 month observation
period. It is unknown if the cause of
death was a direct result of the HIV
or for some other reason.
Medication History
| |
At
Baseline n=84 |
At
End n=84 |
Num.
With
both |
Mean
Change
in CD4 |
Mean
Change
in HVL |
Num
days
HVL change |
Zero
Meds* |
64
|
29 |
9 |
+17 |
-0.02 |
169 |
1
or 2
Meds |
17 |
25 |
15 |
+37 |
-0.55 |
177 |
| 3
Meds |
3
|
30**
|
25
|
+67
|
-0.72 |
211 |
*Meds- the number of Antiretrovirals
medications
**28 of the group had at least one protease
inhibitor
Of the 29 patients in the cohort who
were never placed on Antiretrovirals
therapy, six refused treatment, six
had both CD4 counts greater than 500/Fl
and HVL less than 5000 cop/ml. The average
number of visits was 9.1 for this group
(0meds), but despite frequent contact,
only nine had both baseline and follow-up
lab values.
The mean change in CD4 count and HVL
was compared was calculated for each
subgroup based on the final number of
medications to determine the effect
on Antiretrovirals interventions.
Patient Visits and Length of
Follow-up
The average number of visits
for the total group was 8.67 during
the observation period. The average
number of visits for the BHCHP/PCP cohort
was 14.17, those followed by another
provider 4.64, and without a known provider
2.28. The majority of visits for the
BHCHP/PCP cohort was performed in a
hospital based primary care site, with
only 22 percent of the visits done at
an outreach site. Whereas, 72 percent
occur in the outreach sites for the
other homeless cohort. Process Indicators
There was a range of 36 percent to 56
percent of preventive health measures
not documented in the EMR: syphilis
testing (36 percent), PPDs (46 percent),
PAP smears (28 percent), and adult vaccinations
specifically Pneumovax and influenza
(56 percent), Hepatitis B or C (37 percent).
Eighty-two percent of patients with
CD4 counts less than 200/Fl were placed
on either Bactrim, Dapsone, AP, or atovaquone.
DISCUSSION
Client Level Outcomes
Of the 84 HIV positive homeless patients
whom BHCHP clinicians managed, 30 were
treated with combination therapy that
included three drugs. In the triple
drug group there was an increase in
CD4 count of 69 cells/Fl and decrease
in HVL of 0.72 log10 in the 25 who had
both baseline and follow-up labs recorded.
All but two patients were treated with
a protease inhibitor, the others with
one non-nucleoside reverse transcritase
inhibitor and two nucleoside reverse
transcriptase inhibitors. The suppression
of viral load lasted an average of 210
days and 52 percent had completed suppression
with HVL levels undetectable.
Improvement was also noted in those
treated with one or two medications,
all of which were nucleoside reverse
transcriptase inhibitors, but not to
the same degree (CD4 increase of 37
cells/Fl and HVL decrease 0.55 log10).
Twenty-nine patients under the case
of BHCHP were not treated with any anti-retrovirals.
Some of these patients were in a category
where it is clinically appropriate to
monitor without initiation of medications
because baseline CD4 was greater than
500 cells/Fl and HVL less than 5000
cop/ml, and some refused therapy. Others
appear to meet the criteria for initiation
of treatment but were not started despite
frequent contact with a clinician. It
is unclear why the remainder were not
started on medications. Eleven had only
one documented CD4 count, 22 with only
one HVL. This would suggest that this
subpopulation may have been getting
disjointed care and would not be good
candidates for therapy. It is probably
to the patient_s benefit not to be started
on a complex medical regimen before
they have committed to close follow-up
and frequent monitoring. An important
limitation of this study is that only
patients followed by BHCHP were monitored
for medications interventions and laboratory
data. Therefore, the results may be
biased toward those who are receiving
care from a specialized system of care
designed specifically for the homeless.
This study also did not evaluate compliance
with use of the medications. A prospective
study of HIV in the homeless population,
monitoring the outcomes and compliance
with medication regimens of a broader
group of patients would be necessary
to determine the best course of treatment.
System Level Outcomes
The BHCHP/PCP cohort were seen an average
of 14.1 visits per patient over a 17
month period. Despite frequent contact,
there is evidence that care was chaotic.
Only 49 of the patients had at least
two points measured of both the CD4
and HVL, before and after initiation
of Antiretrovirals treatment, despite
evidence that 55 had medications started.
A closer look at the location of visits
was done to try to explain this phenomenon.
It does not seem that site location
was a primary reason for disrupted care
as 78 percent of the visits occurred
in the Imuno-Deficiency Clinic or Homeless
Clinics at both Massachusetts General
Hospital and Boston Medical Center,
the only sites within the BHCHP network
where these laboratory tests can be
obtained. Other possible reasons for
this lack of continuity are: a) Patients
who were not placed on any medications
were proportionally less likely to have
laboratory monitoring implying a self-selection
of patients into treatment regiments;
and b) Disjointed clinical systems within
the broader BHCHP system. Further evaluation
would benefit both homeless patients
and the BHCHP network. Accessing results
of preventive health measures is easily
done using the EMR. This baseline information
is helpful for setting standards for
the future. Similar to paper charts,
it is not clear if these tests are not
being done or not being documented.
As with any measurement of quality,
it is important to have agreement among
providers as to what is an acceptable
standard and provide feed back on a
frequent basis on how well they are
abiding to the standards.
Adherence is a valid concern not only
for the homeless but for the most motivated
and educated patients. This being said,
the benefit of improved CD4 counts and
decreased HVL in the BHCHP/PCP cohort
treated with a three-drug regimen is consistent
with findings in other cohorts and suggests
that more homeless patients should be
placed on aggressive combination treatment.
Though there are a number of complex factors
involved in treating the HIV infected
homeless patient, every effort should
be made to increase the likelihood of
compliance by developing systems of care
that are unique to the population. The
EMR was shown to be a valuable tool in
assessing the BHCHP system of care. It
allowed for determination of the overlap
of care provided to non-BHCHP patients,
to identify patients who were lost to
follow-up, and those who were intermittently
or not engaged at all. The EMR allowed
quick assessment of the level of charting
of routine preventive health measures.
The merit of the EMR is enhanced when
there are rewards and feedback to the
providers using it, particularly if it
imbibes a sense of improvement in the
overall provision of patient care.
