Adherence, Assessment and Counseling

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		Performance Measure
		Numerator
		Denominator
		Patient Exclusions
		Data Element
		Data Sources
		National Goals, Targets or Benchmarks for Comparison
		Outcome Measures for Consideration
		Basis for Selection and Placement in Group 2
		US Public Health Service Guidelines
		References/Notes

Percentage of clients with HIV infection on ARVs who were assessed and counseled [ 1, 2 ] for adherence two or more times in the measurement year.

Number of HIV-infected clients, as part of their primary care, who were assessed and counseled for adherence two or more times at least three months apart.

Number of HIV-infected clients on ARV therapy who had a medical visit with a provider with prescribing privileges [ 3 ] at least once in the measurement year.

1. Patients newly enrolled in care during last six months of the year
2. Patients who initiated ARV therapy during last six months of the year

1. Is the client HIV-infected? (Y/N)
   1. If yes, was the client on ARVs?(Y/N)
      1. If the client was on ARVs, did he/she receive adherence counseling during the measurement year? (Y/N)
         1. If yes, list the quarters of these visits.

• Electronic Medical Record/Electronic Health Record
• CAREWare, Lab Tracker, or other electronic data base
• HIVQUAL reports on this measure for grantee under review
• Medical record data abstraction by grantee of a sample of records

IHI Goal: 90% [ 4 ]

National HIVQUAL Data [ 5 ]

	2003	2004	2005	2006
Top 10%	95.8%	92.0%	97.5%	98.4%
Top 25%	82.7%	79.2%	88.3%	91.6%
Mean*	57.5%	39.7%	46.8%	55.7%

*from HAB data base

• Percent of undetectable viral loads among patients on ARV in the measurement year
• Percent of patients with ARV-resistance developed during therapy in the measurement year
• Mortality rates
• Incidence of HIV-related hospitalizations in the clinic population
• Incidence of clients with progression to AIDS in the clinic population

"Adherence is a key determinant in the degree and duration of virologic suppression. Among studies reporting on the association between suboptimal adherence and virologic failure, nonadherence among patients on HAART was the strongest predictor for failure to achieve viral suppression below the level of detection. HIV viral suppression, reduced rates of resistance, and improved survival have been correlated with high rates of adherence to antiretroviral therapy.

Prior to writing the first prescriptions, clinicians need to assess the patient's readiness to take medication. Patients need to understand that the first regimen is the best chance for long-term success. Resources need to be identified to assist in success. Interventions can also assist with identifying adherence education needs and strategies for each patient." [ 6 ]

Measure reflects important aspect of care that impacts HIV-related morbidity and focuses on treatment decisions that affect a sizable population. Although discussions of the importance of adherence to ARVs is important to begin prior to initiation of treatment, there is no standard of care for discussions to occur every 6 months for patients who may be years away from ARV treatment.

"...adherence counseling and assessment should be done at each clinical encounter" (10/10/06) . [ 7 ]

[1] Assessment of adherence includes: 1) patient reports of adherence by: a) quantifiable scales, e.g. missed 3 out of 10 doses; b) qualitative scale, e.g. Likert scale; or 2) quantification such as pharmacy dispensing records, pill counts or direct observation therapy.

[2] Adherence counseling can be provided by any member of the multidisciplinary primary care team.

[3] A "provider with prescribing privileges" is a health care professional who is certified in their jurisdiction to prescribe ARV therapy.

[4] IHI Measure reads, " Percent of Patients/Clients Assessed for Adherence to Antiretroviral (ARV) Therapy in the Past 4 Months"
(http://www.ihi.org/IHI/Topics/HIVAIDS/HIVDiseaseGeneral/Measures/PercentofPatientsClientsAssessedfor
AdherencetoAntiretroviralARVTherapyinthePast4Months.htm)

[5] (http://www.hivguidelines.org/admin/files/qoc/hivqual/proj%20info/HQNatlAggScrs3Yrs.pdf)

[6] Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
[April 7, 2005] (http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL04072005001.pdf)

[7] Ibid.