the association between ancillary services and clinical and healthcare utilization outcomes for hiv-...

The Association between Ancillary Services and Clinical and Healthcare

Utilization Outcomes for HIV-Infected Children

Pediatric AIDS Clinical Trials Unit Meeting

New Orleans, Louisiana 25 April 2001

AuthorsManya Magnus, Norine Schmidt,

Barbara Brown, and Patricia Kissinger for the FACES Program at Children’s

Hospital, New Orleans

Acknowledgements

The authors gratefully acknowledge the staff and clients at FACES and HOP for their assistance.

A special thanks to FACES volunteer Joe Park, who

contributed enormously to the collection of additional data regarding ER and hospital visits.

The data for this study were collected as part of the

Health Resources and Services Administration (HRSA) grant number 250-OA-13(8); the analyses were supported under HRSA contract number 98-0702(P).

Introduction Evaluation of the association

between ancillary services and clinical outcomes entry and retention into health care

This study performed under a HRSA contract as an extension of an existing comprehensive evaluation plan at FACES

Description of FACES Located in metropolitan New Orleans The only provider of comprehensive

ancillary services to HIV-infected women and children in the area

The majority of the program’s clients are low-income and from minority groups

Provides a wide range of clinical and supportive services to clients

Services provided by FACES include intensive case management home visits transportation services referrals for financial assistance referrals for housing assistance mental health counseling substance abuse counseling psychosocial support crisis management medications not covered by other sources

Services, continued child care respite care activities for children developmental assessments and interventions concrete items (e.g., formula, diapers, etc.) funeral assistance vocational employment and coordination referrals for legal assistance health education peer education/counseling community advisory board

Background Ryan White Care Act

Provides support for approximately 500,000 people infected or affected by HIV/AIDS who lack insurance or are underinsured

RWCA funds services through “titles”

Received $1.4 Billion in funding for fiscal year 1999; administered by HRSA

Soon up for re-authorization

Background

Competitive contract

Eight sites awarded

Only one other maternal-child site

Study completed in January 2000

Research question

What is the association between ancillary services, clinical outcomes, and entry and retention into health care?

Research question

Neediest clientsleast likely to have positive outcomes & most likely to use services

Clients with fewer needsfewer servicesbest outcomes

Time

Databases set up to track services and not outcomes

Research question

Common problems in evaluation/outcomes research

Prospective studies best

Better study designs: pre-post design, randomized trials

Ethical issues

Study Design

Retrospective

Used existing data sources

Study period from 1/1/97 through 12/31/98

Longitudinal, individual-level data

Methodology Component I Component II Component III

comparative descriptive descriptive

Women who receive FACES services and

attend HOP

Women who receive FACES services and

attend HOP Children who receive FACES services and

attend HOP vs.

Women who attend HOP only

Inclusion criteria: Women of childbearing age who enrolled in HOP and FACES between 1/ 1/ 97 and 12/ 31/ 98 were included (new clients)

Inclusion criteria: Women enrolled in FACES between 1/ 1/ 97 and 12/ 31/ 98 Enrolled in HOP at any time

Inclusion criteria: Children (0-13 yrs.) who received any FACES service between 1/ 1/ 97 and 12/ 31/ 98 Enrolled in HOP at any time

N=155 at baseline N=198 at baseline N=42 at baseline

Data Sources

Association between ancillary

services an outcomes

Data Analysis

Univariate and bivariate analyses

Multivariate analysis with Generalized Estimating Equations (GEE)

Stata software (College Station, Texas) was used for all analysis

Bonferonni correction (=0.006)

Data Analysis Difficulty in using frequency of contacts as proxy

for need

To adjust for the confounding effect of need, a dynamic needs adjustment factor was developed

The needs adjustment factor (NAF) included clinical, behavioral, and social stressors and was re-calculated for each six-month interval

The needs adjustment factor was included in the multivariate analysis, along with other confounders

EligibilityTo be eligible for this study, the child had

to:

Be HIV-infected Have received at least one FACES

service during the study period Receive medical care within the

MCLNO system

Results 58 children eligible from FACES

10 (17%) excluded due to no clinical data available during study period

6 (10%) excluded due to not being seen within MCLNO system

42 (72%) children included in study

Selected Baseline Characteristics of FACES

Children (N=42)Characteristic Percent

1 to 5 years old 50

African-American 88

Perinatally infected 98

Permanent housing 86

Primary caregiver 64

No immune suppression (Cat. 1) 62

Use of ARV treatment (any) 83

On study 33

Percentage of Children Utilizing FACES Services (N=42)

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Results*

Number of services received:

Receipt of more than one transportation service per month was associated with the development of moderate or severe immune suppression

OR 4.31, 95% CI 1.98-9.35, p<0.0001

*all ORs are adjusted for age, NAF (calculated for particular outcome) (including immune status), length of time enrolled in primary care and FACES.

ResultsReceipt of any versus no:Ancillary service was associated with:

more than 75% adherence with required appointments

OR 4.35, 95% CI 1.85-10.00, p<0.006

improved retention OR 8.28, 95% CI 2.04-33.60, p<0.006

ResultsReceipt of any versus no:Transportation service was associated with:

Being prescribed an antiretroviral treatment OR 13.55, 95% CI 6.25-29.42, p<0.006

having one or more ER visit per monthOR 6.71, 95% CI 2.35-19.18, p<0.006

ResultsReceipt of any versus no:Case management contact was

associated with:

having no ER visits per monthOR 4.76, 95% CI 1.64-14.29,

p<0.006

ResultsReceipt of any versus no:Neurodevelopmental service was associated

with:

being prescribed a protease inhibitorOR 4.86, 95% CI 1.59-14.81, p<0.006

having one or more ER visit per monthOR 6.09, 95% CI 1.92-9.32, p<0.006

Results Number of contacts varied by the level

of client needs. Children with higher levels of need Received more services overall per

month (mean 3.63 vs. 2.26, p<0.05) Received more transportation

services per month (mean 0.86 vs. 0.26, p<0.001)

than those with lower levels of need

A thorn in the side…

What about the finding of increased increased ER visits???

Additional Analyses

Additional data were collected to further explore the association between ER visits and hospital visits, and ancillary services

Methods A FACES volunteer abstracted data on

all ER and hospital visits analyzed in Component II

Discharge diagnoses for each visit were recorded in narrative form and then coded as one of the following categories:

MethodsVisits were coded as:

acute HIV-related

non-acute HIV-related

acute non-HIV-related

non-acute non-HIV-related

Results

There were 24 ER visits:• 3 (13%) resulted in a hospital admission• 2 (8%) were HIV-related but not acute• the remainder (79%) were HIV-related

or -unrelated acute and necessary

Discussion Ancillary services are associated with

improved retention and several improved clinical outcomes for high-risk, HIV-infected children

Children receive appropriate changes in services as needs change suitable allocation of resources

Limitations Sample size Selection bias

selection for services referral patterns available medical records

Retrospective design Use of secondary data Lack of control group Some social services are available from multiple

sources besides FACES Blurring of maternal and child service receipt Complex needs -- difficult to quantify stressors

Strengths One of few evaluations of HIV- and

child-specific ancillary service programs

Longitudinal analysis with individual-level data

Needs adjustment factor adjusts for changing needs in a dynamic fashion

For more information...

Please contact FACES at 504-821-4611

or email manyadm@tulane.edu

Please accept our thanks for your attention.