Maintaining the continuity of HIV-care records for patients transferring care between centers: Challenges, workloads, needs and risks

With improved life expectancy, the medical records of HIV-infected patients are likely to be transferred repeatedly between HIV caregivers. The challenges, and risk for introducing medical error from incomplete record transfers are poorly understood. 

We measured number of requests for record transfer, the workload incurred, and explore, using genotypic antiretroviral resistance testing results (GART), the potential risk of incomplete records. Using retrospective database and chart review, we examined all patients followed at the Southern Alberta Clinic between 1 January 2004 and 1 January 2015, and determined how many patients transferred care into and out our program, the associated requests and the workload for record transfer. Using a complete record of all GART tests, the potential importance of absent historic records in current treatment decisions was analyzed. 

The annual churn rate was 22 ± 3.4%. We received requests for only 70% of patient records who had left our care. Median time for receipt of incoming medical records was 28 days; average clerical time for processing data was 2 hours/record. Of all GART results, 25% exhibited resistance. Of 111 patients with potentially misleading GART results (i.e., documented historical resistance not visible on more recent GART), 34 (30.6%) had moved in from elsewhere. Rigorous maintenance of the continuity of the HIV record is not universally practiced. 

Resources, costs and logistic challenges as well as a lack of appreciation of risks clearly shown by GART testing, may be relevant barriers. Addressing such issues is pressing as aging and transfers of care are increasingly common.

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By:  Gill MJ1,2,3, Ody M1, Lynch T1,4, Jessiman-Perreault L1, Krentz HB1,2.

• 1 Southern Alberta HIV Clinic, Alberta Health Services , Calgary , Canada.
• 2 Department of Medicine , University of Calgary , Calgary , Alberta , Canada.
• 3 Department of Microbiology , Immunology, and Infectious Diseases, University of Calgary , Calgary , Canada.
• 4 Department of Pathology and Laboratory Medicine , University of Calgary , Calgary , Canada.
• AIDS Care. 2016 Feb 1:1-6. 

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Do “Virtual” and “Outpatient” Public Health Tuberculosis Clinics Perform Equally Well? A Program-Wide Evaluation in Alberta, Canada

Background

Meeting the challenge of tuberculosis (TB) elimination will require adopting new models of delivering patient-centered care customized to diverse settings and contexts. In areas of low incidence with cases spread out across jurisdictions and large geographic areas, a “virtual” model is attractive. However, whether “virtual” clinics and telemedicine deliver the same outcomes as face-to-face encounters in general and within the sphere of public health in particular, is unknown. This evidence is generated here by analyzing outcomes between the “virtual” and “outpatient” public health TB clinics in Alberta, a province of Western Canada with a large geographic area and relatively small population.

Methods

In response to the challenge of delivering equitable TB services over long distances and to hard to reach communities, Alberta established three public health clinics for the delivery of its program: two outpatient serving major metropolitan areas, and one virtual serving mainly rural areas. The virtual clinic receives paper-based or electronic referrals and generates directives which are acted upon by local providers. Clinics are staffed by dedicated public health nurses and university-based TB physicians. Performance of the two types of clinics is compared between the years 2008 and 2012 using 16 case management and treatment outcome indicators and 12 contact management indicators.

Findings

In the outpatient and virtual clinics, respectively, 691 and 150 cases and their contacts were managed. Individually and together both types of clinics met most performance targets. Compared to outpatient clinics, virtual clinic performance was comparable, superior and inferior in 22, 3, and 3 indicators, respectively.

Conclusions

Outpatient and virtual public health TB clinics perform equally well. In low incidence settings a combination of the two clinic types has the potential to address issues around equitable service delivery and declining expertise.

Below:  TB Prevention and Care Program of Alberta: The organization of TB services in the Province of Alberta, Canada

Below:  The age- and sex-adjusted incidence of tuberculosis in Alberta, 1989–2013: The age- and sex-adjusted incidence of TB in Alberta over the 25 years 1989–2013 was estimated in three population groups: Registered or Status Indians (SI), the foreign-born (FB) and Canadian-born ‘Others’ (CBO). The population estimates used in the analysis were derived from Canadian censuses conducted in 1986, 1991, 1996, 2001, and 2006. [5] After 2006 the long form of the Canadian census, which had previously estimated the foreign-born population by age and sex, was discontinued. However, it was noted that in 2001 and 2006 the proportion of the population, other than Status Indians, that was foreign-born by 5-year age and sex grouping, was relatively constant. Accordingly, the foreign-born population in 2011 was calculated on the basis of the proportions in 2006. Inter-censal estimates were estimated using linear interpolations between censuses; estimates from 2012 and 2013 were obtained by linear extrapolation. Adjustment of rates was carried out using the direct method with the total Alberta population as the reference population. The three-clinic model began in 1999; see red arrow.

Full article at:   http://goo.gl/lOQh49

By:   

Richard Long, Courtney Heffernan, Mary Lou Egedahl

Faculty of Medicine and Dentistry, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada

Richard Long, James Talbot

School of Public Health, University of Alberta, Edmonton, Alberta, Canada

Zhiwei Gao

Clinical Epidemiology Unit, Department of Medicine, Memorial University, St. John’s, Newfoundland, Canada

James Talbot

Alberta Health Province of Alberta, Edmonton, Alberta, Canada

  

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The Impact of Non-Antiretroviral Polypharmacy on the Continuity of Antiretroviral Therapy (ART) among HIV Patients

Improved survival achieved by many patients with HIV/AIDS has complicated their medical care as increasing numbers of co-morbidities leads to polypharmacy, increased pill burdens, and greater risks of drug–drug interactions potentially compromising antiretroviral treatment (ART). We examined the impact of non-antiretroviral polypharmacy on ART for all adults followed at the Southern Alberta Clinic, Calgary, Canada. Polypharmacy was defined as ≥5 daily medications. 

We compared the impact of polypharmacy on continuous (i.e., remaining on same ART for ≥6 months) vs. non-continuous (i.e., discontinuing or switching ART) ART dosing frequency, number of ART pills, number of non-ART medications, and age. Of 1190 (89.5%) patients on ART, 95% were on three-drug regimens, 63.9% on QD ART, and 62% ≥3 ART pills daily; 32.2% were experiencing polypharmacy. Polypharmacy was associated with lower CD4, AIDS, >180 months living with HIV, higher numbers of ART pills, and older age; 32.1% stopped or switched ART. Polypharmacy increased the risk for non-continuous ART (36.8% vs. 30.0%; p < 0.01). Non-continuous ART increased with daily ART pill count but not increased age. Non-adherence and adverse effects accounted for the majority of non-continuous ART. 

We found a strong association between polypharmacy and non-continuous ART, potentially leading to effective ART being compromised. Collaborative approaches are needed to anticipate the negative impacts of polypharmacy.

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By: Hartmut B. Krentz, PhD,^1,2 and M. John Gill, MB, ChB^1,2

¹Southern Alberta Clinic, Calgary, Alberta, Canada.

²Department of Medicine, University of Calgary, Calgary, Alberta, Canada.

  

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Primary Healthcare Needs & Barriers to Care among Calgary’s Homeless Populations

Despite Canada’s universal healthcare system, significant barriers impede individuals experiencing homelessness from accessing health services. Furthermore, there is a paucity in the qualitative literature describing how Canadians experiencing homelessness access health care services. Our objective was to qualitatively explore perceived healthcare needs and barriers among individuals experiencing homelessness in one large Canadian city – Calgary, Alberta.

We conducted a qualitative descriptive study that included open-ended interviews and focus groups with a variety of stakeholders who are involved in healthcare among Calgary’s homeless populations. These included individuals experiencing homelessness (n = 11) as well as employees from several healthcare service providers for those experiencing homelessness (n = 11). Transcripts from these interviews were thematically analyzed by two analysts.

Stakeholder interviews yielded several pervasive themes surrounding the health care needs of the homeless and barriers to accessing care. Some of the primary health care needs which were identified included mental health, addictions, and allied health as well as care that addresses the social determinants of health. Notably, it was difficult for many stakeholders to pinpoint specific health care priorities, as they identified that the health care needs among Calgary’s homeless populations are diverse and complex, often even describing the needs as overwhelming. Types of barriers to primary care that were identified by stakeholders included: emotional, educational, geographical, financial and structural barriers, as well as discrimination.

Our findings highlight the diverse primary health care needs of Calgary’s homeless populations. Despite the fact that Canada has a universal publicly funded health care system, individuals experiencing homelessness face significant barriers in accessing primary care.

Full article at: http://goo.gl/bShd8n

By: David J. T. Campbell^1*, Braden G. O’Neill², Katherine Gibson³ and Wilfreda E. Thurston⁴

¹Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Room G236 Health Sciences Centre, 3330 Hospital Dr NW, Calgary T2N 1 N4, AB, Canada

²Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

³1 Canadian Field Hospital, Canadian Armed Forces, Petawawa, ON, Canada

⁴Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

  

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Wait Time To What? Could Reducing Wait Times for Child Mental Health Services Worsen Outcomes?

Below: Theoretical pathways linking shortened wait times to different clinical outcomes

Addressing wait times for health interventions is a Canadian priority (Mendelsohn, 2002). In response, multiple wait time reduction initiatives have been launched. Chief among these is a key component of the federal-provincial “10-year Plan to Strengthen Health Care” (Health Canada, 2006) with associated monitoring to track progress in priority areas (Canadian Institute for Health Information, 2014). While mental illness was not one of the five priority areas (cancer care, cardiac care, diagnostic imaging, joint replacement, and sight restoration) identified in this initiative, mental illness has been designated in some priority lists, with some including a focus on children. A case in point exists in Alberta whereby children’s mental health was identified as one of six priority areas for access standards which led to child wait time benchmark recommendations (Access Standards Working Group Children’s Mental Health Subcommittee, 2009) and a performance indicator of percent of children receiving scheduled mental health treatment within 30 days (Government of Alberta, 2014). Unfortunately, reports of clinical outcomes from child mental health service wait time reduction initiatives seem nonexistent despite potential benefits and harms...

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