# Presentation: 669407

## Identifying Treatment Challenges and Highlighting Collaborative Opportunities to Improve Care for Veterans with HIV/AIDS or Hepatitis 

- S. Randal Henry, DrPH, MPH
- Amy Justice, MD
- Steven Wright, PhD
- Susan Zickmund, PhD
- Hildi Hagedorn, PhD
- Henry Anaya, PhD

## Agenda/Speakers

- Speakers
- Randal Henry, DrPH, MPH		10 Minutes
- Amy Justice, MD			15 Minutes
- Steven Wright, PhD			15 Minutes
- Susan Zickmund, PhD		10 Minutes
- Hildi Hagedorn, PhD			10 Minutes
- Henry Anaya, PhD			10 Minutes
- Question and Answer Session	20 Minutes

**Notes:**
The workshop will consist of three speakers and a panel of three respondents.  
Dr. Henry will discuss the growing health disparity in the area of HIV/AIDS and the impact of HIV infection upon racial and ethnic minorities. 
Amy Justice is the Principal Investigator (PI) of the Veterans Aging Cohort Study, a longitudinal cohort of veterans with and without HIV infection of which more than half are men of color.  She will address the role of co-morbidity in determining outcome disparities among those with chronic viral infections (HIV or HCV).” 
Steven Wright is the Director of Epidemiology for the Office of Quality and Performance.  He will discuss methods of assessing health disparities and opportunities for operations and research to collaborate in evaluating the effect of quality improvement efforts on reducing health disparities.  
Respondents include: (1) Susan Zickmund, Co-Chief of Qualitative Research, Veterans Health Administration, Center for Health Equity Research and Promotion.  Her research focuses on disparities in HCV care and treatment. 
Hildi Hagedorn, Implementation Research Coordinator, QUERI-Substance Use Disorders.  Her work focuses on the integration of services for hepatitis infections into substance use disorders treatment. 
Henry Anaya’s research focuses on increasing early identification of HIV among homeless veterans.  The panelists will respond to the speakers and explore collaborative research opportunities to improve quality.

## Objectives

- This workshop will review:
- (1) HIV and HCV related health disparities in the VA
- (2) measures for monitoring health inequities
- (3) treatment challenges
- (4) identify opportunities for partnerships with Operations and other QUERI centers

## Background

- Vulnerable patients groups are particularly disadvantaged
- No one entity can address the multiple needs of the vulnerable patient group

**Notes:**
such as persons with very low-incomes, who are homeless, have transportation problems, live in rural areas or those with multiple medical comorbidities, substance abuse disorders or psychiatric illnesses Racial and ethnic minorities, particularly African Americans and Latinos, are overrepresented in the this group.

## The Call

- We seek partners to help address the needs of veterans at highest risk for impaired access
- who, as a result, do not benefit from improvements in chronic illness identification, care, and treatment

**Notes:**
We want to extend the benefits of specialist HIV and hepatitis care to underserved persons living in rural areas. 
To do this, we must collaborate with others

## The Goal

- Identify collaborative opportunities to improve access to care and increase the equitable distribution of HIV, HCV and specialist care for veterans with co-morbid health conditions.
- Our goal is that each attendee identify potential partners for collaboration to...

## The Purpose

- Our purpose is threefold:
- Highlight the impact of growing disparities in HIV/AIDS and HCV upon racial and ethnic minorities
- Discuss methods of assessing disparities
- Identify opportunities for operations and research to collaborate in reducing health disparities.

**Notes:**
Highlight particular challenges such as reducing disparities in HCV care and treatment, increasing integration of services for hepatitis infections into substance use disorders treatment, and improving the quality for homeless patients

## The Challenge

- Few programs or treatment models are designed to:
- address the needs of low-income patients with HIV and/or HCV and housing problems
- manage patients with multiple co-occurring medical, substance use, or psychiatric illnesses
- Provide comprehensive, integrated care for patients that require multiple co-morbid conditions
- Sylvestre D, et al, Co-occurring hepatitis C, substance use, and psychiatric illness: Treatment issues and developing integrated models of care, Journal of Urban Health 5.13.06

## Highlighting The Challenge

**Co-Morbid Conditions****	****	****	****% of Patients**
- Low Income						74.5
- Depression						47.6
- Substance Use Disorder				33.2
- Hepatitis C						31.9
- Lack of Housing					31.8
- STDs							24.8
- Hepatitis B						23.0
- PTSD							19.4
- Schizophrenia	  			  	  8.6
- Henry, SR, et al, Disparities in HIV Clinic Appointment Attendance, Factors Associated With Missed HIV Clinic Appointments, QNM 2008 Poster

**Notes:**
Veterans with multiple co-morbid conditions require additional follow-up care and treatment. 
Co-morbidities common to HIV-infected and HCV-infected patients include substance abuse disorders, and mental health disorders.
Patients with co-morbid conditions may require additional organizational support to maintain adherence to medical recommendations such as follow-up appointments and ART regimes. 

## Disparities

- HIV/AIDS has become increasingly overrepresented in the African American and, Latino-American community.

- Among HCV patients, African Americans are more likely to be homeless and less like to receive anti-viral treatment than whites

## Slide 11

**Notes:**
Over the past two decades, the Burden of the HIV epidemic has shifted to racial and ethnic minority communities

The proportional distribution of AIDS diagnoses among races/ethnicities has changed since the beginning of the epidemic. The proportion of AIDS diagnoses among whites (not Hispanic) has decreased; the proportions among non-Hispanic blacks and Hispanics have increased. The proportions of AIDS diagnoses among Asians/Pacific Islanders and American Indians/Alaska Natives have remained relatively constant, at approximately 1% of all diagnoses.
Of adults and adolescents diagnosed with AIDS during 2006, 48% were black (not Hispanic), 29% were white (not Hispanic), 20% were Hispanic, 1% were Asian/Pacific Islander, and less than 1% were American Indian/Alaska Native.

## Disproportionate Rates

- The HIV prevalence rate for:
- African American men was six times the rate for white men
- Hispanic men was more than twice the rate for white men
- African American women was nearly 18 times the rate for white women
- Hispanic women was more than four times the rate for white women
- African American women was greater than the rate for all other groups, except for black men
- CDC.GOV

**Notes:**
Among the estimated number of persons living with HIV at the end of 2006, 46.1% (1,715.1 per 100,000 population) were black, 34.6% (224.3 per 100,000) were white, 17.5% (585.3 per 100,000) were Hispanic, 1.4% (129.6 per 100,000) were Asian/Pacific Islander, and 0.4% (231.4 per 100,000) were American Indian/Alaska Native (Table). Males accounted for 74.8% of prevalent HIV cases (685.7 per 100,000). 

Although adult and adolescent blacks accounted for 13% of the population in the 33 states during 2001–2005 [3], they accounted for 50.5% of the 184,170 new HIV/AIDS diagnoses; whites accounted for 72% of the population and 29.3% of diagnoses, and Hispanics accounted for 13% of the population and 18.1% of diagnoses. Among racial/ethnic populations, blacks accounted for the largest percentages of cases diagnosed in both males (43.9%) and females (67.2%) (Table 1). 
During 2001—2005, blacks had the largest percentage of HIV/AIDS diagnoses in all age groups and in the IDU and high-risk heterosexual transmission categories (Table 1). Among men and women with IDU and persons with high-risk heterosexual contact, more than half were black (men: 54.0% and 65.7%, respectively; women: 58.9% and 69.5%, respectively). More MSM with HIV/AIDS diagnoses were white (42.8%), with smaller proportions of blacks (36.1%) and Hispanics (19.0%). 

## Disproportionate Rates

- Disproportionate rates of HIV infection in racial and ethnic minority communities underscore the need for effective intervention efforts for prevention, treatment, and care.

## Randal Henry

## Disparities

- Racial and ethnic minorities are more likely to acquire HIV/AIDS, and more likely to die of HIV/AIDS once they acquire the infection.

- This is primarily because improved HIV outcomes and decreased mortality rates as a result of treatment with highly active antiretroviral therapy (HAART) have not benefited minorities to the same extent as whites.
- CDC.gocv

**Notes:**
African American account for 13% of the population and nearly half of the new HIV diagnoses on 2006

## Disparities

- Regardless of location (rural, urban, or suburban), racial and ethnic minorities are significantly impacted by HIV infection,
- Poverty, unequal access to health care, racism, substance and alcohol abuse, limited infrastructure and capacity, social apathy, and homophobia all contribute to the transmission of HIV infection and the ramifications of this infection.

## Amy Justice, MD

- Principal Investigator, Veterans Aging Cohort
- Study and Chief of General Internal Medicine
- (Yale)

## Understanding Racial Disparities in HIV Using Data From the Veterans Aging Cohort 3-Site Study and VA Administrative Data

*Methods*: We used national administrative data to compare survival by race and used data from the Veterans Aging Cohort 3-Site Study (VACS 3) to compare patients’ health status, clinical management, and adherence to medication by race.

- (*Am J Public Health. *2003;93:1728–1733)

## Slide 19

## Slide 20

## Why?

- Minority veterans were
- More likely to have comorbid disease
- More likely to have more than one comorbid disease
- More likely to have high viral load and low CD4 cell count
- No significant differences found for
- Proportion on HAART
- Number of CD4 cell counts or viral loads
- HAART adherence
*Conclusions:* Survival differences may derive from more comorbidities and severity of HIV disease at presentation for care.
*Implication*: Targeting interventions to optimize of care for chronic disease complicated by comorbidity and toxicity is a promising means of decreasing racial and ethnic disparities in health outcomes with VHA

## How Can VACS Help?

- (Observational data) Understand how people of differing race/ethnicity respond to health care for chronic disease
- (Intervention research) Improve tailoring of health care to individual patient
- Severity of HIV infection
- Burden of comorbid disease
- Health behaviors
- Substance use
- Risky sex
- HAART adherence

## Prevalence of HCV Infection

**Percent**

*Veterans Aging Cohort Study, Baseline, lab or ICD-9 code*

## Steven Wright, PhD

- Director of Epidemiology, Office of Quality and
- Performance (OQP)

## Steven Wright

- Steven Wright is the Director of Epidemiology for the Office of Quality and Performance.  He will discuss methods of assessing health disparities and opportunities for operations and research to collaborate in evaluating the effect of quality improvement efforts on reducing health disparities.

## Disparities in the Quality of Care

- Steven M. Wright, PhD
- Director of Epidemiology
- Office of Quality and Performance

## Slide 27

| INDICATOR | VA 2008 
 | VA 2007
 |       Commercial 2007 |       Medicare 2007 |       Medicaid 2007 |
| --- | --- | --- | --- | --- | --- |
| Breast cancer screening | 87% | 86% | 69% | 67% | 50% |
| Cervical cancer screening  | 92% | 91% | 82% | n/a | 65% |
| Colorectal cancer screening | 79% | 78% | 56% | 50% | n/a |
| LDL Cholesterol < 100 after AMI, PTCA, CABG | 66% | 62% | 59% | 56% | 38% |
| Diabetes: DM control HbA1c < 9.0%  | 84% | 84% | 71% | 71% | 52% |
| Diabetes: LDL-C<100 | 68% | 64% | 44% | 47% | 31% |
| Diabetes: Eye Exam   | 86% | 85% | 55% | 63% | 50% |
| Diabetes: Renal Exam   | 93% | 91% | 81% | 86% | 74% |
| Diabetes: BP < 140/90 | 78% | 77% | 64% | 59% | 56% |
| Hypertension: BP < 140/90 | 75% | 76% | 62% | 58% | 53% |
| Smoking Cessation Counseling (3) | 89% | 83% | 76% | n/a | 70% |
| Smoking : Medications offered(3) | 84% | n/a | 51% | n/a | 39% |
| Smoking: Referral/strategies (3) | 92% | n/a | 48% | n/a | 39% |
| Immunizations: influenza  | 84% | 72% | 49% | 72% |   |
| Immunizations: pneumococcal | 94% | 90% | n/a | 67% |   |

## But...Health Disparities PersistResearch Findings & Current Investigations

- Evidence synthesis summarizes VA research  June 2006 (1981 - 2006 articles)
- On objective health indicators, non-white veterans generally fare worse than whites
- Reasons for disparities not clear but may relate to:
- lifestyle
- attitudes towards invasive procedures
- communication styles of patients and providers
- OQP operational focus on disparities:
- Race/ethnicity
- Technical process and intermediate outcome measures of Quality
- Patient Satisfaction
- Gender
- Technical Quality
- Patient Satisfaction

## Ethnicity/RaceGlobal Measures of Technical Quality

- _Process Measures_ (e.g., preventive services, inpatient care metrics) show little difference
- _Intermediate outcomes_ (e.g. BP, LDL chol, Hgb A1c) are worse for black, Hispanic veterans
- Analyses adjusted for age, gender, income, Medicare, self-reported health status, depression, site of regular provider, geographic region

## Ethnicity/RacePatient Perceptions of Quality

- Hospital Quality Report Card in June 2008 and follow-up report examined veteran and system characteristics
- Survey of Health Experiences of Patients (SHEP)
- Overall Quality of Care (inpatient & outpatient)
- Veterans Health Service Standards
- Lots of data (FY2005 - FY2007)
- Outpatients 748,681 responded
- Inpatients  183,771 responded
- Covariates – age, gender, health status, other demographics

## Slide 31

|       Black-White Differences in Patient Satisfaction Scores for Overall Quality and Other           Dimensions by Ethnic/Race Groups, Outpatient SHEP FY05-FY07 |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
|  | Dimension Scores for Ethnic/Race Groups |  |  |  |  |
| 
Dimension | Hispanic | White | Black  | Other
Minority | B-W Diff |
| Overall Quality | 71.5 | 79.7 | 67.4 | 72.3 | 12.3 |
| Access | 70.0 | 83.1 | 73.1 | 74.9 | 10.0 |
| Courtesy | 91.1 | 95.8 | 91.7 | 91.5 | 4.1 |
| Continuity of care | 80.9 | 78.1 | 74.0 | 73.9 | 4.1 |
| Information and Education | 69.9 | 73.6 | 69.0 | 66.7 | 4.6 |
| Overall Coordination of Care | 72.3 | 77.0 | 70.6 | 68.1 | 6.4 |
| Visit Coordination of Care | 79.5 | 85.5 | 83.0 | 80.0 | 2.5 |
| Specialist Care | 76.8 | 81.5 | 78.4 | 76.5 | 3.1 |
| Patient Preferences | 78.0 | 82.7 | 78.2 | 76.6 | 4.5 |
| Emotional Support | 81.8 | 84.5 | 79.5 | 78.4 | 5.0 |
| Pickup Pharmacy | 59.8 | 68.4 | 57.0 | 61.4 | 11.4 |
| Mailed Pharmacy | 75.4 | 83.2 | 73.7 | 77.2 | 9.5 |

## Slide 32

| BIack-White Differences in Patient Satisfaction Scores for Overall Quality and Other Dimensions by Ethnic/Race Groups, Inpatient SHEP FY05-FY07 |  |  |  |  |  |
| --- | --- | --- | --- | --- | --- |
|  | VHSS Scores for Ethnic/Race Groups |  |  |  |  |
| 
Dimension | Hispanic | White | Black  | Other minority | 
B-W Diff |
| Overall Quality | 76.4 | 79.2 | 71.4 | 75.3 | 7.8 |
| Access | 78.4 | 81.9 | 78.1 | 78.0 | 3.8 |
| Courtesy | 87.7 | 90.8 | 85.9 | 74.8 | 4.9 |
| Information and Education | 68.6 | 68.3 | 65.0 | 77.9 | 3.3 |
| Coordination of Care | 77.3 | 79.3 | 75.3 | 87.0 | 4.0 |
| Transition to Outpatient | 70.5 | 70.2 | 68.3 | 64.9 | 1.9 |
| Patient Preferences | 71.2 | 75.8 | 69.9 | 75.6 | 5.9 |
| Emotional Support | 66.0 | 66.5 | 61.4 | 66.4 | 5.1 |
| Family Involvement | 74.8 | 75.9 | 75.4 | 70.1 | 0.5 |
| Physical Comfort | 82.8 | 84.0 | 81.4 | 62.0 | 2.6 |

## Gender DisparitiesTechnical Quality of Care

- Significant and durable gaps in outpatient care for women in relationship to:
- Management of cardiovascular risk factors including those with diabetes, HTN, IHD
- Colorectal cancer screening
- Immunization
- Depression Screening
- No association with presence of designated women’s health providers
- Age an important effect modifier, variability by VISN and facility

- Gender DisparitiesTechnical Quality of Care

## VA Health Disparities Opportunities for Collaboration

- OQP custodian of rich source of data for health disparities research (EPRP and/or SHEP).  Many examples:
- Chronic pain (race)
- Alcohol Counseling (race)
- Immunization (gender)
- Quality of Care (mental health, MS, SCI, Chronic illness, rural/urban)
- Understanding disparities important to VHACO; collaboration with subject experts is vital
- HSR&D Centers of Excellence (eg, Center for the Study of Health Care Provider Behavior, CHERP)

## Susan Zickmund, PhD

- Co-Chief Qualitative Research, Center for Health
- Equity Research and Promotion (CHERP)

## Roadmap 

- HCV racial disparities and treatment challenges.
- Measurement issues in capturing racial disparities.
- And present an example of how researchers and VA Operations might effectively collaborate.

## Prevalence of Hepatitis C (HCV)

-  HCV affects 1.6% of the United States population.
- Is 5 times more prevalent than the human immunodeficiency virus** **(HIV) infection.
-  20% of patients progress to cirrhosis in 20 years.
-  10% succumb to liver cancer / end-stage liver disease.
- HCV is the primary reason for liver transplantation in the US.

## Prevalence of HCV in the VA

- HCV prevalence in the VA is 5.4%.
- VA has more than 3 times the rate of HCV than that of the general US population.
- Prevalence for whites in the VA is 3.2%, but is 11.0% for African Americans (AA).

## VA HCV Treatment Disparities 

- Studies report low treatment rates within the VA, 8%-13%.
- Bini et al. found AA significantly less likely to be considered candidates by GI clinicians.
- Butt et al. found similar results with both monoinfected HCV veterans and HCV-HIV co-infected.
- AAs were more likely to decline treatment when it was offered.

## Inside the Black Box...

- Reasons for treatment disparities are currently unknown.
- One reason may be the lower cure (sustained viral clearance rate) for AA.
- May be an association with communication with providers.
- Retrospective chart review pilot study of patients initiating HCV treatment.
- We found that providers in their CPRS notes told AA that they had a lower cure rate than whites.
- We found that of those who withdrew/refused treatment, 76% were AA versus 56% were whites.

## Potential Barrier: Communication and Trust

- Our work outside the VA showed that nearly 40% of HCV patients reported conflict with providers*
- A current interview study of methadone using veterans who rejected HCV treatment explained that a chief reason was a lack of trust in providers:
* “**They just don’t seem to think [treatment] is important.  I have to ask and ask and they still don’t suggest it.”  *
*“**I’ve had this condition for a long time and no one before this suggested that I get treatment.  It’s like no one wanted me to get it.” *

****Zickmund, et al. Hepatology *****(39) April 2004**

## Measuring Racial Disparities Challenges

**Complex social factors.**
**A need exists for complex methods and for collaborations.**

## Mixed Methods 

- 50 AA & 50 whites: audiotape every HCV clinic, interview patients and providers.  Outcome measure: patient dropout of treatment initiation process or starts treatment.

## Opportunity to Partner with VA  Operations  

- In closing, an example of how researchers and Operations can integrate their work to further research in health disparities.
- Our opportunity drew on results of the SHEP report to fashion what is called in our CHERP model a 2nd generation study. designed to further our understanding of why disparities exist
- Rapid turn around SHEP QI project* interviewing 30 AA & 30 whites at 3 major VA centers on satisfaction with VA care:
_***Preliminary Evaluation of Differences in Satisfaction with VA Health Care between African American and White Patients, **__*An Internal VA Report Prepared for the Associate Deputy Under Secretary for Health, Quality and Safety, *__**(S. Zickmund/M. Fine)**_**.**

## Results and Conclusion

- Significant racial disparities in ***satisfaction with overall VA care and outpatient VA care (Likert scale).***
- African Americans reported lower levels of ***trust in their VA medical providers*** (69% of AA trusted vs. 90% of whites).
- More African American patients expressed dissatisfaction with ***adequacy of pain management*** (48% vs. 15%).
**Mixed methods and the combined efforts of research and Operations may be one critical way to understand the complexities of racial health disparities.**

## Hildi Hagedorn, PhD

- IRC, QUERI-Substance Use Disorders (SUD)

## Challenges Facing SUD Patients with HIV/HCV

- Missed opportunities for testing
- If disease is identified, patient level barriers interfere with establishing a successful connection with a specialty clinic
- For HCV, patients who attend an appointment in a specialty clinic encounter clinicians without training in management of SUD

**Notes:**
System breaks down at several points:
1. SUD clinics (except opiate agonist treatment clinics) often do not view screening for infectious disease as part of their mission. SUD patients are often not connected to Primary Care so, despite huge risk factors, do not receive screening.
2. If disease is identified, barriers such as homelessness, lack of transportation, extreme poverty, and lack of social support interfere with appointment attendance and compliance with treatment regimens.
3. For HCV, patients who make it to a referral in a specialty clinic often encounter clinicians who have not received training in management of patients with substance use disorders. Patients are referred to SUD treatment and told to return when abstinent.

## Liver Health Initiative Preceptorship

- Bring SUD and HCV clinicians together to plan for integration of care
- Train SUD clinicians to implement hepatitis testing, education, and vaccination
- Train HCV clinicians in standardized screening, brief interventions, and referral protocols for SUD
- Develop expedited referral mechanisms between clinics

**Notes:**
Liver Health Initiative Preceptorship Program: SUD QUERI and Minneapolis HCRC
1. Brings SUD and HCV providers together to develop plans for integration of care. 
2. Trains SUD clinic staff to implement hepatitis screening, education, and prevention services.
3. Trains HCV clinic staff in standardized screening, brief intervention, and referral protocols for psychiatric disorders and SUD disorders.
4. Promotes development of expedited referral mechanisms between the two clinics.

## Collaborative Opportunities

- How to expand LHI beyond volunteer clinics?
- What is the best model for a similar program for HIV?
- Partners:
- VISN Leaders
- HIV/HEP C QUERI
- Public Health Strategic Healthcare Group
- Office of Mental Health Services

**Notes:**
How do we expand the reach of the Liver Health Initiative beyond volunteer clinics?
What is the best model for a similar program of integrated services for HIV?
Potential Partners: 
--VISN Leaders: Currently discussing VISN rollout of Liver Health Initiative with VISN 23 leadership. Could work with other VISNs in similar way.
--HIV/HEP QUERI: Working with SUD QUERI on developmental evaluation of implementing routine HIV testing in SUD clinics.
--Public Health Strategic Healthcare Group 
--Office of Mental Health Services

## Henry Anaya, PhD

- Investigator, QUERI-HIV/Hepatitis

## Homelessness in the United States

- The urban homeless population in the US is estimated to be 61% minority*
- 42% African-American
- 13% Latino
- 4% Native American
- 2% Asian
- 600,000 homeless individuals at any given time in the US
- >200,000 homeless veterans

****US Conference of Mayors, 2004*

## Homelessness and HIV

- Homeless: 3X the risk for HIV
- CDC recommends annual testing; many homeless do not receive testing
- Barriers
- Counseling time
- Trouble prioritizing prevention
- Lack of return for results

## A Multi-Agency HIV Rapid Testing Outreach Project in Los Angeles County Homeless Shelters

- Project Goals
- Evaluate success of multi-agency effort
- Evaluate success of incorporating RT in homeless shelters
- Evaluate costs of HIV RT implementation
- Evaluate sustainability of outreach effort