HIV Quality of Care Program

Transcription

1 New York State HIV Quality of Care Program Annual Data Report Based on 2014 Performance Data 193 sites submitted data for Each represents a site 1

2 New York State Department of Health AIDS Institute Johanne Morne, MS Director, AIDS Institute Bruce Agins, MD, MPH Medical Director Lyn Stevens, MSNP, ACRN Deputy Director, Office of the Medical Director Clemens Steinböck, MBA Director of Quality Initiatives Daniel Belanger, LMSW Director NYS HIV Quality of Care Program Daniel Tietz Consumer Involvement Specialist Christopher G. Wells Data Analyst Leah Hollander Program Assistant 2

3 Contents Executive Summary...5 Reporting Conventions and Glossary...11 ehivqual Review Patient Characteristics...13 Viral Load Suppression...17 Viral Load Suppression at Last Viral Load: Last Viral Load of Review Period...17 Suppressed at First Viral Load After 12 Weeks on ART Among Newly Treated...18 Suppressed at Last Viral Load After 12 Weeks on ART Among Newly Treated...18 Viral Load Levels at Time of Last Measurement Among All...19 Not Suppressed...19 Retention Month Retention Rate (calculated from clinic-wide caseloads) Month Retention Rate Month Retention Rate by Patient Characteristics...22 Not Retained...23 Clinical Visit Frequency...25 Viral Load Suppression and Retention by Patient Chracteristic Month Retention and Viral Load Suppression by Age...26 Viral Load Suppression and Retention by Patient Group...27 Disparities in Viral Load Suppression and Retention by Patient Group...29 Antiretroviral Therapy Usage...30 Antiretroviral Therapy...30 Not on ART...30 Baseline Resistance Testing...32 ARV-Naïve with a Baseline Resistance Test Prior to ARV Initiation...32 Sexually Transmitted Infections...33 Genital Chlamydia Testing...33 Genital Gonorrhea Testing...33 Genital Chlamydia Infection and Treatment...34 Genital Gonorrhea Infection and Treatment...34 Extragenital Chalmydia and Gonorrhea Testing, Infection and Treatment among MSM and Transgender...35 Tobacco Use Screening and Cessation Counseling...36 Tobacco Use Screening...36 Tobacco Cessation Counseling...36 ARV Medication Safety...37 Contraindicated ART Regimens...37 Frequency of Contraindicated Regimens...37 Regimens Contraindicated for Reasons Other than Number of Medications in Regimen...39 Acceptable Regimens Considered Non-Standard for Reasons Other than Number of Medications in Regimen...39 Appendix A: Descriptive Analysis of Patient Characteristics...40 Last Viral Load Suppressed Month Retention...41 Sexually Transmitted Infections

4 Appendix B: Performance Data for New York State HIV Ambulatory Care Programs...44 Appendix C: Longitudinal Heatmaps...46 Viral Load Suppresion: Final Suppressed...46 ARV Therapy Month Retention...56 Appendix D: Performance Data for New York State HIV Adolescent Care Programs

5 Executive Summary The New York State Department of Health (NYSDOH) AIDS Institute HIV Quality of Care (QOC) Program, overseen by the Office of the Medical Director (OMD), is committed to promoting the quality of HIV clinical care and supportive services delivered to people with HIV in New York State (NYS) and to building capacity for quality management in HIV programs throughout the region. Major activities of the program include: performance measurement of clinical care and services, improvement coaching and consultation, exchange of improvement resources, peer learning, and collaborative participation of clinical experts and consumer representatives. The Quality of Care Program is committed to ensuring that patients who are in care receive the best care to achieve the desired outcomes of good health and viral suppression. These goals are fundamental to New York State's Ending the Epidemic Initiative (ETE). Performance data focusing on viral load suppression are a vital component of the ETE metrics and drive actions by providers to achieve the goals set forth in the Governor's Initiative to End the Epidemic. The HIVQUAL framework, developed by the NYSDOH AIDS Institute in 1992, is based on the concept that quality management programs should reflect a balance between quality improvement and performance measurement activities and be built on a sustainable programmatic infrastructure. This organizational approach to quality management emphasizes the development of systems and processes to support improvement activities involving both clinic staff and consumers. These structural features are designed to be sustainable even with staff turnover or leadership changes. The ultimate goals of these ongoing improvement activities are to improve health outcomes for people living with HIV at the local agency level and to advance the quality of HIV care throughout the state. Performance measurement of HIV ambulatory care clinics occurs annually through self reporting. Most facilities submit data directly for a sample of their caseload, using the web-based ehivqual application. For the first time, for the 2014 review, 13 community health centers submitted data on their entire caseload, from a data warehouse maintained by Azara Healthcare, an organization that extracted their data directly from their EMRs. Given that this was the first time this approach was used, the submissions underwent a preliminary comparison with the same sites' scores for 2013 to validate the Azara extract. The results from these 13 facilities, which represent 42 individual clinics, are presented seperately from the other submissions. Indicators were developed and refined in partnership with the NYS Quality Advisory Committee and the NYS Consumer Advisory Committee. While facility scores and benchmarks using approved submissions are available immediately through the ehivqual application, this report summarizes clinic-level scores and offers comprehensive benchmarking data to facilitate comparison between providers. Mean scores for each indicator are calculated. Sparklines are used to show the range of performance in the State, displaying maximum performance scores along with lowest values. The highest and lowest quartiles were used to identify providers performing well and those providers who need to improve their rates, respectively. Heat maps are also displayed to enhance visualization of performance (see p. 46). Additional analyses were performed to underscore subpopulation differences in care and highlight disparities that require specific attention. Design and Methodology In 2016, a total of 193 participating clinics completed a review of the quality of care provided in 2014 at their respective facilities. For the 2014 review period (January 1 - December 31, 2014), 151 clinics submitted data directly to ehivqual; 85 clinics did so through manual entry of a random sample while 66 did so through direct upload of their entire HIV clinic caseload. The remaining 42 5

6 Executive Summary clinics submitted data on all their HIV positve patients via the EMR extraction facilitated by Azara Healthcare. The Azara extract captured HIV positive patients even if they visited the clinic for non- HIV-specific ambulatory care. The Azara extract was limited to data available in a mapped field, unlike in chart reviews where data may be found in other chart notes. For these reasons, the data from sites that submitted through direct submission to ehivqual is presented separately from the data from sites that submitted using the Azara extract. Eligibility Criteria Criteria for inclusion in the eligible caseload focused on those patients in ambulatory care at a hospital or health center clinic. The Veteran's Administration, private practitioners working outside of institutional medical settings, prisons, and jails are not currently included in the NYSDOH HIV Quality of Care Program. The eligible caseload for clinics submitting data through the direct submission process consisted of all HIV positive patients 13 years and older who had at least one HIV primary care visit during the 2014 review year. For Azara extract submissions, the eligible caseload was defined as HIV positive patients 13 years and older who had at least one ambulatory care visit during the 2014 review year. were excluded from the report if providers identified that they were engaged in ongoing HIV care elsewhere. Submission Process Providers submitting data through direct submission determined their total caseload and submitted data for two mutually exclusive subsets of patients drawn from this group of patients: 1) the core review, representing a random sample of the total caseload; 2) the new patient review, representing all new patients not included in the core review sample. For submissions coming from the Azara extract, data was submitted for the entire eligible caseload. 1. Core Review Standardized statistical sampling tables were used to determine the number of records to be abstracted from the total case list of eligible patients. The patient sample for 2014 was based on a 90% confidence interval with a two-tailed error width of ±8% based on a point estimate of a 50% response to any of the indicators that applied to the total clinic population; sampling was not constructed to ensure reliable representation of patient characteristics and performance rates among demographic subgroups. Clinic staff generated a list of random charts for review from the total patient caseload. If a patient who had been included in the sample was found to be ineligible or if a patient chart could not be found, a replacement patient chart was then randomly selected from the remaining eligible list of patient records. Some centers optionally imported their entire patient caseload for the core review. 2. New Patient Review New patients were defined as patients who were 1) newly diagnosed during the 2014 review period or 2) returning to clinic after at least a two-year lapse in care. While some new patients were captured in the core review, providers also reported visits, viral load, antiretroviral therapy (ART), baseline resistence screening, and CD4 data for all other new patients in their 2014 caseload. These data are incorporated into the anlaysis for indicators measuring care of newly treated patients, so that all relevant patients from the caseload are included*. *Note: this introduces a potential sample bias towards newly diagnosed and returning to care patients. 6

7 Executive Summary Data Management Data collected by participating clinics are stored in the password protected ehivqual application. Clinic staff are expected to report their data to NYSDOH staff by entering or uploading it into the ehivqual application and to generate their reports for internal use during the review to initiate improvement projects. Technical support is provided through staff from the Office of the Medical Director. The following clinics were not able to successfully complete the ehivqual review by the final reporting deadline: AllMed Medical & Rehabilitation of New York Brooklyn Hospital Center PATH Center New York Methodist Hospital Citicare, Inc., Family Health Services Data Analysis Data were analyzed using SAS statistical software. The scores presented here were derived from calculations for a given year based on measures that represented clinical standards of practice at the time of the review. Adult performance rates are displayed for each indicator. Clinic means and interquartile range (IQR) analyses were used to help visualize the spread of performance and to assist providers in understanding how their performance compared with that of others. Mean scores were calculated as the average of individual patient scores from the entire sample submitted by each clinic. Analysis by Subpopulation In addition to cross-tabulations of retention and ARV therapy with age, gender, race/ethnicity, risk factor, and housing status, classification and regression tree analyses were conducted to identify combinations of factors associated with poor outcomes to guide areas for improvement. Hierarchical logistic regression analysis was not performed to test for significance in variation among subgroups. Results Viral Load Suppression (VLS) (p ) A key HIV measure is the viral load suppression (VL<200 copies/ml) rate, as measured by the last viral load of the year. The clinic mean rate for VLS of all patients who had at least one visit in 2014 was, for all clinics, 76% (range=0-100%, patients=20,298); for clinics submiting data directly to ehivqual, 78% (range=23-100%, patients=10,375); and, for clinics submitting via the Azara extract, 70% (range=0-100%, patients=9,923). Unsuppressed patients are characterized in the report by region, gender, race/ethnicity, risk factor, age and housing status. without a viral load value recorded during the 2014 review period were considered unsuppressed. Viral Load Suppression in Newly Treated on ART (p. 18) Viral load suppression rates were measured for patients who initiated ART during the review period and had been treated for at least 12 weeks. The clinic mean rate for newly treated patients suppressed at first viral load test after 12 weeks on ART was, for all clinics, 84% (range=0-100, n=1,700); for clinics submiting data directly to ehivqual, 85% (range=0-100%, n=674); and, for clinics submitting via the Azara extract, 80% (range=0-100%, n=1,026). The clinic mean rate for suppressed at last viral load test after 12 weeks on ART among newly treated patients was, for all clinics, 86% (range=0-100%, n=1,700); for clinics submiting data directly to ehivqual, 86% 7

8 Executive Summary (range=0-100%, n=674); and, for clinics submitting via the Azara extract, 85% (range=50-100%, n=1,026). Retention (p ) Retention rates were measured over 12- and 24-month periods. 12-month retention rates were calculated from clinic-wide caseloads; patients were considered retained in care if they had at least one primary care visit in each 6 month period of the year. The clinic mean for 12-month retention was, for all clinics, 84% (range=0-100%, n=58,235); for clinics submiting data directly to ehivqual, 85% (range=0-100%, n=49,504); and, for sites submitting via the Azara extract, 79% (range=0,100%, n=8,731). 24-month retention was assessed over a consecutive 24-month period; patients were considered retained in care if they had at least one primary care visit in each 6-month period of the review period and of the previous year, with a minimum of 60 days between the first primary care visit in the prior 6-month period and the last primary care visit in the subsequent 6-month period. The clinic mean for 24-month retention was, for all clinics, 76% (range=0-100%, n=14,995); for clinics submiting data directly to ehivqual, 76% (range=0-100%, n=8,088); and, for clinics submitting via the Azara extract, 75% (range=0-100%, n=6,907). who did not meet the 24-month retention criteria, and could not be accounted for by death, relocation, or care outside the system, are characterized in the report by region, gender, race/ethnicity, risk factor, age, and housing status. Antiretroviral Therapy (p ) Antiretroviral therapy usage was measured for all patients. The clinic mean rate for ART prescription during the 2014 review period was, for all clinics, 92% (range 0-100%, n=20,298); for clinics submitting directly to ehivqual, 93% (range=33-100%, n=10,375); and for clinics submitting via the Azara extract, 88% (range=0-100%, n=9,923). not prescribed antiretroviral therapy are characterized in the report by region, gender, race/ethnicity, risk factor, age, and housing status. Baseline Resistance Testing (p. 32) Rates of baseline resistance tests performed were measured for ARV-naïve patients who initiated ARV therapy and had one or more VL >500 copies/ml. The clinic mean for baseline resistance tests performed prior to ARV initiation (either during or at any time preceding the review period) was, for all clinics, 77% (range=0-100%, n=1,825); for clinics submitting directly to ehivqual, 82% (range=0-100%, n=1,076); and, for clinics submitting via the Azara extract, 61% (range=0-100%, n=749) STI Screening (p ) The clinic mean scores for genital Chlamydia testing among eligible patients were, for all clinics, 60% (range=0-100%, n=20,298); for clinics submitting directly to ehivqual, 57% (range=0-100%, n=10,375); and, for clinics submiting via Azara extract, 68% (range=0-100%, n=9,923). The clinic mean score for genital gonorrhea testing among eligible patients were, for all clinics, 59% (range=0-100%, n=20,298); for clinics submitting directly to ehivqual, 58% (range=0-100%, n=10,375); and, for clinics submiting via Azara extract, 63% (range=0-100%, n=9,923). 8

9 Executive Summary STI Screening by Sub- Genital Chlamydia Testing Genital Gonorrhea Testing Mean Clinic Score Mean Clinic Score Women % 61% Men % 58% MSM % 67% MtF % 60% Extragenital Chlamydia and gonorrhea testing rates were low for MSM and MtF transgender patients. Clinic mean scores for rectal testing for Chlamydia were: 15% for MSM (n=7,386) and 20% for MtF (n=529). Clinic mean scores for rectal gonorrhea testing were: 15% for MSM (n=7,386) and 19% for MtF (n=529). Clinic mean scores for pharyngeal gonorrhea testing were: 14% for MSM (n=7,386) and 19% for MtF (n=529). Results of Selected Key Indicators for All Clinics Quality of Care Indicator Clinics Mean Clinic Score Viral Load Suppression: Last Viral Load % Retention (24-Month) % Antiretroviral Therapy % Baseline Resistance Testing* % Tobacco Use Screening % *measured for all newly treated patients 9

10 Executive Summary Conclusion Key findings of the 2014 HIV performance measurement review include an average clinic viral load suppression (last viral load) rate of 76% and an average clinic 24-month retention in care rate of 76%. Note that eligibility criteria for the viral load suppression indicators changed in 2013 to include all patients who had at least one visit during the 12-month review period. In 2011, only patients who were on ART for a minimum of 12 weeks with one visit in each 6-month period of the review were eligible. High performance rates from the 2014 ehivqual review include patients on antiretroviral therapy (92%). Low performance rates include extragenital Chlamydia and gonorrhea testing for MSM and MtF transgender patients [rectal Chlamydia testing: 15%; rectal gonorrhea testing: 15%; pharyngeal gonorrhea testing: 14%]. The New York State HIV QOC Program will advance its improvement work to reduce identified gaps in the quality of care provided to HIV positive patients in NYS. A focus on education, coaching, and peer learning activities will build capacity among HIV providers for the use of improvement methodologies and tools to improve critical indicators of care. Based on the 2014 review findings, specific recommendations include: All performers who scored at or below the 25th percentile of all HIV clinics submitting 2014 ehivqual data in New York State for viral load suppression were asked to submit clinic-wide improvement plans to improve this critical indicator and quarterly VLS rates to track improvement. Those facilities that were unable to submit data in a timely manner and are not included in the 2014 review underwent formal inspection monitoring visits and will be targeted for intensive technical support and corrective action as required. Learning networks and regional groups also focused on viral load suppression, offering providers the opportunity to engage in peer learning as well as group improvement activities. Providers who scored highly on viral load suppression have been invited to share their knowledge and experiences. Clinic-specific improvement profiles are being developed to offer providers a simple and consolidated report of key clinical indicator results, improvement activities, and QM program infrastructure assessment findings. Clinics will develop plans to improve quality of care based on these reports; findings will inform priorities for coaching and external technical assistance. The public data release on the Health Data New York website, initiated with data from the 2011 NYS ehivqual review, is in the process of being extended with data from the 2014 review. The public has full access to facility, regional, and statewide performance on a wide array of clinical indicators on the website. The accompanying visualization tools allow for filtering, sorting, and exporting of these data. Facility scores can be viewed on a map that can be scrolled or zoomed to areas of interest. Additional analytical tools will be added over time. The ehivqual review for calendar year 2016 is being conducted. The NYSDOH AIDS Institute will continue to work to shorten the timeline for reporting of performance measurement results and maximize opportunities for importing data queried directly from EMRs. 10

11 Reporting Conventions and Glossary Data analyzed in this report were submitted by New York State HIV Ambulatory Care Clinics for the January 1 - December 31, 2014 review period. Clinic-level data from the 2007, 2009, 2011 and 2013 review periods are included in cases for which longitudinal data are available. Note that through 2011 only patients with at least one HIV primary care visit in each six-month period of the year were eligible for the review. In 2013, eligibility changed to include all patients who had at least one visit during the 12-month review period. In addition to the total number of clinics and the total number of eligible patients, clinic-level indicator scores were used to calculate aggregate scores: means, medians, percentiles, and minimum and maximum values. Example: Viral Load Suppression: Last Viral Load Suppressed Clinics Mean - average clinic score Median - score separating the top half from the bottom half of all clinic scores s - score below which a certain percentage of clinic scores fall Maximum - highest clinic score Minimum - lowest clinic score Number of clinics - number of clinics with a score for a particular indicator Number of eligible patients - total number of sampled patients who are eligible for a particular indicator Spread - the distribution of clinic scores. Each line represents one clinic score. The mean clinic score is highlighted in red. The 25th and 75th percentiles are highlighted in blue. Heatmaps - (below) the percentile and number of eligible patients for each clinic-level score. Each clinic is a single row, with the number of eligible patients in the appropriate year. Red indicates that the clinic score was at or below the 25th percentile, orange indicates that the clinic score was between the 25th and 75th percentiles, and green indicates that the clinic score was at or above the 75th percentile. Clinic Mean Median 25th 75th Min Max NYS % 81% 72% 87% 23% 100% Color Key Rate of Suppression (%) 0 to 25th 26th to 75th 76th to 100th Number of eligible patients 42 The color represents the rate of the indicator Program Name All NYS Reporting Clinics Clinic Clinic Clinic Clinic Clinic Clinic Clinic

12 ehivqual Review 2014 The following section presents data from both the Direct ehivqual Submission Review and the Azara Extract Submission Review. When not specifically noted, the data incorporates information from both reviews. Direct ehivqual Submission Review The data analyzed in this review comes from the 151 clinics that submitted their data through direct submission to the ehivqual application. For most indicators, the data analyzed come from the sample of the total caseload, the core review. For the following indicators, the data analyzed comes from both the core review and the new patient review: 1. Suppressed at first viral load test after 12 weeks on ART among newly treated patients 2. Suppressed at last viral load test after 12 weeks on ART among newly treated patients 3. Baseline resistance test performed prior to ARV initiation 4. New patient visit frequency Azara Extract Submission Review The data analyzed in this review comes from the 13 healthcare organizations, representing 42 individual clinics, that submitted their data via the Azara extract. The following is a list of the 13 organizations included in the Azara extract: Asian and Pacific Islander Coalition on HIV/AIDS (APICHA) Betances Health Center Brightpoint Health Brownsville Multi-Service Family Health Center Callen-Lorde Community Health Center Cornerstone Family Healthcare Harlem United-Upper Room AIDS Ministries Housing Works Hudson River HealthCare Lutheran Medical Center Open Door Family Medical Center, Inc. Whitney M. Young Jr. Health Services William F. Ryan Community Health Center Network ehivqual Submissions from HIV Quality of Care Program ehivqual Review. Data submitted directly through ehivqual application on or before 12

13 Patient Characteristics - Direct ehivqual Submission Review Core Review Newly Diagnosed* Returning to Care after 2+ Year Lapse* # % # % # % NYS % % % Gender: Male % % % Gender: Female % % % Gender: MtF 111 1% 8 1% 5 1% Gender: FtM 5 0% 5 0% 2 0% Race/Ethnicity: Black % % % Race/Ethnicity: Hispanic % % % Race/Ethnicity: White % % 72 14% Race/Ethnicity: Asian 132 1% 41 3% 2 0% Race/Ethnicity: Other 325 3% 32 3% 16 3% Risk Factor: Heterosexual % % % Risk Factor: MSM % % % Risk Factor: IDU % 42 3% 86 16% Risk Factor: Other** % 94 7% 54 10% Age: 13 to % % 22 4% Age: 25 to % % % Age: 50 to % % % Age: 60 to % 50 4% 51 10% Age: % 12 1% 4 1% Housing: Stable % % % Housing: Unstable 635 6% % 46 9% Housing: Unknown % 70 6% 39 7% NYS: Total % % % NYS: Central West % 111 9% 57 11% NYS: Long Island 444 4% 109 9% 24 5% NYS: Lower Hudson 417 4% 25 2% 23 4% NYS: Mid Hudson 175 2% 5 0% 3 1% NYS: Northeast 209 2% 35 3% 34 6% NYC: Total % % % NYC: Bronx % % 88 17% NYC: Brooklyn % % 74 14% NYC: Manhattan % % % NYC: Queens 917 9% 102 8% 30 6% NYC: Staten Island 181 2% 5 0% 7 1% * Newly Diagnosed and Returning to Care after 2+ Year Lapse patients include applicable patients from the core review as well as patients from the new patient review (see pg. 6). **Other risk factors may include hemophilia/coagulation disorders, transfusion, other risk factors, and unknown risk factors. ehivqual Submissions from HIV Quality of Care Program ehivqual Review. Data submitted directly through ehivqual application on or before 13

14 Patient Characteristics - Azara Extract Submission Review All Newly Diagnosed* Returning to Care after 2+ Year Lapse* # % # % # % NYS % % % Gender: Male % % 68 72% Gender: Female % % 23 24% Gender: MtF 418 4% 31 5% 4 4% Gender: FtM 68 1% 0 0% 0 0% Race/Ethnicity: Black % % 40 42% Race/Ethnicity: Hispanic % % 37 39% Race/Ethnicity: White % 85 13% 12 13% Race/Ethnicity: Asian 280 3% 26 4% 3 3% Race/Ethnicity: Other 639 6% 48 7% 3 3% Risk Factor: Heterosexual % % 41 43% Risk Factor: MSM % % 33 35% Risk Factor: IDU 746 8% 46 7% 9 9% Risk Factor: Other** % % 12 13% Age: 13 to % % 1 1% Age: 25 to % % 57 60% Age: 50 to % % 33 35% Age: 60 to % 31 5% 4 4% Age: % 6 1% 0 0% Housing: Stable % % 32 34% Housing: Unstable % % 20 21% Housing: Unknown % % 43 45% NYS: Total % % % NYS: Central West 0 0% 0 0% 0 0% NYS: Long Island 181 2% 5 1% 1 1% NYS: Lower Hudson 186 2% 5 1% 3 3% NYS: Mid Hudson 498 5% 21 3% 4 4% NYS: Northeast 206 3% 6 1% 4 4% NYC: Total % % 83 87% NYC: Bronx 796 8% 49 7% 14 15% NYC: Brooklyn % % 14 15% NYC: Manhattan % % 52 55% NYC: Queens 338 3% 32 5% 3 3% NYC: Staten Island 0 0% 0 0% 0 0% * Newly Diagnosed and Returning to Care after 2+ Year Lapse patients are subsets of All. **Other risk factors may include hemophilia/coagulation disorders, transfusion, other risk factors, and unknown risk factors ehivqual Submissions from HIV Quality of Care Program ehivqual Review. Data submitted directly through ehivqual application on or before 14

15 Percent of Direct ehivqual Submission Core Review (n=10,375) and Azara Extract Submission All (n=9,923) by Characteristic Region Housing Age Risk Race Gender Gender: Male Gender: Female Gender: MtF Gender: FtM Black Hispanic White Asian Other Race Heterosexual MSM IDU Other Risk Factor* 13 to to to to Stable Unstable Unknown NYS: Central West NYS: Long Island NYS: Lower Hudson NYS: Mid Hudson NYS: Northeast NYC: Total NYC: Bronx NYC: Brooklyn NYC: Manhattan NYC: Queens NYC: Staten Island Direct ehivqual Submission62% 74% Azara Extract Submission 37% 21% 1% 4% 0% 1% 51% 44% 30% 29% 14% 17% Direct ehivqual Submission 1% Azara Extract Submission 3% 3% 6% 49% 29% 25% 52% 13% 8% 13% 12% 5% 5% 49% 63% 32% 24% 12% 7% 2% 1% 80% 61% 6% 14% 14% 25% 10% 0% 4% 2% 4% 2% 2% 5% 2% 2% 78% 89% 25% 8% 19% 17% 24% 61% 9% 3% 2% 0% 0% 20% 40% 60% 80% 100% ehivqual Submissions from HIV Quality of Care Program ehivqual Review. Data submitted directly through ehivqual application on or before 15

16 Percent of Direct ehivqual Submission Newly Diagnosed (n=1,261) and Azara Extract Submission Newly Diagnosed (n=676) by Characteristics Region Housing Age Risk Race Gender Gender: Male Gender: Female Gender: MtF Gender: FtM Black Hispanic White Asian Other Race Heterosexual MSM IDU Other Risk Factor* 13 to to to to Stable Unstable Unknown NYS: Central West NYS: Long Island NYS: Lower Hudson NYS: Mid Hudson NYS: Northeast NYC: Total NYC: Bronx NYC: Brooklyn NYC: Manhattan NYC: Queens NYC: Staten Island Direct ehivqual Submission 75% 77% Azara Extract Submission 24% 18% 1% 5% 0% 0% 47% 46% Direct ehivqual Submission 28% 30% Azara Extract Submission 18% 13% 3% 4% 3% 7% 44% 25% 45% 51% 3% 7% 7% 18% 18% 18% 64% 58% 13% 18% 4% 5% 1% 1% 84% 52% 10% 22% 6% 26% 9% 0% 9% 1% 2% 1% 0% 3% 3% 1% 77% 95% 21% 7% 18% 20% 29% 63% 8% 5% 0% 0% 0% 20% 40% 60% 80% 100% ehivqual Submissions from HIV Quality of Care Program ehivqual Review. Data submitted directly through ehivqual application on or before 16

17 Viral Load Suppression Suppression is defined by a viral load value of <200 copies/ml (either detectable or undetectable). without a viral load value recorded are considered unsuppressed. Viral Load Suppression at Last Viral Load: * 100% 90% Direct ehivqual Submissions 78% Mean Clinic % Suppressed 80% 70% 60% 50% 40% 30% 20% 72% 75% 74% 73% 70% Azara Extract Submissions 76% All Submissions 10% 0% *In 2011, only patients who were on ART for a minimum of 12 weeks with one visit in each 6-month period of the review period were eligible for the viral load suppression measures. Furthermore, during this time period, VL <400 copies/ml (and undetectable), was also considered suppression. In 2013, eligibility changed to include all patients who had at least one visit during the 12-month review period and the current definition of suppression came into use. Last Viral Load of Review Period 2014 Mean: 76%, 2013 Mean: 73% Direct ehivqual Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 81% 72% 87% 23% 100% Azara Extract Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 76% 62% 86% 0% 100% Last Viral Load Suppressed: Percentage of patients who are considered suppressed as derived from the last recorded viral load of the review period; suppressed defined as a viral load <200 copies/ml (either detectable or undetectable). Exclusions: None 17

18 Suppressed at First Viral Load After 12 Weeks on ART Among Newly Treated 2014 Mean: 84%, 2013 Mean: 76% Direct ehivqual Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 90% 78% 100% 0% 100% Azara Extract Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 82% 70% 100% 0% 100% ART Naïve Suppressed at First Viral Load After 12 Weeks on ART: Percentage of patients who began ARV therapy for the first time during the review period who are considered suppressed at the first viral load during review period after 12 weeks of initiation of therapy; suppressed defined as viral load <200 copies/ml (either detectable or undetectable). Exclusions: who did not receive a viral load test at least 12 weeks after the initiation of ART Suppressed at Last Viral Load After 12 Weeks on ART Among Newly Treated 2014 Mean: 86%, 2013 Mean: 82% Direct ehivqual Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 100% 80% 100% 0% 100% Azara Extract Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 85% 75% 100% 50% 100% ART Naïve Suppressed at Last Viral Load After 12 Weeks on ART: Percentage of patients who began ARV therapy for the first time during the review period who are considered suppressed at the last viral load during review period after 12 weeks of initiation of therapy; suppressed defined as a viral load <200 copies/ml (either detectable or undetectable). Exclusions: who did not receive a viral load test at least 12 weeks after the initiation of ART 18

19 Viral Load Levels at Time of Last Measurement Among All * 3% 9000 Number of % % Direct ehivqual Submission Azara Extract Submission % 4% 5% 6% Suppressed (<200) ,000-9,999 10,000-99, ,000 Viral Load Value (copies/ml) % 8% *Note: 21 patients (4 direct ehivqual, 17 Azara extract) who received VL tests are excluded because of contradictory VL test results reported on the same day. 561 patients (200 direct ehivqual and 361 Azara extact) with no VL test during the review period are also excluded. Not Suppressed (n=4,374) Of the 20,298 patients included in the review*, 4,374 were not suppressed at the last HIV viral load test of the review period. *Includes core review for direct ehivqual submissions and all patients for Azara extract submissions Not Suppressed by Region % of Not Suppressed at Last VL (direct ehivqual) % of Not Suppressed at Last VL (Azara extract) NYS: Total 20% (2076/10375) 23% (2289/9923) Central West 16% (161/1038) 0% (0/0) Long Island 11% (51/444) 18% (33/181) Lower Hudson 18% (75/417) 18% (34/186) Mid Hudson 26% (46/175) 17% (85/498) Northeast 11% (22/209) 24% (49/206) NYC: Total 21% (1721/8092) 24% (2088/8852) Bronx 23% (606/2602) 45% (354/796) Brooklyn 20% (388/1935) 34% (552/1642) Manhattan 20% (481/2457) 18% (1078/6076) Queens 21% (193/917) 31% (104/338) Staten Island 29% (53/181) 0% (0/0) 206 2% 243 3% 19

20 Not Suppressed by Characteristic % of Not Suppressed at Last VL (direct ehivqual) % of Not Suppressed at Last VL (Azara Extract) NYS 20% (2076/10375) 23% (2289/9923) Gender: Male 20% (1276/6395) 21% (1579/7368) Gender: Female 20% (768/3864) 26% (546/2069) Gender: MtF 28% (31/111) 34% (144/418) Gender: FtM 40% (2/5) 29% (20/68) Race/Ethnicity: Black 23% (1215/5322) 30% (1310/4381) Race/Ethnicity: Hispanic 19% (608/3137) 19% (561/2910) Race/Ethnicity: White 12% (172/1459) 15% (253/1713) Race/Ethnicity: Asian 11% (14/132) 8% (23/280) Race/Ethnicity: Other 21% (67/325) 22% (142/639) Risk Factor: Heterosexual 19% (988/5079) 26% (744/2851) Risk Factor: MSM 18% (468/2562) 18% (945/5172) Risk Factor: IDU 22% (302/1394) 30% (227/746) Risk Factor: Other* 24% (318/1340) 32% (373/1154) Age: 13 to 24 33% (154/468) 37% (202/545) Age: 25 to 49 23% (1196/5123) 24% (1481/6256) Age: 50 to 59 17% (548/3307) 20% (469/2366) Age: 60 to 69 12% (145/1237) 18% (125/676) Age: % (22/240) 15% (12/80) Housing: Stable 18% (1480/8336) 18% (1094/6051) Housing: Unknown 26% (366/1404) 24% (592/2475) Housing: Unstable 36% (230/635) 43% (603/1397) *Other risk factors may include hemophilia/coagulation disorders, transfusion, other risk factors, and unknown risk factors 20

21 Retention 12-Month Retention Rate 2014 Mean: 84%, 2013 Mean: 83% Direct ehivqual Submissions (calculated from clinic-wide caseloads) Clinics 12-Month Calculated Retention Rate: Percentage of patients who had at least one primary care visit in the first six months of the review period and in the second six months of the review period. Exclusions: None For each review to be submitted through ehivqual, a clinic must separately report: (1) the total number of patients seen for one or more clinical visits for primary care with a provider with prescribing privileges during the review period; and (2) the total number of patients seen for one or more clinical visits for primary care with a provider with prescribing privileges during each six-month half of the review period. 24-Month Retention Rate Seen at Least Once in Each Half of the Review Period Mean: 76%, 2013* Mean: 79% Clinic Mean Median 25th 75th Min Max NYS % 88% 83% 92% 0% 100% Azara Extract Submissions Clinics Clinics Seen at Least Once in Each Half of the Review Period Seen at Least Once in Each 6 Month Interval During the Previous 24 Months Clinic Mean Clinic Mean Median Median 25th 25th 75th Min Max NYS % 87% 76% 92% 0% 100% Direct ehivqual Submissions 75th Min Max NYS % 78% 69% 89% 0% 100% Azara Extract Submissions Clinics 24-Month Retention Rate: Percentage of patients who had at least one primary care visit in each 6-month period of the review period and of the previous year, with a minimum of 60 days between the first primary care visit in the prior 6-month period and the last primary care visit in the subsequent 6-month period. (Measurement period is a consecutive 24-month period of time.) Exclusions: None Seen at Least Once in Each 6 Month Interval During the Previous 24 months *In 2013, patients who were documented to be deceased at any time in the measurement year, patients who were incarcerated for greater than 90 days of the measurement year, and patients who were known to relocate out of the service area or transferred medical care at any time in the measurement year were excluded. 21 Clinic Mean Median 25th 75th Min Max NYS % 80% 67% 88% 0% 100%

22 24-Month Retention by Patient Characteristic Direct ehivqual Submission Azara Extract Submission NYS Mean (76%) Language Housing Age Risk Race Gender Gender: Male Gender: Female Gender: MtF Gender: FtM Black Hispanic White Asian Other Race Heterosexual MSM IDU Other Risk Factor* 13 to to to to Stable Unstable Unknown English French or Creole Spanish ASL Other 0%, n=0 25%, n=4 76%, n= %, n= %, n= %, n= %, n=69 67%, n=261 71%, n=49 74%, n= %, n= %, n= %, n= %, n-=244 72%, n=436 76%, n= %, n= %, n= %, n= %, n= %, n=498 75%, n=965 73%, n=760 64%, n=242 65%, n=233 73%, n= %, n= %, n= %, n= %, n=90 90%, n=208 79%, n= %, n= %, n=204 80%, n=61 78%, n= %, n= %, n=361 61%, n= %, n=989 77%, n= %, n= %, n=211 75%, n=152 85%, n=13 76%, n=108 74%, n= %, n= %, n=523 83%, n= %, n=58 100%, n=1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent Retained of Subgroup *Other risk factors may include hemophilia/coagulation disorders, transfusion, other risk factors, and unknown risk factors 22

23 Not Retained (n=3,643) Of the 14,995 patients eligible for the 24-month retention measure, 3,643 were not retained in care. Not Retained by Region % of Not Retained (direct ehivqual) % of Not Retained (Azara extract) NYS: Total 23% (1894/8088) 25% (1749/6907) Central West 25% (214/873) 0% (0/0) Long Island 37% (135/361) 24% (36/151) Lower Hudson 24% (86/354) 13% (20/156) Mid Hudson 25% (35/139) 17% (68/409) Northeast 23% (41/175) 18% (26/146) NYC: Total 22% (1383/6186) 26% (1599/6054) Bronx 20% (399/1963) 42% (185/445) Brooklyn 23% (350/1503) 23% (238/1055) Manhattan 23% (456/1992) 26% (1106/4310) Queens 26% (150/583) 30% (70/235) Staten Island 19% (28/145) 0% (0/0) 23

24 Not Retained by Characteristic % of Not Retained (direct ehivqual) % of Not Retained (Azara Extract) NYS 23% (1894/8088) 25% (1749/6907) Gender: Male 24% (1146/4852) 26% (1342/5107) Gender: Female 23% (726/3163) 21% (306/1490) Gender: MtF 28% (19/69) 33% (87/261) Gender: FtM 75% (3/4) 29% (14/49) Race/Ethnicity: Black 26% (1063/4121) 28% (809/2927) Race/Ethnicity: Hispanic 20% (489/2485) 22% (462/2107) Race/Ethnicity: White 24% (274/1148) 27% (333/1229) Race/Ethnicity: Asian 19% (17/80) 10% (21/208) Race/Ethnicity: Other 21% (54/244) 28% (124/436) Risk Factor: Heterosexual 24% (986/3118) 24% (474/2014) Risk Factor: MSM 23% (434/1869) 26% (946/3635) Risk Factor: IDU 20% (235/1150) 25% (123/498) Risk Factor: Other* 25% (239/965) 27% (206/760) Age: 13 to 24 36% (86/242) 35% (81/233) Age: 25 to 49 27% (1022/3796) 27% (1185/4326) Age: 50 to 59 21% (599/2791) 22% (391/1764) Age: 60 to 69 15% (160/1055) 15% (80/523) Age: % (25/204) 20% (12/61) Housing: Stable 22% (1478/6738) 24% (1065/4457) Housing: Unknown 30% (296/989) 24% (410/1745) Housing: Unstable 33% (120/361) 39% (274/705) *Other risk factors may include hemophilia/coagulation disorders, transfusion, other risk factors, and unknown risk factors 24

25 Clinical Visit Frequency 2000 Number of Visits for Each Patient During the Review Period* Number of Direct ehivqual Azara Extract Number of Visits per Patient *9 patients from the direct ehivqual submission review and 8 patients from the Azara extract review with >30 visits are not shown in the above graph. The maximum number of visits was 47 and 42 among direct ehivqual submissions and Azara extract submissions, respectively. 25

26 Viral Load Suppression and Retention by Patient Characteristic 24-Month Retention and Viral Load Suppression by Age* Direct ehivqual Submissions (n=8,088) % of 100% 80% 60% 40% 78% % Suppressed 67% % Retained 75% 63% 78% 68% 81% 73% 84% 78% 88% 89% 81% 86% 20% 0% <19 n= n= n=945 Azara Extract Submissions (n=6,907) n=1451 Age n= n= n=554 % of 100% 80% 60% 40% 100% 67% % Suppressed % Retained 70% 64% 81% 82% 82% 70% 74% 74% 86% 87% 82% 85% 20% 0% <19 n= n= n= n= n= n=1055 *Restricted to patients eligible for 24-month retention indicator. Last viral load and 24 month retention are used to define suppression and retention. Younger patients are less likely to be continuously engaged in care and to achieve viral load suppression. Those in the <19 group for the Azara extract review showed 100% retention; however, sample sizes were small. While viral load suppression rates increased for most age groups between 2013 and 2014, retention rates decreased for all age groups (with the exception of the <19 Azara extract group). Note: In this analysis, any patients without viral load testing data were considered unsuppressed. 65+ n= Age

27 Viral Load Suppression and Retention by Patient Group Direct ehivqual Submissions (n=8,088)* MSM: Asians, Pacific Islanders, Alaskan Natives MSM: White % Retained 91% 94% % Suppressed 79% 93% MSM 30: Black, Hispanic, Multi-Race Heterosexual Females Heterosexual Males 77% 77% 76% 86% 84% 84% Patient Group Unknown IDU 76% 83% 80% 82% Other 73% MSM < 30: Black, Hispanic, Multi-Race Transgender MtF 69% 80% 76% 78% Women < 30: Black, Hispanic, Multi-Race 62% 71% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % Suppressed and Retained *Restricted to patients eligible for the 24-month retention indicator. Last viral load and 24-month retention are used to define suppression and retention. 27

28 Azara Extract Submissions (n=6,907)* MSM: Asians, Pacific Islanders, Alaskan Natives MSM: White % Retained 85% 92% % Suppressed 73% 91% MSM 30: Black, Hispanic, Multi-Race 75% 86% Heterosexual Females 79% 82% Patient Group Other MSM < 30: Black, Hispanic, Multi-Race Unknown Heterosexual Males IDU 74% 81% 71% 80% 73% 78% 74% 76% 75% 76% Transgender MtF Women < 30: Black, Hispanic, Multi-Race 64% 66% 71% 74% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % Suppressed and Retained *Restricted to patients eligible for the 24-month retention indicator. Last viral load and 24-month retention are used to define suppression and retention. All patient groups analyzed above from the direct ehivqual submission review and most patient groups analyzed from the Azara extract review show higher rates of viral load suppression than retention. This indicates that viral load suppression is achievable without retention, as measured by the ehivqual indicator. 28

29 Disparities in Viral Load Suppression and Retention by Patient Group The ehivqual review revealed statewide disparities in viral load suppression and retention in care. Disparities were characterized by mutually exclusive patient subgroups and arranged in order of ascending viral load suppression. Direct ehivqual Submissions Risk Group # % Suppressed % Retained Women < 30: Black, Hispanic, Multi-Race % 62% Transgender MtF 54 78% 76% MSM < 30: Black, Hispanic, Multi-Race % 69% Other % 73% IDU % 80% Unknown % 76% Heterosexual Males % 76% Heterosexual Females % 77% MSM 30: Black, Hispanic, Multi-Race % 77% MSM: White % 79% MSM: Asians, Pacific Islanders, Alaskan Natives 32 94% 91% Azara Extract Submissions Risk Group # % Suppressed % Retained Women < 30: Black, Hispanic, Multi-Race 58 64% 74% Transgender MtF % 66% IDU % 75% Heterosexual Males % 74% Unknown % 73% MSM < 30: Black, Hispanic, Multi-Race % 71% Other % 74% Heterosexual Females % 79% MSM 30: Black, Hispanic, Multi-Race % 75% MSM: White % 73% MSM: Asians, Pacific Islanders, Alaskan Natives % 85% 29

30 Antiretroviral Therapy Usage Antiretroviral Therapy 2014 Mean: 92%, 2013 Mean: 91% Direct ehivqual Submissions Clinics Antiretroviral Therapy: Percentage of patients with at least one ART drug prescribed at any time during or before the review period, and not ended before the review period. Exclusions: None Clinic Mean % Treated % Treated NYS % 95% Azara Extract Submissions Clinics Not on ART (n=1,331) Clinic Mean % Treated % Treated NYS % 92% Of the 20,298 patients included in the review*, 1,331 were not prescribed an ART drug during or before the review period. *Includes core review for direct ehivqual submissions and all patients for Azara extract submissions Not on ART by Region % of Not on ART (direct ehivqual) % of Not on ART (Azara extract) NYS: Total 5% (565/10375) 8% (766/9923) Central West 3% (27/1038) 0% (0/0) Long Island 3% (14/444) 7% (12/181) Lower Hudson 8% (34/417) 4% (7/186) Mid Hudson 7% (13/175) 3% (14/498) Northeast 4% (8/209) 4% (9/206) NYC: Total 6% (463/8092) 8% (724/8852) Bronx 6% (147/2602) 18% (141/796) Brooklyn 6% (124/1935) 9% (147/1642) Manhattan 6% (141/2457) 7% (395/6076) Queens 6% (51/917) 12% (41/338) Staten Island 3% (6/181) 0% (0/0) 30

31 Not on ART by Characteristic % of Not on ART (direct ehivqual) % of Not on ART (Azara Extract) NYS 5% (565/10375) 8% (766/9923) Gender: Male 5% (324/6395) 7% (536/7368) Gender: Female 6% (235/3864) 8% (175/2069) Gender: MtF 5% (6/111) 12% (49/418) Gender: FtM 0% (0/5) 9% (6/68) Race/Ethnicity: Black 6% (344/5322) 10% (423/4381) Race/Ethnicity: Hispanic 5% (148/3137) 6% (187/2910) Race/Ethnicity: White 4% (51/1459) 5% (92/1713) Race/Ethnicity: Asian 2% (3/132) 4% (10/280) Race/Ethnicity: Other 6% (19/325) 8% (54/639) Risk Factor: Heterosexual 6% (284/5079) 8% (218/2851) Risk Factor: MSM 5% (126/2562) 6% (331/5172) Risk Factor: IDU 5% (67/1394) 10% (74/746) Risk Factor: Other* 7% (88/1340) 12% (143/1154) Age: 13 to 24 10% (46/468) 17% (94/545) Age: 25 to 49 6% (308/5123) 8% (470/6256) Age: 50 to 59 4% (145/3307) 6% (149/2366) Age: 60 to 69 4% (54/1237) 8% (51/676) Age: 70+ 5% (12/240) 3% (2/80) Housing: Stable 5% (410/8336) 6% (388/6051) Housing: Unknown 7% (97/1404) 5% (131/2475) Housing: Unstable 9% (58/635) 18% (247/1397) *Other risk factors may include hemophilia/coagulation disorders, transfusion, other risk factors, and unknown risk factors 31

32 Baseline Resistance Testing ARV-Na ve with a Baseline Resistance Test Prior to ARV Initiation 2014 Mean: 77%, 2013 Mean: 74% Direct ehivqual Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 98% 78% 100% 0% 100% Azara Extract Submissions Clinics Clinic Mean Median 25th 75th Min Max NYS % 60% 44% 100% 0% 100% Baseline Resistance: Percentage of patients who had one or more VL values recorded as >500 copies/ml during the review period prior to ARV initiation, were ARV-na ve at the start of the review period, and initiated ARV therapy during the review period, for whom a baseline resistance test was performed any time prior to ARV initiation, either during the review period OR at any time preceding it. Exclusions: None 32

33 Sexually Transmitted Infections Genital Chlamydia Testing Women: Mean=62% Men: Mean=59% MtF: Mean=61% (Direct ehivqual) Genital Testing Mean % Screened (Direct ehivqual) (Azara extract) Genital Testing Mean % Screened (Azara Extract) NYS % % Gender: F % % Females % 53 74% Gender: M % % MSM % % Gender: MtF % % Genital Chlamydia Testing: Percentage of patients who had one or more genital (urine, cervical, urethral, or vaginal) tests for Chlamydia performed during the review period. Exclusions: None Genital Gonorrhea Testing Women: Mean=61% Men: Mean=58% MtF: Mean=60% Genital Gonorrhea Testing: Percentage of patients who had one or more genital (urine, cervical, urethral, or vaginal) tests for gonorrhea performed during the review period. Exclusions: None (Direct ehivqual) Genital Testing Mean % Screened (Direct ehivqual) (Azara extract) Genital Testing Mean % Screened (Azara Extract) NYS % % Gender: F % % Females % 53 72% Gender: M % % MSM % % Gender: MtF % % 33