Provider Cardiovascular Risk Management in an Urban HIV Practice: Challenges and Opportunities

Transcription

1 Provider Cardiovascular Risk Management in an Urban HIV Practice: Challenges and Opportunities Presented by: Martha Abshire, PhD(Candidate), MS, RN Yvonne Commodore-Mensah, PhD,RN Cheryl Dennison Himmelfarb, PhD, MSN, APN Jason Edward Farley, PhD, CRNP, MPH (PI) JOHNS HOPKINS SCHOOL OF NURSING

2 No Disclosures Funding The Center for Excellence in Cardiovascular Health NINR pilot grant P30NR F31 1 F31 NR A1 (PI: Abshire) TL1 TR (PI: Beach) T32 NR (PI: Allen) 2

3 Purpose To examine provider self efficacy and the use of evidence-based CVD prevention practices in a retrospective cohort of PLWH in an urban HIV clinic 3

4 Age-adjusted Mortality Rate per 10,000 PLWH Cardiovascular-related Disease is a Leading Cause of Non-HIV-related Death Age-adjusted Mortality Rate in HIV+ by Underlying Cause of Death, New York City ( ) DEATHS N=68,669 Overall HIV-Related Non-HIV-Related Cardiovascular-Related Cancer-Related Substance Abuse-Related Sackoff, et al. Ann Int Med. 2006;145:

5 Potential CVD Risk in HIV Patients Traditional CVD Risk Factors (Non-HIV) HIV Infection Inflammatory Response Treatment of HIV ART metabolic side effects 5

6 Background Provider-patient relationship impacts patient adherence to guideline-based care. 8 Provider use of guidelines to drive care has been implemented less than optimally in many populations. 9 Known barriers to the delivery of guideline based care include the heavy workload of providers, time to execute guideline based care, and the rigidity of guidelines. 10 6

7 Methods Study Design: Retrospective medical record review utilizing electronic, manual and database abstraction procedures Setting: Inner-city HIV clinic based at Johns Hopkins Hospital Sample Design: Two-stage sampling: 20/37(54%) providers agreed to participate. 12 MDs, 6 NPs, 2 PAs participated. 10 randomly chosen medical records were selected per provider Exclusion Criterion: Clinically-diagnosed CVD Ethics Approval: Johns Hopkins Medicine IRB 7

8 Methods (cont d) Data abstraction process 1. Manual chart reviewed by Trained RAs 2. Records converted into PDF format 3. Second search conducted by using key words in PDFs 4. Demographic data verified through clinical and social work databases 5. Data abstraction verified by Research Nurse Statistical methods Descriptive statistics STATA 13 8

9 Provider Characteristics 9

10 Provider Characteristics (N=20) Characteristic % Sex (Females) 65 Race/Ethnicity Black/African American 5 Caucasian/White 65 Other 30 Profession designation Physician (MD)/(DO) 60 Nurse Practitioner (NP) 30 Physician Assistant (PA) 10 Number of years in practice (Mean ± SD ) 13.2 ± 8.22 Number of years providing HIV care (Mean ± SD ) 11.3 ± 5.63 Continuing Education on CVD prevention (No) 32 10

11 % responding familiar/comfortable MD vs. NP/PA Self-Efficacy on CVD Risk Management (N=20) 100% 90% *p= % 70% MD 60% 50% NP/PA 40% 30% 20% 10% 0% CVD prevention guidelines Dietary modification Exercise/PA Meds to manage CVD risk* Smoking cessation 11

12 Provider reported barriers to CVD prevention % of Providers rating barriers as most important /important Patient factors 71% Time to implement these recommendations in clinic Complexity of the individual patient Knowledge/agreement with guideline recommendations Your personal ability to mitigate CV risk factors 61% 39% 21% 18% 12

13 Patient Characteristics 13

14 Patient characteristics (N=200) Characteristic n(%) Age, mean ± SD 48.1±8.9 Females 83 (42) Race Black/African American Caucasian/White Other 156 (78) 34 (17) 10 (5) Employed 64 (33) High School Education 40 (21) Viral load 50 copies 104(55) Type of care Primary Specialty 151 (77) 46 (23) 14

15 CVD Risk Management 15

16 Patient Characteristics Provider Management Weight Body Mass Index (BMI) kg/m 2 (mean ± SD) BMI <18.5 (Underweight) BMI (Normal) BMI (Overweight) BMI 30 (Obese) Documented history of overweight/obesity BMI 25 at first visit Dietary Counseling (BMI >25) Recommended physical activity Weight reduction measures 27.0±6.9 2 (1) 75 (43) 57 (32) 42 (24) 81 (41) 114 (57) 54 (47) 45 (40) 26 (23) 16

17 Patient Characteristics Smoking Smoking status Current Past Never Not documented 89 (44) 41 (21) 49 (25) 21 (10) Provider Management Documented history of smoking 179 (89) Current smokers Asked about nature of tobacco use Advised to quit Offered assistance to quit Prescribed smoking cessation medications 89 (45) 85 (96) 59 (66) 45 (51) 21 (24) 17

18 Blood Pressure Patient Characteristics Blood Pressure over 12 months Mean SBP (mmhg) ± SD Mean DBP (mmhg) ± SD 129 ± ± 8.7 Provider Management Documented history of HTN or on anti-htn meds If BP elevated, hx of HTN or taking anti-htn meds Salt reduction recommended DASH diet recommended Alcohol reduction recommended Weight reduction recommended 93/200 (47) 94/200 (47) 30 (34) 22 (25) 12 (14) 25 (29) 18

19 Cholesterol Patient Characteristics Cholesterol over 12 months Mean HDL-C Mean LDL-C Mean Total Cholesterol LDL-C > 130 Mean if LDL-C > ± ± ± /119 (14) ± 27.1 Provider Management Documented history of dyslipidemia On lipid meds 55/190 (28) 47/200 Of those on lipid-lowering meds Mean LDLC Controlled (LDL-C<130) 96.7 ± /38 (74) 19

20 Summary of findings CVD risk prevalence was high CVD risk management, especially lifestyle modification, was suboptimal Provider self-efficacy was generally high, but CVD medication management is a possible area for improvement. Important barriers to providing CVD risk management were patient-specific factors and time 20

21 Limitations Retrospective chart review and self-reported measures by providers CVD management guidelines have changed since this data was collected. Unvalidated measures were used to examine provider self-efficacy and barriers 21

22 Implications for Research & Practice CVD risk management in PLWH is complex and increased education, particularly for primary care providers is important Evidence-based guidelines for managing CVD risk in PLWH should be developed Provider related barriers to managing CVD risk must be addressed to improve provider adherence to CVD guidelines 22

23 Acknowledgements Jackie Johnson (Research Assistant) Kelly Lowensen (Research Nurse) Johns Hopkins Moore Clinic Providers Johns Hopkins Moore Clinic Patients 23

24 nursing.jhu.edu