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The American Journal of Managed Care June 2019
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Currently Reading
Enhanced Care Coordination Improves HIV Viral Load Suppression Rates
Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
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Thomas B. Valuck, MD, JD; Sarah Sampsel, MPH; David M. Sloan, PhD; and Jennifer Van Meter, PharmD

Enhanced Care Coordination Improves HIV Viral Load Suppression Rates

Ross G. Hewitt, MD; Debra Williams, EdD; Richard Adule; Ira Feldman, MPS; and Moe Alsumidaie, MBA, MSF
Enhanced care coordination in New York City that leveraged surveillance data with a health plan’s Medicaid managed care roster improved its HIV viral load suppression rate.
RESULTS

Study Population Derivation

The cross-referenced state list contained 1741 members (Figure 1). After eliminating members who were disenrolled from the plan as of January 1, 2016, the study population consisted of 1429 actively enrolled members during the 2-year study interval. Of those, 1410 members had at least 1 viral load value, 1216 had more than 1 viral load value, and 901 had more than 2 viral load values. Of those, 500 members had an initial viral load value within 90 days before or after the program initiation date of January 1, 2016 (comparable group). Of those, 316 members had an initial unsuppressed viral load value (unsuppressed-at-baseline group).

Baseline Characteristics

The targeted population represented 24% (1429/5919) of the total identified HIV-positive Medicaid population actively enrolled with the plan at the time of the program initiation. The baseline characteristics of all targeted members, those with comparable (baseline and current) viral loads, and those with unsuppressed viral loads at baseline are summarized in Table 1. Because of the nearly 6-month gap between receipt of the list from the state and the program initiation, 184 listed members had already achieved viral load suppression. The comparable and unsuppressed groups were representative of the total population with respect to age, gender, and baseline CD4 count. A relative proportion (13%-15%) of those referred to the street outreach intervention contributed to the composition of all 3 groups.

Program Contact

Contact with either the outreach or peer care connection interventions is summarized in Table 2. The total population, comparable, and unsuppressed groups had 56%, 61%, and 61% successful contacts with the outreach team, respectively, compared with 40%, 44%, and 44% successful contacts by the care coordinators and the peer educators/counselors combined, respectively. Thus, a notable portion of members from all groups were engaged in care but did not have any successful contact with the program staff. Despite our best efforts, the program could not contact every targeted member.

Viral Load Suppression

The viral load suppression rates at last observation were 40.9%, 47.4%, and 38.6% for the total population, comparable, and unsuppressed-at-baseline groups, respectively, suggesting that members in the program experienced significantly improved viral load suppression (P <.01 for both groups) (Figure 2). Members with viral loads in the suppressed range increased by 10.6% in the comparable group. However, members with viral loads of 100,000 copies/mL or greater increased by 3%. The observed increase in viral load suppression was even greater in the unsuppressed-at-baseline group, as seen in Figure 2B. Members with viral loads in the suppressed range increased by 38.61% at current viral load measurement, whereas members with viral loads of 100,000 copies/mL or greater increased by 3.16%. The fact that some members’ viral loads increased to more than 100,000 copies/mL indicates poor, if any, medication adherence in this small percentage of the population.

Viral load movement patterns in the comparable group are visualized in a KDE plot (Figure 3) (P <.01). This plot confirms that many members experienced viral load suppression, even those in the high viral load ranges (≥10,000 copies/mL). Nonetheless, the plot also demonstrates that members who had higher viral loads at program initiation were somewhat less likely to lower their viral loads at current viral load measurement.

Approximately one-third of members with unsuppressed viral loads at baseline in the higher viral load ranges (>10,000) achieved viral load suppression at current viral load measurement, compared with 40% to 51% of members in the lower viral load ranges (eAppendix Figure [available at ajmc.com]) (P <.01).

However, of the 1410 members with at least 1 viral load value, 44% (417/945) who were successfully contacted achieved viral suppression compared with 34% (157/465) who were not (OR, 1.55; 95% CI, 1.23-1.95; P <.01). Therefore, successful contact was associated with an improved health outcome.


 
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