Care Enrollment Research Articles

Patterns of Laboratory Monitoring in Adults with Diabetes: What Factors Affect the Implementation of Clinical Practice Guidelines?

National evidence-based guidelines recommend that people with diabetes have their HbA1c, blood lipids and albumin:creatinine ratio (ACR) monitored at least annually. However, international literature indicates a quality of care gap between the published clinical recommendations and actual clinical practice. A prospective cohort study was conducted to examine the patterns of laboratory monitoring in people with diabetes by linking patient profile data generated in routine primary care practice in 2 major regions of New Zealand between 2005 and 2012 with national and regional datasets (primary care enrolment, laboratory tests, hospitalizations, mortality and pharmaceuticals).We identified 56,933 people aged ≥35 years with diabetes. People were defined as being monitored according to recommended guidelines if they had ≥1 test a year from entry into the cohort. The proportion monitored yearly varied between 27.5% and 100% (mean=72.7%, SD=24.0%) for HbA1c, 17.1% to 100% (mean=66.0%, SD=27.5%) for blood lipids and 10% to 100% (mean=57.3%, SD=29.0%) for ACR. For most of laboratory monitoring indices, increasing age, body mass index (BMI), race, area deprivation, smoking status and having a previous cardiovascular disease (CVD) event were significantly associated with a higher likelihood of being monitored according to the guidelines. This study revealed that a small proportion of people with diabetes were being consistently monitored according to the recommended guidelines over an 8-year period, with HbA1c being monitored the most. Risk factors for CVD were associated with an increased likelihood of being monitored according to recommended guidelines. Developing more pro-active audit and feedback strategies for appropriate monitoring may support primary care achievement of recommended monitoring goals.

Operating Characteristics of a Tuberculosis Screening Tool for People Living with HIV in Out-Patient HIV Care and Treatment Services, Rwanda

BackgroundThe World Health Organization (WHO) 2010 guidelines for intensified tuberculosis (TB) case finding (ICF) among people living with HIV (PLHIV) includes a recommendation that PLHIV receive routine TB screening. Since 2005, the Rwandan Ministry of Health has been using a five-question screening tool. Our study objective was to assess the operating characteristics of the tool designed to identify PLHIV with presumptive TB as measured against a composite reference standard, including bacteriologically confirmed TB.MethodsIn a cross-sectional study, the TB screening tool was routinely administered at enrolment in outpatient HIV care and treatment services at seven public health facilities. From March to September 2011, study enrollees were examined for TB disease irrespective of TB screening outcome. The examination consisted of a chest radiograph (CXR), three sputum smears (SS), sputum culture (SC) and polymerase chain reaction line-probe assay (Hain test). PLHIV were classified as having “laboratory-confirmed TB” with positive results on SS for acid-fast bacilli, SC on Lowenstein-Jensen medium, or a Hain test.ResultsOverall, 1,767 patients were enrolled and screened of which; 1,017 (57.6%) were female, median age was 33 (IQR, 27–41), and median CD4+ cell count was 385 (IQR, 229–563) cells/mm3. Of the patients screened, 138 (7.8%) were diagnosed with TB of which; 125 (90.5%) were laboratory-confirmed pulmonary TB. Of 404 (22.9%) patients who screened positive and 1,363 (77.1%) who screened negative, 79 (19.5%) and 59 (4.3%), respectively, were diagnosed with TB. For laboratory-confirmed TB, the tool had a sensitivity of 54.4% (95% CI 45.3–63.3), specificity of 79.5% (95% CI 77.5–81.5), PPV of 16.8% and NPV of 95.8%.ConclusionTB prevalence among PLHIV newly enrolling into HIV care and treatment was 65 times greater than the overall population prevalence. However, the performance of the tool was poorer than the predicted performance of the WHO recommended TB screening questions.

Pregnancy in Sickle Cell Disease Patients: A Single Centre Study

1.1.Background: In Nigeria, there is a gradual improvement in Health care delivery in the past three decades, this has also impacted positively on the live span of Sickle cell disease with increasing number of the females attaining the age of marriage and becoming pregnant. This however, poses obstetric complications if pregnancy progresses without adequate care and follow-up. This study aimed at determining the prevalence and challenges of SCD pregnant women seen in ante-natal clinic in Port Harcourt, River state (South-south region) Nigeria. 1.2.Methodology: This was a ten years retrospective study, conducted at Braithwaite Memorial Specialist Hospital, Port Harcourt. The Subjects were seen at the Ante-natal Clinic of the Hospital and a total of 35,976 pregnant women had their ante-natal care and delivery at the hospital from January 2003-January 2013. All the patients were screened for SCD, on enrollment for ante-natal care. Other relevant investigations were also carried out including Full blood Count, Genotype, Electrolyte, Urea, Creatinine, Fasting blood sugar, abdominal Ultrasound and Urinalysis. Data analysis was obtained using Statistical software Epi-info version 7.02 by WHO, Geneva, Switzerland and CDC, USA. 1.3.Result:A total of 35,976 pregnant women were seen at the ante-natal clinic within the study period. Twenty eight thousand, eight hundred and fifteen (80.09%) of women were Hb AA, 7,109 (19.77%) were Hb AS and 52 were Hb SS (prevalence of 1.4 per 1000 pregnant women). The average booking gestational ages of 22.2 and 29.1 weeks were recorded for SCD and non-SCD participants respectively. The Tertiary level of education was relatively higher among the SCD (60%) compared to non-SCD (58.05%) population, although this was not statistically significant. A total of 13,276 (39.2%) and 49 (94.2%) of non-SCD and SCD respondents respectively had Hb concentration below 11 g/dl (anemia) (P=0.001). 1.4.Conclusion:The prevalence of sickle cell disease in pregnancy is on the gradual increase in this region, probably due to improving Health care provision in Nigeria. A common challenge among the SCD patients is that more than 94% had Hemoglobin level below 11g/dl which may pose some challenge in successful management of the patients.

Parasite dynamics in the peripheral blood and the placenta during pregnancy-associated malaria infection.

BackgroundMalaria infections during pregnancy lead to sequestration of parasite infected red blood cells in the placenta. Placental infection can result in adverse outcomes for mothers and infants. Despite many studies, it remains unclear which peripheral blood infections during pregnancy lead to development of placental malaria. Understanding the timing of peripheral infections that lead to placental malaria and the ability of intermittent preventive treatment with sulfadoxine–pyrimethamine (SP-IPT) and artemisinin-based combination therapy to clear infections will enable the rational design of new interventions to decrease the burden of malaria in pregnancy.MethodsMicrosatellite markers were used to genotype peripheral and placental malaria infections in an observational cohort in Blantyre, Malawi. Genotypes were compared to determine the timing of infections that sequester in the placenta. The effects of SP-IPT and artemether–lumefantrine as curative treatment were also evaluated by assessing the occurrence of peripheral infections or matching genotypes between peripheral and placental parasites following treatment.ResultsGenotypes from 92 peripheral samples prior to delivery, 26 peripheral samples at delivery, and 29 placental samples were compared. Thirty percent of women with genotyped parasites in their placentas that had peripheral infections detected during pregnancy had matching peripheral-placental genotypes. Matching genotypes were not associated with gestational age and occurred from 13 to 39 weeks. Among women with more than one genotyped peripheral infection during pregnancy, 80 % had persistent infection with the same genotype while the remaining were new infections. Among infections treated with SP or artemether–lumefantrine, 28/84 (33 %) and 9/56 (16 %) had infection detected after treatment, respectively. Recrudescent infections were detected after both treatments and occurred up to 76 days after treatment. Women treated with SP-IPT and artemether–lumefantrine had genotypes matching treated infections detected in the placenta.ConclusionsPlacental malaria can occur at any time during pregnancy. In the context of late enrollment in antenatal care, interventions that protect all women of childbearing age and throughout pregnancy are needed. Currently used medications do not always clear peripheral or placental infections. The ability of anti-malarial drugs to prevent or clear placental infections should be considered in the development of future interventions.

A longitudinal, HIV care continuum: 10-year restricted mean time in each care continuum stage after enrollment in care, by history of IDU.

We present a novel, patient-centric, longitudinal summary of patient progress through the HIV care continuum. Using this new approach, we compare person-time spent alive, in care, on antiretroviral therapy (ART), and virally suppressed among people who inject drugs (PWID) and those who do not (non-IDU). Prospective clinical observational cohort study. We followed ART-naive patients with detectable HIV viral loads who enrolled in the Johns Hopkins HIV Clinical Cohort from enrollment until the occurrence of several care continuum-related milestones, including ART initiation and viral suppression, and until several care continuum-related failures, including loss to clinic and death. We added and subtracted cumulative incidence curves to estimate the proportion of the cohort in each of seven continuum stages across the 10 years following enrollment in clinical care. PWID composed 32% of the study sample (n = 1443). Over 10 years following enrollment in care, PWID and non-IDU spent only 23 and 37%, respectively, of person-time in care, on ART, and virally suppressed. PWID lost 8.9 more months of life compared with non-IDU and spent an additional 5.0 months on ART but not virally suppressed, and an additional 5.5 months in care but not on ART. There were not meaningful improvements in the 5-year restricted mean person-time differences comparing PWID to non-IDU across enrollment cohorts (2000-2003, 2004-2007, 2008-2014). Efforts to increase viral suppression among PWID should focus on increasing ART initiation and improving adherence to therapy.

High weight gain during pregnancy increases the risk for emergency caesarean section – Population-based data from the Swedish Maternal Health Care Register 2011–2012

ObjectiveThe aim was to investigate maternal background factors' significance in relation to risk of elective and emergency caesarean sections (CS) in Sweden. Study designPopulation-based, retrospective, cross-sectional study. The Swedish Maternal Health Care Register (MHCR) is a national quality register that collects data on pregnancy, delivery and postpartum period. All women registered in MHCR 2011 to 2012 were included in the study sample (N = 178,716). Main outcomesThe risk of elective and emergency caesarean section in relation to age, parity, education, country of origin, weight in early pregnancy and weight gain during pregnancy was calculated in logistic regression models. ResultsMultiparous women demonstrated a doubled risk of elective CS compared to primiparous women, but their risk for emergency CS was halved. Overweight and obesity at enrolment in antenatal care increased the risk for emergency CS, irrespective of parity. Weight gain above recommended international levels (Institute of Medicine, IOM) during pregnancy increased the risk for emergency CS for women with normal weight, overweight or obesity. ConclusionThere is a need of national guidelines on recommended weight gain during pregnancy in Sweden. We suggest that the usefulness of the IOM guidelines for weight gain during pregnancy should be evaluated in the Swedish context.

Community-Based HIV and Health Testing for High-Risk Adolescents and Youth.

Adolescents account for 40% of new HIV infections, and HIV testing strategies to increase uptake of testing are needed. A community-based adolescent and youth HIV and health testing campaign was conducted in seven slum neighborhoods of Port-au-Prince, Haiti, from December 2014 to September 2015. Community health workers provided community sensitization and recruited 10- to 24-year-olds to test for HIV, syphilis, gonorrhea/chlamydia, and to screen for tuberculosis (TB) and pregnancy. HIV-infected individuals were escorted to the GHESKIO HIV clinic for same-day enrollment in care. Among 3425 individuals eligible for testing, 3348 (98%) accepted an HIV test. HIV prevalence was 2.65% (n = 89). Median age was 19 [interquartile range (IQR) 17-20]; 73% were female. HIV prevalence was 0.6-7.4% across slum neighborhoods. All HIV-infected individuals enrolled in care the same day as testing; median CD4 was 529 cells/μL [IQR 363-761]. Syphilis prevalence was 2.60% (65/2536) and gonorrhea/chlamydia prevalence was 6.25% (96/1536). Among 168 (5%) individuals who reported TB symptoms, 7.7% (13/168) had microbiologically confirmed disease. One hundred twenty-nine females (5% of all females) were pregnant. This community-based testing campaign identified an adolescent and youth population with an HIV prevalence six times higher than the estimated national adolescent HIV prevalence (0.4%) in Haiti, including perinatally infected adolescents. This type of community-based campaign for HIV testing within a package of services can serve as a model for other resource-poor settings to identify high-risk adolescents and youth, and curb the global HIV epidemic among adolescents.

Psychometric properties of the Barriers to Treatment Participation Scale-Expectancies.

Expectations concerning barriers to children's psychosocial care seem to be major drivers when seeking help, but validated questionnaires measuring expectations are not available. Therefore, this study examined the psychometric properties of the parent and adolescent versions of the Barriers to Treatment Participation Scale-Expectancies (BTPS-exp), in terms of consistency, structure, parent-child agreement, and validity. The authors obtained data via questionnaires on 1,382 Dutch children aged 4-18 years (response rate 56.6%) enrolled in psychosocial care, and on 666 children (response rate 70.3%) from the community. Internal consistencies of the BTPS-exp total and subscales of both versions were good (lowest Cronbach's alpha = .85). Fit of the data with the assumed scale structure was acceptable. Correlation coefficients between the parent and adolescent scores were low (Pearson's r total scale = 0.25). Parents expecting multiple barriers was significantly more likely in non-Dutch ethnicity (odds ratio [OR] = 1.4; 95% confidence interval [CI] [1.1, 1.9]), in lower parental educational levels (primary education: OR = 3.0; 95% CI [1.5, 6.1]; lower-level secondary education: OR = 2.0; 95% CI [1.3, 3.1], both vs. university), in single parent families (1.3; 1.1-1.6), in case of child psychosocial problems (OR = 1.3; 95% CI [1.0, 1.5]) and in adolescents with psychosocial problems (OR = 2.1; 95% CI [1.4, 3.1]). Expecting multiple barriers did not affect the association between psychosocial problems and care enrollment. The authors conclude that the BTPS-exp has good psychometric properties regarding reliability and structure and is reasonably valid. Parents and adolescents have their own separate views, implying that it is valuable to assess both. Use of the scale might be helpful in providing direction to improve access to psychosocial care for children and adolescents. (PsycINFO Database Record

Assessment of linkages from HIV testing to enrolment and retention in HIV care in Central Mozambique.

IntroductionEffectiveness of the rapid expansion of antiretroviral therapy (ART) throughout sub-Saharan Africa is highly dependent on adequate enrolment and retention in HIV care. However, the measurement of both has been challenging in these settings. This study aimed to assess enrolment and retention in HIV care (pre-ART and ART) among HIV-positive adults in Central Mozambique, including identification of barriers and facilitators.MethodsWe assessed linkages to and retention in HIV care using a mixed quantitative and qualitative approach in six districts of Manica and Sofala provinces. We analyzed routine district and health facility monthly reports and HIV care registries from April 2012 to March 2013 and used single imputation and trimmed means to adjust for missing values. In eight health facilities in the same districts and period, we assessed retention in HIV care among 795 randomly selected adult patient charts (15 years and older). We also conducted 25 focus group discussions and 53 in-depth interviews with HIV-positive adults, healthcare providers and community members to identify facilitators and barriers to enrolment and retention in HIV care.ResultsOverall, 46% of the monthly HIV testing reports expected at the district level were missing, compared to 6.4% of the pre-ART registry reports. After adjustment for missing values, we estimated that the aggregate numbers of adults registered in pre-ART was 75% of the number of persons tested HIV-positive in the six districts. In the eight health facilities, 40% of the patient charts for adults enrolled in pre-ART and 44% in ART were missing. Of those on ART for whom charts were found, retention in treatment within 90 and 60 days prior to the study team visit was 34 and 25%, respectively. Combining these multiple data sources, the overall estimated retention was 18% in our sample. Individual-level factors were perceived to be key influences to enrolment in HIV care, while health facility and structural-level factors were perceived to be key influences of retention.ConclusionsEfforts to increase linkages to and retention in HIV care should address individual, health facility, and structural-level factors in Central Mozambique. However, their outcomes cannot be reliably assessed without improving the quality of routine health information systems.

Georgia Latino Enrollment in the Affordable Care Act: A Qualitative, Key Informant Analysis

Georgia Latino Enrollment in the Affordable Care Act: A Qualitative, Key Informant Analysis

Abstract IA29: Race, ethnicity, and outcomes in breast cancer

Abstract The racial divide in breast cancer outcomes is well known. Breast cancer is the most common cause of cancer in women in the United States, and the second leading cause of cancer death.1 Black race is associated with a worse prognosis in operable breast cancer2 and in other hormone dependent cancers such as uterine and prostate cancer, but generally not other cancer types.3,4 Black women are more likely to present with advanced stage disease5, have triple negative breast cancer (TNBC), exhibit greater non-adherence and poorer tolerance to chemotherapy6 and endocrine therapy7, and have more comorbidities8 and experience more disparities in care.9-11 Black race has also been associated with worse outcome in male breast cancer.12 Although breast cancer incidence and mortality have declined by about 35% in the United States since 1990, mortality rates have declined less in black women, contributing to a widening of the racial gap which has contributed to about a 35% higher mortality rate for black women compared with others.13 However, a widening racial gap has also been observed for women in the U.S. Department of Defense healthcare system, suggesting that factors other than disparities in care may be playing a role. 14 With regard to ethnicity, Hispanic women also exhibit higher rates of TNBC, but otherwise experience similar outcomes as non-Hispanic women. There is emerging evidence that differences in outcomes may be due in part due to factors other than disparities in care. In this review, we explore some of the biological factors that may be contributing to the racial divide in breast cancer.

Abstract 133: Comparison of CMS Medicare Beneficiaries Enrolled in Fee-For-Service and Managed Care Programs. The Atherosclerosis Risk In Communities (ARIC) Study

Background: Healthcare utilization analyses often are conducted with Centers for Medicare and Medicaid (CMS) data from fee-for-service (FFS) Medicare beneficiaries. Although use of preventive care services is greater among beneficiaries in managed care programs compared with those in FFS care, evidence of the effect of managed care enrollment on health outcomes is mixed. We compared the health status of ARIC cohort participants enrolled in FFS to those enrolled in managed care. Methods: Data for participants of the ARIC Study cohort were linked with CMS Medicare claims for the years 1991-2012 (N=14,695). Participants missing coverage start date or enrolled prior to 1991 were excluded from analyses (N=2,513). Enrollment in FFS and managed care was ascertained at the start of CMS Medicare coverage. Switch from initial FFS enrollment to managed care was ascertained in follow-up through December 31, 2012. Demographics and comorbidities were ascertained from ARIC clinical examination and follow-up data up to the coverage start date. Mortality was ascertained from start date of CMS Medicare coverage through December 31, 2012; rates were modeled using Poisson regression adjusted for age at time of coverage start. Cox proportional hazard regression models, adjusted for demographic characteristics and comorbidities, were used to examine the hazard ratio of all-cause mortality among those in FFS compared to those enrolled in managed care. Results: At the start of Medicare coverage, 10,983 and 1,087 ARIC participants were enrolled in FFS and managed care, respectively. In comparison with managed care beneficiaries, those in FFS at the start of coverage were more likely to be white (91% vs. 73.5%), male (43% vs. 38.5%) and have less than a high school education (20.4 vs. 11.8%). Comorbidity burden was greater among those enrolled in FFS compared to those in managed care. The age-adjusted rate of mortality (per 100,000 person-years; median follow-up 11.2 years) was 5.9 (95% CI 5.7, 6.1) among those in FFS and 3.5 (95% CI 2.9, 4.1) among those in managed care. The mortality hazard ratio, comparing FFS to managed care beneficiaries was 1.29 (95% CI 1.08, 1.55). During the time from coverage start to end of follow-up, 4,200 beneficiaries switched from FFS to managed care. With the exception of gender, education and proportion with a history of cancer, demographic characteristics and comorbidities of beneficiaries who switched vs. those who remained in FFS were comparable. The mortality hazard ratio, assessed from start of coverage through December 31, 2012, was 1.59 (95%CI 1.46, 1.74) among those remaining in FFS, as compared to those who switched to managed care. Conclusion: Generalizability of inferences from FFS CMS Medicare data may be limited by a greater observed mortality rate among FFS beneficiaries compared to those in managed care. Further analyses are needed to confirm this finding.

Enrollment in HIV Care Two Years after HIV Diagnosis in the Kingdom of Swaziland: An Evaluation of a National Program of New Linkage Procedures.

To improve early enrollment in HIV care, the Swaziland Ministry of Health implemented new linkage procedures for persons HIV diagnosed during the Soka Uncobe male circumcision campaign (SOKA, 2011–2012) and the Swaziland HIV Incidence Measurement Survey (SHIMS, 2011). ion of clinical records and telephone interviews of a retrospective cohort of HIV-diagnosed SOKA and SHIMS clients were conducted in 2013–2014 to evaluate compliance with new linkage procedures and enrollment in HIV care at 92 facilities throughout Swaziland. Of 1,105 clients evaluated, within 3, 12, and 24 months of diagnosis, an estimated 14.0%, 24.3%, and 37.0% enrolled in HIV care, respectively, after adjusting for lost to follow-up and non-response. Kaplan-Meier functions indicated lower enrollment probability among clients 14–24 (P = 0.0001) and 25–29 (P = 0.001) years of age compared with clients >35 years of age. At 69 facilities to which clients were referred for HIV care, compliance with new linkage procedures was low: referral forms were located for less than half (46.8%) of the clients, and few (9.6%) were recorded in the appointment register or called either before (0.3%) or after (4.9%) their appointment. Of over one thousand clients newly HIV diagnosed in Swaziland in 2011 and 2012, few received linkage services in accordance with national procedures and most had not enrolled in HIV care two years after their diagnosis. Our findings are a call to action to improve linkage services and early enrollment in HIV care in Swaziland.

Abstract PD6-07: Genomic sequencing in metastatic breast cancer patients to inform clinical practice at the University of North Carolina at Chapel Hill

Abstract Background: An increasing number of molecularly-targeted therapies for metastatic breast cancer (MBC) are clinically-available (approved and investigational). These anti-cancer agents target specific molecular abnormalities such as mutated, amplified, deleted, or rearranged genes. Reporting of unique tumor genetic alterations is not included in routine clinical/diagnostic panels. In MBC, knowledge of mutational status may foster efficient transitions in clinical care and trial enrollment at disease progression. We describe the development and implementation of a clinically-integrated genomic sequencing program and report how information regarding targetable genomic aberrations in MBC patients (pts) is used to improve clinical practice in an academic setting. Methods: Genomic sequencing of investigative biomarkers was prospectively offered to pts with MBC. DNA libraries were prepared separately from a retrieved archival FFPE tumor sample and a matched normal sample from each pt. Relevant targets were enriched by custom Agilent SureSelect hybrid capture baits using standard protocols. Samples were sequenced on Illumina HiSeq 2000/2500 platforms. Mutational findings were reviewed by a molecular tumor board (MTB); variants identified to be potentially actionable underwent confirmatory testing in a CLIA-approved laboratory. Confirmed findings were inserted into the pt's EMR accessible by both the pt and the treating oncologist. Results: Of the 725 MBC pts seen at UNC since 1/1/2012, 194 (27%) contributed samples for genomic sequencing. Of those whose tumors were sequenced, average age at MBC diagnosis was 54 (25 - 91); 73% were Caucasian, 16% African American. De novo MBC accounted for 39 (20%) sequenced pts. Of sequenced patients, sites of metastatic disease included bone only (7%), visceral only (46%), and both bone and visceral (47%). Approximately 1/3 of pts were consented for sequencing at time of initial MBC diagnosis, 1/4 after 1st line therapy for MBC, and the remaining at or beyond their 2nd line. In total, 131 (68%) pts have sequencing results available of which 43% of pts had reportable mutations deemed actionable by the MTB. Specific mutations and observed frequency by subtype are shown below. Pts (19%) whose tumors were sequenced were more commonly enrolled in a therapeutic clinical trial for MBC, a higher rate than seen in the non-sequenced group (7%) (p<0.001). To date, 27% of pts' tumors harbored an alteration that is an eligibility requirement for a molecularly-targeted therapeutic trial accruing pts at UNC. Observed Mutation by Clinical Subype Genes Total # (56 pts)HR+/HER2- (25 pts)HER2+ (13 pts)TNBC (18pts)PIK3CA15933TP5315456CCND19531NF-14103FGFR13300PTEN3012KRAS2011MDM22110PIK3R12002ROS12011TSC12011Other*14518TOTAL73281728*Mutations observed only once Conclusion: Preemptive genomic sequencing can be integrated into the clinical and operational practice of a comprehensive cancer center. Currently this research tool and program provides valuable information that has the potential to foster both clinical trial eligibility and/or enrollment. With longer follow-up, we hope such an approach ultimately will improve patient outcomes. Citation Format: Grilley-Olsen J, Keith KC, Hayward M, Dees EC, Deal A, Ivanova A, Benbow JM, Parker J, Patel NM, Eberhard D, Mieczkowski P, Weck KE, Hayes DN, Muss H, Jolly T, Reeder-Hayes K, Earp HS, Sharpless N, Carey L, Anders CK. Genomic sequencing in metastatic breast cancer patients to inform clinical practice at the University of North Carolina at Chapel Hill. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD6-07.

Abstract TMP10: A Retrospective Comparison of Medical Eligibility for Acute Ischemic Stroke Clinical Trials Compared with Hospital Enrollment Rates: Greater Cincinnati/Northern Kentucky Population

Introduction: Low rates of enrollment into stroke clinical trials are an ongoing challenge for the stroke research community. We sought to retrospectively describe the association between medical eligibility and recruitment rates for two acute clinical trials. Methods: Within a population of 1.3 million, we screened local hospital admissions in 2010 using ICD-9 discharge codes 430-436, and performed chart review. Within the region are 15 adult acute care hospitals, all of which are covered by the same stroke team for clinical care and trial enrollment. Medical eligibility, the number of eligible patients/total number of patients, was calculated for the IMS-III trial and the CLEAR-ER trials using their inclusion/exclusion criteria. The number of patients enrolled in the trial per month of open enrollment was determined for each hospital. Statistical analysis included paired signed rank test and regression. Results: In 2010, 2035 ischemic strokes (IS) were hospitalized in the region. Regional medical eligibility was 1.7% for IMS III and 4.5% for CLEARER (p=0.001), overall regional hospital enrollment/month was 0.81 for IMS III and 1.84 for CLEAR-ER (p=0.001). Eligibility rates per hospital ranged from 0-9.5%, and recruitment rates per hospital/mo ranged from 0-0.38. Hospital-level eligibility and recruitment rates were significantly correlated (see figure for both trials combined, adjusted r2 = 0.57, p<0.001.) Discussion: Within our population, medical eligibility explained 57% of the variability in hospital-level enrollment rates for two acute IS trials. The use of population-based epidemiology in trial planning may identify optimal trial enrollment criteria, which must be weighed against proper patient selection. Many other factors impact enrollment rates, such as competing trials, which were not considered here. Further evaluation of our population-based eligibility rates in sites outside our region and with additional clinical trials is needed.

Hospice Admission Following Community-Based, Specialist-Level Palliative Care: Incidence, Timing and Predictors (S716)

•Understand the rate of hospice conversion during long-term interdisciplinary, community-based palliative care, and describe the sociodemographic and clinical factors that predict this conversion.•Understand sociodemographic and clinical factors that may predict hospice referral timing after community-based, specialist-level palliative care using statistical evidence. Community-based palliative care is emerging to support seriously ill homebound patients. Timely referral to hospice is a key objective. Interdisciplinary palliative care models may provide repeated opportunities to facilitate appropriate hospice admission. We conducted a retrospective cohort analysis of a large sample to explore hospice utilization after enrollment in one such model. To evaluate the incidence and timing of hospice conversion after enrollment in a palliative care program. Patients (n=1505) were enrolled during 2010-2013 in a community-based, ‘high-touch’ model of specialist palliative care that included home visits by an MD/NP and social worker, telephonic outreach by an RN specialist, and access to 24/7 on-call care. Data entered into an electronic medical record at the time of service were extracted for this analysis. Outcomes included hospice admission (yes/no) and duration of palliative care enrollment, and covariates included sociodemographics, diagnosis, Karnofsky Performance Status (KPS), referral source, and insurance status. The sample had a mean age of 71.6 years (SD=14.5) and was 58.7% women, 32.9% White, 29.8% Black, and 28.5% Hispanic. The mean length of stay (LOS) in the palliative care program was 310 days; median was 210 (range 1-1589). A total of 334 patients (22.2%) were admitted to hospice. In multivariate analysis, predictors of hospice admission were shorter LOS in palliative care (p<0.001), cancer diagnosis (p<0.001), lower KPS (p<0.001), and lower poverty level (p=0.03). The only significant predictor of a longer LOS was higher KPS (p<0.01). During months of care by a ‘high-touch’ palliative care model, about one-fifth of patients were admitted to hospice, and relevant predictors of this outcome included cancer diagnosis, lower performance status, and higher socioeconomic status.

A longitudinal, HIV care continuum: 10-year restricted mean time in each care continuum stage after enrollment in care, by history of IDU

A longitudinal, HIV care continuum: 10-year restricted mean time in each care continuum stage after enrollment in care, by history of IDU

Impact of a youth-friendly HIV clinic: 10 years of adolescent outcomes in Port-au-Prince, Haiti.

IntroductionAdolescents account for over 40% of new HIV infections in Haiti. This analysis compares outcomes among HIV-positive adolescents before and after implementation of an adolescent HIV clinic in Port-au-Prince, Haiti.MethodsWe conducted a cohort study using programmatic data among HIV-positive adolescents aged 13 to 19. Data from 41,218 adolescents who were HIV tested from January 2003 to December 2012 were included. Outcomes across the HIV care cascade were assessed before and after implementation of an adolescent clinic (2009), including HIV testing, enrolment in care, assessment for antiretroviral therapy (ART) eligibility, ART initiation and 12-month retention. Pre-ART outcomes were assessed 12 months after HIV testing. Factors associated with pre-ART and ART attrition were identified through multivariable competing risk and Cox proportional hazards regression modelling.ResultsCumulatively, 1672 (4.1%) adolescents tested HIV positive (80% female, median age 16 years). Retention by cascade step comparing pre- and post-clinic included the following: 86% versus 87% of patients enrolled in care, 61% versus 79% were assessed for ART eligibility, 85% versus 92% initiated ART and 68% versus 66% were retained 12 months after ART initiation. Pre-ART attrition decreased from 61% pre-clinic to 50% post-clinic (p<0.001). Pre-ART attrition was associated with being female (sub-distributional hazard ratio (sHR): 1.59; CI: 1.31–1.93), syphilis diagnosis (sHR: 1.47; CI: 1.16–1.85) and slum residence (sHR: 0.84; CI: 0.72–0.97). ART attrition was associated with syphilis diagnosis (hazard ratio (HR): 2.23; CI: 1.35–3.68) and CD4 <50 cells/µL (HR: 1.88; CI: 1.15–3.06).ConclusionsImplementation of a youth-friendly adolescent clinic improved retention in HIV care among adolescents, particularly in the assessment of ART eligibility and ART initiation. Additional interventions are needed to improve retention among pre-ART patients and support long-term retention among ART patients.

Challenges in Retention of People living with HIV/AIDS, along Continuum of Care and Treatment in Pakistan

Retention of people living with HIV/AIDS (PLHIV) during HIVcare and treatment is vital for success of antiretroviral therapy (ART) interventions. ART health care services are planned to reduce HIVrelated morbidity and mortality, associated with HIV infection and prevention of appearance of drug resistance [4]. PLHIV may be lost along the care and treatment cascade pathway firstly; HIV testing to enrolment into care services; secondly, enrolment in care to ART eligibility; thirdly, eligibility to initiation of ART, and lastly, initiation to lifelong ART [4].

Factors associated with initiation of antiretroviral therapy in the advanced stages of HIV infection in six Ethiopian HIV clinics, 2012 to 2013.

IntroductionMost HIV-positive persons in sub-Saharan Africa initiate antiretroviral therapy (ART) with advanced infection (late ART initiation). Intervening on the drivers of late ART initiation is a critical step towards achieving the full potential of HIV treatment scale-up. This study aimed to identify modifiable factors associated with late ART initiation in Ethiopia.MethodsFrom 2012 to 2013, Ethiopian adults (n=1180) were interviewed within two weeks of ART initiation. Interview data were merged with HIV care histories to assess correlates of late ART initiation (CD4+ count <150 cells/µL or World Health Organization Stage IV).ResultsThe median CD4 count at enrolment in HIV care was 263 cells/µL (interquartile range (IQR): 140 to 390) and 212 cells/µL (IQR: 119 to 288) at ART initiation. Overall, 31.2% of participants initiated ART late, of whom 85.1% already had advanced HIV disease at enrolment. Factors associated with higher odds of late ART initiation included male sex (vs. non-pregnant females; adjusted odds ratio (aOR): 2.02; 95% CI: 1.50 to 2.73), high levels of psychological distress (vs. low/none, aOR: 1.96; 95% CI: 1.34 to 2.87), perceived communication barriers with providers (aOR: 2.42, 95% CI: 1.24 to 4.75), diagnosis via provider initiated testing (vs. voluntary counselling and testing, aOR: 1.47, 95% CI: 1.07 to 2.04), tuberculosis (TB) treatment prior to ART initiation (aOR: 2.16, 95% CI: 1.43 to 3.25) and a gap in care of six months or more prior to ART initiation (aOR: 2.02, 95% CI: 1.10 to 3.72). Testing because of partner illness/death (aOR: 0.64, 95% CI: 0.42 to 0.95) was associated with lower odds of late ART initiation.ConclusionsProgrammatic initiatives promoting earlier diagnosis, engagement in pre-ART care, and integration of TB and HIV treatments may facilitate earlier ART initiation. Men and those experiencing psychological distress may also benefit from targeted support prior to ART initiation.