Canadian family physician Medecin de famille canadien · 2013
Adoption of the chronic care model to improve HIV care: in a marginalized, largely aboriginal population.
Клиническое исследованиеСтатьяПоддержка исследования: вне правительства СШАНазвание и аннотация: Перевод в очереди
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Tu David, Belda Patricia, Littlejohn Doreen, Pedersen Jeanette Somlak, Valle-Rivera Juan, Tyndall Mark
Аннотация
OBJECTIVE: To measure the effectiveness of implementing the chronic care model (CCM) in improving HIV clinical outcomes.
DESIGN: Multisite, prospective, interventional cohort study.
SETTING: Two urban community health centres in Vancouver and Prince George, BC.
PARTICIPANTS: Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites.
INTERVENTION: Systematic implementation of the CCM during an 18-month period.
MAIN OUTCOME MEASURES: Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period.
RESULTS: Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P < .001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up.
CONCLUSION: Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an "infectious disease" approach to a "chronic disease management" approach to HIV care for marginalized populations is strongly recommended.
DESIGN: Multisite, prospective, interventional cohort study.
SETTING: Two urban community health centres in Vancouver and Prince George, BC.
PARTICIPANTS: Two hundred sixty-nine HIV-positive patients (18 years of age or older) who received primary care at either of the study sites.
INTERVENTION: Systematic implementation of the CCM during an 18-month period.
MAIN OUTCOME MEASURES: Documented pneumococcal vaccination, documented syphilis screening, documented tuberculosis screening, antiretroviral treatment (ART) status, ART status with undetectable viral load, CD4 cell count of less than 200 cells/mL, and CD4 cell count of less than 200 cells/mL while not taking ART compared during a 36-month period.
RESULTS: Overall, 35% of participants were women and 59% were aboriginal persons. The mean age was 45 years and most participants had a history of injection drug use that was the presumed route of HIV transmission. During the study follow-up period, 39 people died, and 11 transferred to alternate care providers. Compared with their baseline clinical status, study participants showed statistically significant (P < .001 for all) increases in pneumococcal immunization (54% vs 84%), syphilis screening (56% vs 91%), tuberculosis screening (23% vs 38%), and antiretroviral uptake (47% vs 77%), as well as increased viral load suppression rates among those receiving ART (72% vs 90%). Stable housing at baseline was associated with a 4-fold increased probability of survival. Aboriginal ethnicity was not associated with better or worse outcomes at baseline or at follow-up.
CONCLUSION: Application of the CCM approach to HIV care in a marginalized, largely aboriginal patient population led to improved disease screening, immunization, ART uptake, and virologic suppression rates. In addition to addressing underlying social determinants of health, a paradigm shift away from an "infectious disease" approach to a "chronic disease management" approach to HIV care for marginalized populations is strongly recommended.
Предметные рубрики MeSH
AdultAnti-HIV AgentsCanadaChronic DiseaseCommunity Health CentersFemaleHIV SeropositivityHumansIndians, North AmericanMaleMedication AdherenceMiddle AgedOutcome and Process Assessment, Health CarePatient Care TeamPneumococcal VaccinesPneumonia, PneumococcalQuality Indicators, Health CareSocial MarginalizationSyphilisTuberculosis, PulmonaryUrban Health ServicesViral Load