Value Based HIV Care / Quality of life in HIV:

Lessons learned from implementation

Barcelona 07-09-2018

Guido van den Berk

HIV cascade of care NL 2016

HIV monitoring report 2017

HIV Cascade of care OLVG 2014-2017

HIV CARE IN OLVG“ beyond undetectable / fourth 90”

• Patient centered care

- “Valuable parameters”

- Quality of life

- Patient control (Happi App)

• Cost effective

• Continuous improvement

HIV care pathPATIENT / PROMS

nurse

INTERNIST

4 mo 1 month 8 mo 12 mo

Intake nurse PROMS PROMS PROMS

yearly check

Internist

PROMS

yearly check

Internist

Nurse

Internist

6 mo 12 mo

or

Internist Internist

Internist

PROMS

1st year

chronic care

VBHiC outcome indicators

Tier 1 Tier 2 Tier 3

1) Undetectable hiv load

within the first year of care entry

4) Retention in care 8) Quality of life (QoL*)

after 5 years

2) Quality of life (QoL*)

within the first year of care entry

5) Therapy effectiveness (persistent viremic control) 9) Overall mortality

3) Mortality

within the first year of care entry

6) Therapy tolerance

7)Cardiovascular risk

Quality improves

Quality improves

Quality of life in HIV

• Validated questionnaires

• Domains that influence physical and mental health

• Routine questionnaires in care path

– Preferrably via EMR / Hiv app Happi ®

– Eventually on paper

– Dutch and English

QoL Questionnaires (62 items)

• Short Form Health Survey (SF-12)

• Hospital Anxiety & Depression Score (HADS)

• short Stigma scale (Berger)

• Social Support List (SSL-12)

• Sexual Difficulties (~ Natsal-SF)

• Single item measuring Self Esteem (SISE)

• Sleep difficulties (SCL-90-R)

• Medication tolerance

Quality of life patient level

HIV CARE IN OLVG“ beyond undetectable / fourth 90”

• Patient centered

- “ Valuable parameters”

- Quality of life

- Patient control (Happi App)

• Cost effective

• Continuous improvement

Less consultations despite more patients

2012 2013 2014 2015 2016 2017

2.000

4.000

6.000

8.000

10.000

12.000

500

1000

1500

2000

2500

3000

3500

4000

2012 2013 2014 2015 2016 2017

Am

ou

nt

of

cun

sult

atio

ns

Am

ou

nt

of

pat

ien

ts

Jaar

Amount of consultations and amount of patients per year

Amount ofpatients

Amount ofconsultations

Less overall costs despite more patients

2012 2013 2014 2015 2016 2017

2.000

4.000

6.000

500

1000

1500

2000

2500

3000

3500

4000

2012 2013 2014 2015 2016 2017

Am

ou

nt

of

cun

sult

atio

ns

Am

ou

nt

of

pat

ien

ts

Jaar

Cost reduction and patient growth

Amount ofpatients

Cost reduction

€

€

€

€

€

€

€

€

HIV CARE IN OLVG“ beyond undetectable / fourth 90”

• Patient centered

- “ Valuable parameters”

- Quality of life

- Patient control (Happi App)

• Cost effective

• Continuous improvement

Aiming for continuous improvement

• Monitoring at – Patient level– Population level – Process level

• VBHiC improvement meeting one hour every month

• Chaired by working group

• Each working group responsible for one outcomeindicator

Example: HADS at population level

HADS anxiety HADS depression HADS total

25%

How to improve hiv mental health ?

Right (amount of) QoL questions ?

What interventions needed ?

Implementing hiv mental health care path

HADS > 12: exploration by hiv nurse

Multidisciplinary meeting with psych

Dual consultation psych/hiv nurse ?

Referral psych ?

Stigma PhD

Improving mental health

Patient management at process level

Lessons learned• “ Holistic approach” very much appreciated by patients

• Feasible

• Datamanager necessary, ideally good EMR database

• Get everybody involved– Patients (past-present-future)– Caregivers (everybody) – Health insurance (bundle payment)– IT department– ICHOM / HIV outcome initiative

• Learn from each other; benchmarking – Within one centre (retrospectively, amongst caregivers)– Between hiv centres– HIV outcome initiative

• It takes time / perseverance

Thank you for your attention !

Guido van den Berk (g.e.l.vandenberk@olvg.nl)

On behalf of

All patients

The OLVG HIV team

And especially the VBHiC OLVG team: Kees Brinkman

Marie-Jose Kleene

Narda van der Meche

Daoud ait Moha

Martje Dermer

Tino Bekkering

Jacqueline Platen