Current issues in co-morbidities and complications Cristina Mussini.

Current issues in co-morbidities and complications

Cristina Mussini

Source : SHCS 12/2007

Swiss

CohortStudy

H I V

Age distribution of HIV infected individualsin Switzerland from 1988-2007

0%10%20%30%40%50%60%70%80%90%

100%

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Year

Per

cen

t o

f ac

tive

pat

ien

ts

70+60-6950-5940-4930-39<30

Medical comorbidities among 66,840 HIV- and 33,420 HIV+ veterans

0,1

1

10

100

Hyper

tensi

on

Diabet

es

Vascu

lar

Pulmonar

y

Liver

Renal

Pre

vale

nce

(%

)

<40 HIV- <40 HIV+40-49 HIV- 40-49 HIV+50-59 HIV- 50-59 HIV+60+ HIV- 60+ HIV+

(Goulet, CID 2007)

Incidence of Multiple Comorbidities Increases With Age in HIV-Infected Pts• Cohort of HIV-infected patients attending a metabolic clinic; ≤ 30 years (n =

38), 31-40 years (n = 551), 41-50 years (n = 1216), 51-50 years (n = 253), and > 60 years (n = 69)

• Comorbid conditions: diabetes, obesity, cardiovascular disease, hypertension, hepatic disease, kidney disease, osteoporosis, and hypothyroidism

Guaraldi G, et al. Glasgow 2008. Abstract P300. Reproduced with permission.

No comorbidity1 comorbidity2 comorbidities3 comorbidities4 comorbidities5 comorbidities

0

25

50

75

100

≤ 30 31-40 41-50 51-60 > 60Age (Years)

Comorbidities to Consider in patients with HIV infection

Cardiovascular disease

Bone health

Renal impairment

HIV Is Associated with Clinically Confirmed Myocardial Infarction after Adjustment for Smoking and Other Risk Factors

81,229 veterans (33% HIV+) from the Veterans Aging Cohort Study Virtual Cohort (VACS)

During a median 4.6 years, there were 497 MI events (44% HIV+). Rates of MI were higher for HIV+ (21.7, 95%CI 19.0 to 24.7) per 10,000 p-y) than uninfected veterans (13.1, 95%CI 11.7 to 14.8 per 10,000 person-years), resulting in an increased relative risk of MI (HR 1.86, 95%CI 1.54 to 2.26) after adjusting for established risk factors including age (HR 1.04, 95%CI 1.03 to 1.05), Hispanic ethnicity (HR 1.35, 95%CI 1.01 to 1.80); hypertension (HR 1.40, 95%CI 1.15 to 1.70); hyperlipidemia (HR 1.29, 95%CI 1.07 to 1.56); diabetes (HR 2.06, 95%CI 1.69 to 2.50); and smoking (HR 1.48, 95%CI 1.14 to 1.93).

Among HIV-infected participants, baseline CD4 counts, HIV-1 RNA levels, and class of ART were not associated with MI after adjustment for established risk factors (p >0.2).

Freiberg et al. 18th CROI; Boston, 2011. Abst 809

Increased risk of myocardial infarction in HIV- infected patients in France, relative to the general population

“The higher relative risks of MI found in younger men and women raises the possibility of a premature aging effect of HIV infection on the cardiovascular system” Lang et al. AIDS 2010, 24:1228-1230

women

men

clinicaloptions.com/hiv

Answering the Questions: Initiating Antiretroviral Therapy

Results: Of all (ischemic and hemorrhagic) stroke hospitalizations, patients with comorbid HIV infection constituted 0.09% in 1997 vs 0.15% in 2006 (p < 0.0001). Actual numbers of overall US stroke hospitalizations lessened 7% (998,739 to 926,997), while actual numbers of stroke hospitalizations with coexisting HIV infection rose 60% (888 to 1,425). Patients with comorbid HIV infection comprised 0.08% of ischemic strokes in 1997 vs 0.18% in 2006 (p < 0.0001), but their proportion of hemorrhagic strokes did not significantly change. Factors independently associated with higher odds of comorbid HIV diagnosis were Medicaid insurance, urban hospital type, dementia, liver disease, renal disease, and cancer.

An increase of “vascular age” was detected in 162 pts (40.5%) with a mean increase of 15 years (range 1-43) compared to real age.

Guaraldi et al : CID 2009:49; 1756-61

http://www.journals.uchicago.edu/action/showLargeCover?issue=41151595

High Prevalence of Echocardiographic Abnormalities among HIV-infected Persons in the Era of HAART

• The prevalence of subclinical functional and structural cardiac abnormalities was greater than expected for age.

• Abnormalities were mostly associated with expected and often modifiable risks.

• Lifestyle modification should become a greater priority in the management of chronic HIV disease.

Distribution of cardiac abnormalities Distribution of cardiac abnormalities Predictors of Echocardiographic Abnormalities among SUN Predictors of Echocardiographic Abnormalities among SUN

Mondy et al CID. 2011;52:378-86. Mondy et al CID. 2011;52:378-86.

http://cid.oxfordjournals.org/content/52/3/378/F1.large.jpg

Weighted mean difference (WMD) in carotid intima-media thickness (CIMT) (mm) by HIV positivity

Hulten et al Heart 2009; 95:1826-35.

Meta-analysis showing the effect size (Cohen’s D) of the difference in CIMT between patients with rheumatic

disease and control subjects.

Tyrrell et al Arterioscler Thromb Vasc Biol. 2010;30:1014-26.

CV risk factors in an HIV-infected population: the DAD study

Friis-Moller N et al. AIDS 2003;17:1179–1193

52%34%

26%

25%

25%22%

11%

8.5%

3.5%

2.5%

1%

Smoking

TGs ≥203 mg/dL (2.3 mmol/L)

HDL-C ≤35 mg/dL (0.9 mmol/L)

Lipodystrophy

Age (>45 y male; >55 y female)

TC ≥239 mg/dL (6.2 mmol/L)

Family history of CHD

Hypertension

BMI >30 kg/m2

Diabetes

Previous CHD

10 30 40 50 60200Prevalence (%)

Un-modifiable

Potentially modifiable

Lipid & adipose tissueabnormalitiespotentially modifiable

CHD: coronary heart disease; BMI: body mass index; DAD: Data Collection of Adverse Events

clinicaloptions.com/hivHIV/AIDS Highlights From Rome

How Serious Is the Problem of smoking?

Prevalence of smoking among people with Prevalence of smoking among people with HIV is estimated to be HIV is estimated to be higher higher than among the than among the general populationgeneral population

New England clinics: More than 70% of HIV+ New England clinics: More than 70% of HIV+ smokesmoke11

Swiss HIV Cohort Study of HIV+ smokersSwiss HIV Cohort Study of HIV+ smokers

– 72% are current/former smokers

– 96% among IDUs2

1.1. Niaura R, et al. Smoking among HIV-positive persons. Niaura R, et al. Smoking among HIV-positive persons. Ann Behav Med Ann Behav Med 1999; 21(Suppl):S1161999; 21(Suppl):S1162.2. Clifford GM, et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly Clifford GM, et al. Cancer risk in the Swiss HIV Cohort Study: Associations with immunodeficiency, smoking and Highly

Active Antiretroviral Therapy. Active Antiretroviral Therapy. J Natl Cancer InstJ Natl Cancer Inst 2005;97:425-432 2005;97:425-432


Health Effects of Smoking for PLWHAIn PLWHA:In PLWHA:

– HIV meds can exacerbate risks by raising cholesterol and triglycerides

– Smoking aggravates oral diseases, increasing risk of oral cancers

– Increased risk of pulmonary disorders/diseases, including lung cancer, emphysema, chronic obstructive pulmonary disease (COPD), pneumonia and other lung infections over HIV- smokers

– Increased risk for some long-term side effects of HIV disease and treatment, such as:

– Osteoporosis (weak bones that can lead to fractures)

– Osteonecrosis (bone death)

– Weakened immune system can undermine effects of HIV meds

People with HIV who smoke are more likely to suffer:People with HIV who smoke are more likely to suffer:

– Complications from HIV medication such as nausea and vomitingAIDS Project Los Angeles, Smoking Tobacco and HIV. AIDS Project Los Angeles, Smoking Tobacco and HIV. On-line: www.thebody.com/content/treat/art57390.html. July 12, 2010.On-line: www.thebody.com/content/treat/art57390.html. July 12, 2010.


Smoking and Opportunistic Infections

PLWHA who smoke are more likely to develop: PLWHA who smoke are more likely to develop: – Thrush– Oral hairy leukoplakia (whitish mouth sores)– Bacterial pneumonia

– Pneumocystis pneumonia

For women, smoking can increase the risk and severity of For women, smoking can increase the risk and severity of infection with human papillomavirus (HPV)infection with human papillomavirus (HPV)– Increased risk for cervical cancerIncreased risk for cervical cancer– Increased risk for anal cancer (also in MSM)Increased risk for anal cancer (also in MSM)

Mycobacterium avium Mycobacterium avium (the bacteria that causes MAC) has (the bacteria that causes MAC) has been linked to smoking. It has been found in tobacco, been linked to smoking. It has been found in tobacco, cigarette paper, and filters even after they had been cigarette paper, and filters even after they had been burned.burned.

Smoking and HIV: Fact Sheet #803. On-Line: Smoking and HIV: Fact Sheet #803. On-Line: www.aidsinfonet.org, Revised August 11, 2010., Revised August 11, 2010.

http://www.aidsinfonet.org/


Smoking and Cardiovascular Risk““Cigarette smoking is the most important Cigarette smoking is the most important modifiable cardiovascular risk factor among modifiable cardiovascular risk factor among HIV-infected patients.HIV-infected patients.””

““Cessation of smoking is more likely to reduce Cessation of smoking is more likely to reduce cardiovascular risk than either cardiovascular risk than either the choice of antiretroviral therapy or the choice of antiretroviral therapy or the use of any lipid-lowering therapy.the use of any lipid-lowering therapy.””

Grinspoon S, Carr A, Cardiovascular risk and body-fat abnormalities in HIV-infected adults. Grinspoon S, Carr A, Cardiovascular risk and body-fat abnormalities in HIV-infected adults. N Engl J Med N Engl J Med 2005; 352:48–622005; 352:48–62


Smoking and Risk of Death Smoking among PLWHA has been linked to a higher Smoking among PLWHA has been linked to a higher

rate of death, both for current and ex-smokers. rate of death, both for current and ex-smokers.

Greatest increase in the risk of deathGreatest increase in the risk of death60%60%was for was for cardiovascular (heart) disease and some cancers.cardiovascular (heart) disease and some cancers.

Smoking and HIV: Fact Sheet #803. On-Line: Smoking and HIV: Fact Sheet #803. On-Line: www.aidsinfonet.org, Revised August 11, 2010., Revised August 11, 2010.

http://www.aidsinfonet.org/


Smoking and Non-AIDS Cancers

Of 4797 non-AIDS-defining cancers (1981-Of 4797 non-AIDS-defining cancers (1981-2007): 2007):

– Most frequently observed was lung cancer (847 cases)

– Hodgkin’s lymphoma (643 cases)

– Anal cancer (254 cases)

Incidence of other cancers associated with Incidence of other cancers associated with cigarette smoking was also elevated cigarette smoking was also elevated amongst people with HIV, including:amongst people with HIV, including:

– Kidney and laryngeal cancer

Shiels MS, et al. A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals. Shiels MS, et al. A meta-analysis of the incidence of non-AIDS cancers in HIV-infected individuals. J Acquire Immune J Acquire Immune Deficiency Syndrome Deficiency Syndrome (online edition), 2009.(online edition), 2009.


HIV Highlights From San Francisco

Fracture Rates Higher in HIV-Infected Pts in HOPS Cohort vs General Population

Dao C, et al. CROI 2010. Abstract 128. Reproduced with permission.

Fracture rate for HOPS participants compared with inpatient and outpatient adults aged 25-54 yrs

HOPS participants more likely to experience fracture at fragility sites vs controls (P ≤ .05 for wrist and vertebra in men and vertebra and femoral neck in women)

– Fractures at nonfragility sites more common in controls vs HOPS

BMD, vitamin D data not available to assess contribution to fracture risk

Risk Factor Adjusted HR (95% CI)

Hepatitis C coinfection

1.6

1.0 3.00.1

Age ≥ 47 vs < 35 yrs

Nadir CD4+ cell count < 200 (vs ≥ 350)

1.6

≤ .05

1.5

P Value

Diabetes

Substance abuse

1.6

1.6

≤ .05

.01

.05

.05

Fra

ctu

re R

ate

per

10

,000

Pe

rso

ns

50

100

0

2000

2001

2002

2003

2004

2005

2006

2007

2008

HOPSP = .01

NHAMCS-OPDP = .32

What about BONE?

Risk of Osteoporotic Fractures Associated with Cumulative Exposure to

Tenofovir and Other Antiretroviral Agents

Roger Bedimo, MD; Song Zhang, PhD; Henning Drechsler, MD; Pablo Tebas,

MD; Naim Maalouf, MD


Age-adjusted Rates of Osteoporotic Fractures (Entire Cohort)

0

1

2

3

4

5

6

7

8

18-29 30-39 40-49 50-59 60-69 ≥70

Age at Cohort Entry (Years)

Fra

ctu

re R

ate

(p

er

1,0

00 p

ati

en

t-years

)

Vertebral

Hip

Wrist

Total

General population1

1Data from Triant V, et al., JCEM 2008;93: 3499–3504


Antiretroviral Exposure and Risk of Osteoporotic Fractures: HAART Era

MV Model 1: Controlling for CKD, age, race, tobacco use, diabetes and BMI; MV Model 2: Controlling for Model 1 variables + concomitant exposure to other ARVs.


Exposure to Specific Protease Inhibitors and OF Risk: HAART Era

MV Model 1: Controlling for CKD, age, race, tobacco use, diabetes and BMI; MV Model 2: Controlling for Model 1 variables + concomitant exposure to other ARVs.

SMART: BMD Loss With Continuous vs Intermittent ART Continuous ART associated with significantly larger BMD decline than intermittent

ART; only observed disadvantage of continuous treatment in study

– By year, differences in BMD between arms are statistically significant only in the first 1-2 years of follow-up; few patients included in analysis in Years 3-4

Grund B, et al. ICAAC/IDSA 2008. Abstract 2312a.

-3

-2

-1

0

1

2

0 1 3 4Years

Ch

ang

e F

rom

B

L (

%)

2

n = 112 88 54 10n = 96 77 47 15

Est diff: 1.7 0.8 0.5 2.1P values: .003 .26 .64 .40

-4

-3

-2

-1

0

1

0 1 3 4Years

Ch

ang

e F

rom

B

L (

%)

2

Intermittent

Continuous

Intermittent

Continuous

n = 109 86 51 9n = 95 75 47 15

Est diff: 1.3 1.7 1.0 2.5P values: .002 .005 .27 .21

Spine, by DEXA Hip, by DEXA

Permission granted to CCO for use of these graphics.

What about KIDNEY?


HIV Highlights From San Francisco

Cumulative ARV Exposure and Risk of Chronic Kidney Disease in EuroSIDA

Kirk O, et al. CROI 2010. Abstract 107LB.

6843 HIV-infected patients with ≥ 3 serum creatinine measures and corresponding body weight measures from EuroSIDA study

– 21,482 patient-yrs of follow-up

Cumulative exposure to TDF, ATV, LPV/RTV, or IDV each associated with increased risk of chronic kidney disease

Risk of chronic kidney disease after stopping TDF remained elevated for 1 yr

– Within 12 mos, IRR: 4.05 (2.51-6.53)

– After 12 mos, IRR: 1.12 (0.63-1.99)

Risk of chronic kidney disease after stopping ATV or LPV/RTV similar to patients never exposed


Aquitaine Cohort: TDF Use, Alone or With Concomitant PI, Associated With CKD 2693 HIV-infected patients with baseline CrCl > 60 mL/min/1.73 m2

followed from 2004-2008

86 cases of incident CKD during follow-up

– Among patients with CKD, 96% had baseline CrCl < 90 mL/min/1.73 m2

and 90% had ≥ 3 traditional risk factors*

Morlat P, et al. IAS 2011. Abstract WEPDB0104.

Association With CKD (Multivariate Analysis) Risk Ratio (95% CI)

TDF use (adjusted for other risk factors) 2.5 (1.5-4.1)

Without ≥ 6 months of concomitant PI† 1.8 (1.0-3.3)‡

With ≥ 6 months of concomitant PI† 3.5 (2.1-6.1)‡

*Other variables associated with increased CKD: female sex, older age, diabetes, hyperlipidemia, preexisting mild renal dysfunction (CrCl 61-89 mL/min/1.73 m2), and low CD4+ cell count. †PIs used: ATV 41%, LPV 35%, FPV 11%, SQV 4%.‡PI vs without PI: P = .02.

clinicaloptions.com/hivHIV/AIDS Highlights From IAS 2009

Chronic Kidney Disease Associated With Increased Risk of MI

Pts with CKD significantly more likely to receive ABC vs TDF

– 12.3% vs 7.2%; P < .0001

CKD (eGFR < 60 mL/min/1.73 m²) associated with higher risk of MI and CVA after adjustment for last ART regimen

– HR for MI: 3.16 (95% CI: 2.35-4.26)

– HR for CVA: 2.27 (95% CI: 1.88-2.74)

HCV not associated with MI or CVA

Estimated GFR, mL/min/1.73 m2

MI CVA

Rate per 1000 Pt-Yrs

Unadjusted HR

P Value Rate per 1000 Pt-Yrs

Unadjusted HR

P Value

< 60 11.33 3.85 < .0001 30.58 2.95 .002

60-89 3.89 1.33 .048 12.57 1.28 < .0001

≥ 90 2.92 Ref -- 9.74 Ref --

Bedimo R, et al. IAS 2009. Abstract MOAB202.

What we should do as clinicians?

For CVD: do we have to perform a CT scan of the heart in all patients?


EACS Guidelines, 2009

Bone disease: diagnosis


Kidney disease: diagnosis



Smoking Cessation Reduces CVD Risk in HIV

Risk of cardiac events drops sharply when HIV-positive smokers quit.

Previous smokers, compared to the control group, had:

– 73% increase in MI (myocardial infarction) risk

– 60% increase in CHD (coronary heart disease) risk

– 38% increase in CVD (cardiovascular disease) risk

Current smokers, compared to the control group, had:

– 340% elevated risk for MI

– 250% elevated risk for CHD

– 220% elevated risk for CVD

Petoumenos K, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results Petoumenos K, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the DAD Study. CROI 2010; Abstract 124.from the DAD Study. CROI 2010; Abstract 124.


D:A:D Study: Smoking Cessation Reduces Risk of CVD in HIV-Infected Patients Cessation of tobacco smoking reduced risk of MI, coronary heart

disease, and CVD in HIV-infected patients

– No association of time since smoking cessation and mortality risk

Petoumenos K, et al. CROI 2010. Abstract 124. Reproduced with permission.

*Adjusted for: age, cohort, calendar yr, antiretroviral treatment, family history of CVD, diabetes, time-updated lipids and blood pressure assessments.

Never Smoked Previous CurrentBaseline Smoking

< 1 yr 1-2 yrs 2-3 yrs 3+ yrsStopped Smoking During Follow-up

5

IRR

of

MI*

1

0.5

1.73

3.403.73

3.00 2.622.07


Smoking Cessation Reduces CVD Risk in HIV

Current but not previous smokers Current but not previous smokers had an increased risk for all-cause had an increased risk for all-cause mortality.mortality.

Quitting smoking during the study Quitting smoking during the study reduced the risk of an adverse reduced the risk of an adverse cardiac outcome.cardiac outcome.

Petoumenos K, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results Petoumenos K, et al. Rates of cardiovascular disease following smoking cessation in patients with HIV infection: results from the DAD Study. CROI 2010; Abstract 124.from the DAD Study. CROI 2010; Abstract 124.

The The 5 A5 A’’s s for for Patients Willing to QuitPatients Willing to Quit

ASK ASK about tobacco use at every visitabout tobacco use at every visit

ADVISE ADVISE to quit with a clear, strong, to quit with a clear, strong, personalized messagepersonalized message

ASSESS ASSESS willingness to make a quit attempt willingness to make a quit attempt within the next 30 dayswithin the next 30 days

ASSIST ASSIST in quit attempt with a brief in quit attempt with a brief (3-5 min) counseling intervention(3-5 min) counseling intervention

ARRANGE ARRANGE for follow-up (for follow-up (ANTICIPATE ANTICIPATE relapse)relapse)

Smoking Cessation Interventions

• Complementary and alternative approachesComplementary and alternative approaches

– Acupuncture, meditation, herbs, hypnosis

• Behavioral change approachesBehavioral change approaches

– “Cold turkey”

– Individual or group therapeutics

– Cognitive Behavioral Therapy (CBT)

– Motivational approaches and health behavior

theories

. DRUGS

Pre-Action Stage Progression

ContemplationContemplationPrecontemplation ActionActionPreparationPreparation MaintenanceMaintenance

PC CC PP

Moving forward at least 1 stage doubles the chance that the patient will quit in the next 6 months.

Assessment Periods

Per

cent

age

Abs

tinen

t

Percentage Abstinent Over 18 Months for Smokers in Precontemplation (PC), Contemplation (C), and Preparation (P/A) Stages Before Treatment (n=570)

Pretest 1 6 12 18

30

20

10

0

PC

CP/A

Prochaska, JO, Velicer, WF, Fava, Jl, et al. Prochaska, JO, Velicer, WF, Fava, Jl, et al. (2001). Evaluating a population-based recruitment approach and a stage-based (2001). Evaluating a population-based recruitment approach and a stage-based expert system intervention for smoking cessation. Addictive Behavior, 26, 583-602. expert system intervention for smoking cessation. Addictive Behavior, 26, 583-602.

Initiating HAART > 350 cells/mLMay Decrease Non-AIDS Defining Complications

Cardiovascular Disease

– HOPS Cohort

– FIRST

– SMART Trial

Cancer

– French Hospital Database

– Chiao

• CNS– CHARTER

• Renal & Bone– Dao– Ganesan

Adjusted rate ratios for CHD among HIV+ individuals by recent and lowest CD4

20,775 HIV+ and 215,158 HIV–, contributing for 90,961 and 1,133,444 p-y, respectively

HIV+ had 399 CHD events (447/105 p-y) including 248 MI. HIV– had 3463 CHD events (311/105 p-y), including 1825 MI, for an adjusted CHD RR of 1.2 (95%CI 1.1 to 1.4; p <0.001), and an adjusted MI RR of 1.4 (95%CI 1.3 to 1.7; p <0.001).

Increased risk for cardiovascular complications is not seen for patients with relatively preserved CD4, possibly supporting earlier initiation of ART.

Klein et al 18th CROI; Boston, 2011. Abst 810

Recent CD4 Lowest KP CD4

RR 95%CI p value

RR 95%CI p value

ART+, CD4 ≥ 500 0.9 (0.8-1.1)

0.377 0.8 (0.5-1.3)

0.396

ART+, CD4 201-499 1.4 (1.2-1.6)

<0.001

1.0 (0.8-1.2)

0.818

ART+, CD4 < 200 1.7 (1.3-2.2)

<0.001

1.4 (1.3-1.7)

<0.001

ART-, CD4 ≥ 500 1.3 (0.9-1.9)

0.191 1.2 (0.7-2.0)

0.514

ART-, CD4 201-499 1.1 (0.7-1.6)

0.75 1.3 (0.9-1.9)

0.142

ART-, CD4 < 200 1.5 (0.7-3.4)

0.287 1.0 (0.5-2.0)

0.932

Early Initiation of ART in HIV-infected Individuals is Associated with Reduced Arterial Stiffness

Early Initiation of ART in HIV-infected Individuals is Associated with Reduced Arterial Stiffness

Ho et al, CROI 2010Ho et al, CROI 2010

•Nadir CD4+ count <350/L is an independent predictor of arterial stiffness in HAART-treated individuals.

•Prospective studies evaluating the CV risk associated with early vs late initiation of HAART are warranted

•Nadir CD4+ count <350/L is an independent predictor of arterial stiffness in HAART-treated individuals.

•Prospective studies evaluating the CV risk associated with early vs late initiation of HAART are warranted

Nadir CD4 < 350 N=65 median

(IQR)

Nadir CD4 ≥ 350 N=15 median

(IQR)

p-value

Aix@75(%) 17 (10-22) 4 (-8- 12) < 0.001

PWV (m/s) 5.5 (4.9-6.3) 5.0 (4.5-5.3) 0.009

Reasons to switch treatment

EACS Guidelines Version 5, 2009■

PRINCIPLES


ANOTHER STRATEGY


Health professionals need to cooperate, Health professionals need to cooperate, communicate, and integrate care in teams to communicate, and integrate care in teams to

ensure that care is continuous and reliableensure that care is continuous and reliable

Institute of Medicine (2003). Health Professions Education: A Bridge to QualityInstitute of Medicine (2003). Health Professions Education: A Bridge to Quality

Healthcare Ecosystem Evolution

Past Context Younger population Fewer complex comorbidities Less sophisticated technology More healthcare resources

Future Context Aging population More complex comorbidities More sophisticated technology Fewer healthcare resources

Past Healthcare System Solo, individualistic care model Disease-centered care Emphasis on acute care

Evolving Healthcare SystemTeam-based collaborative

care model Patient-centered careEmphasis on full range of

healthcare continuum

TIMETIMEPASTPAST FUTUREFUTURE

Evolution

Evolution

Multidisciplinary Practice vs Interprofessional Team

Multidisciplinary Practice – Multidisciplinary Practice – ““a bunch of doctorsa bunch of doctors””- Little or no Little or no interdisciplinaryinterdisciplinary interaction toward patient care interaction toward patient care- No identified leaderNo identified leader

Interprofessional Team – HCPs working as a teamInterprofessional Team – HCPs working as a team- Interdisciplinary interaction to achieve patient health outcomesInterdisciplinary interaction to achieve patient health outcomes- Clearly identified roles and responsibilitiesClearly identified roles and responsibilities- Respect and understanding for respective skills an competenciesRespect and understanding for respective skills an competencies- Approach to address and resolve conflictApproach to address and resolve conflict- Identified leader with leadership competenciesIdentified leader with leadership competencies

Source: Murray, S. Silver, I., Patel, D, Dupuis, M., Hayes, S. & Davies, D. (2008). Community group practices in Canada: Are they ready to reform their practice? Journal of Continuing Education in the Health Profession. 28(2), 73-78.

How Interprofessional Collaboration Makes a Difference

• Higher patient satisfactionHigher patient satisfaction• Enhanced professional fulfillmentEnhanced professional fulfillment• Consistency of communicationsConsistency of communications

• Enhanced patient adherenceEnhanced patient adherence• Team efficiency (QI)Team efficiency (QI)• Patient Safety (QI)Patient Safety (QI)

Current issues in co-morbidities and complications Cristina Mussini.

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