A Cyclical Approach to Continuum Modeling: A Conceptual Model of Diabetic Foot Care

“Cascade” or “continuum” models have been developed for a number of diseases and conditions. These models define the desired, successive steps in care for that disease or condition and depict the proportion of the population that has completed each step. These models may be used to compare care across subgroups or populations and to identify and evaluate interventions intended to improve outcomes on the population level. Previous cascade or continuum models have been limited by several factors. These models are best suited to processes with stepwise outcomes—such as screening, diagnosis, and treatment—with a single defined outcome (e.g., treatment or cure) for each member of the population. However, continuum modeling is not well developed for complex processes with non-sequential or recurring steps or those without singular outcomes. As shown here using the example of diabetic foot care, the concept of continuum modeling may be re-envisioned with a cyclical approach. Cyclical continuum modeling may permit incorporation of non-sequential and recurring steps into a single continuum, while recognizing the presence of multiple desirable outcomes within the population. Cyclical models may simultaneously represent the distribution of clinical severity and clinical resource use across a population, thereby extending the benefits of traditional continuum models to complex processes for which population-based monitoring is desired. The models may also support communication with other stakeholders in the process of care, including health care providers and patients

Differential Survival for Men and Women with HIV/AIDS-Related Neurologic Diagnoses.

ObjectivesNeurologic complications of human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) frequently lead to disability or death in affected patients. The aim of this study was to determine whether survival patterns differ between men and women with HIV/AIDS-related neurologic disease (neuro-AIDS).MethodsRetrospective cohort data from a statewide surveillance database for HIV/AIDS were used to characterize survival following an HIV/AIDS-related neurologic diagnosis for men and women with one or more of the following conditions: cryptococcosis, toxoplasmosis, primary central nervous system lymphoma, progressive multifocal leukoencephalopathy, and HIV-associated dementia. A second, non-independent cohort was formed using university-based cases to confirm and extend the findings from the statewide data. Kaplan-Meier analysis was used to compare the survival experiences for men and women in the cohorts. Cox regression was employed to characterize survival while controlling for potential confounders in the study population.ResultsWomen (n=27) had significantly poorer outcomes than men (n=198) in the statewide cohort (adjusted hazard ratio=2.31, 95% CI: 1.22 to 4.35), and a similar, non-significant trend was observed among university-based cases (n=17 women, 154 men). Secondary analyses suggested that this difference persisted over the course of the AIDS epidemic and was not attributable to differential antiretroviral therapy responses among men and women.ConclusionsThe survival disadvantage of women compared to men should be confirmed and the mechanisms underlying this disparity elucidated. If this relationship is confirmed, targeted clinical and public health efforts might be directed towards screening, treatment, and support for women affected by neuro-AIDS

Kaplan-Meier curves for statewide cohort, stratified by birth sex.

<p>Kaplan-Meier curves for statewide cohort, stratified by birth sex.</p

Interaction of birth sex and county type (n = 225).

<p>*Hazard ratio (HR) with 95% confidence interval (CI), adjusted for ART by treatment era interaction, age, race, birth sex, healthcare facility type, opportunistic infection count, HIV transmission risk category, and neuro-AIDS condition and stratifying on years since AIDS diagnosis and timing of neuro-AIDS.</p><p>**p = 0.0007.</p><p>Note: County at AIDS diagnosis was derived from urban influence codes. “Other area” denotes any county not designated by urban influence codes as a small metropolitan area.</p><p>Interaction of birth sex and county type (n = 225).</p

Characteristics of men and women in the statewide cohort.

<p>SD = Standard deviation.</p><p>*County at AIDS diagnosis with county type derived from urban influence codes.</p><p>MSM = Male sexual contact with male, IDU = Injection drug use, “Other” includes adult heterosexual contact; HMO = Health maintenance organization; OIs = Opportunistic infections.</p><p>**Excludes <i>Pneumocystis</i> pneumonia (PCP).</p><p>⁺Diagnosis prior to 1996.</p><p>Characteristics of men and women in the statewide cohort.</p

Comparison of measures of disease severity by birth sex.

<p>Comparison of measures of disease severity by birth sex.</p

Expanding HIV Screening in the UNMH Emergency Department

Introduction: Access to HIV screening and care may be limited in resource-constrained health care settings. The CDC recommends routine HIV screening for all patients aged 13-64 years, unless the prevalence of undiagnosed HIV in that population has been documented to be New Mexico is ranked 34th in the US for the rate of HIV diagnoses made per year—among the lowest of all 50 states. Meanwhile, NM is ranked 4th for chlamydia, 22nd for gonorrhea, and 20th for syphilis [3]. This discrepancy in sexually transmitted infection rates suggests the possibility of underdiagnosis of HIV infection in NM and, as a result, underestimation of the actual HIV prevalence in the state. As part of an initiative to improve HIV preventive care for UNMH Emergency Department (ED) patients evaluated after a sexual assault [4], we implemented rapid HIV screening that was also available to all UNMH ED patients at risk for HIV, regardless of the reason for their ED visit. This initiative had the secondary benefit of improving HIV screening rates in the ED. Materials/Methods: Two domains for broad infrastructural improvement were identified: (1) the availability of rapid HIV screening in settings where this test could impact decision-making and (2) the connection to outpatient follow-up care for patients at high risk for or diagnosed with HIV. Barriers to improvements included the lack of a mechanism to perform confirmatory testing for all positive rapid screens and the lack of streamlined access to follow-up outpatient care. Through extensive collaboration with stakeholders throughout the health system, we implemented rapid HIV screening in the UNMH ED, a reflex laboratory confirmatory test, and nurse-driven protocols for follow-up of confirmatory testing. In collaboration with partners at UNM and in the community, we established a network of HIV care clinics and a 24/7 connection to care phone line to improve access to care for patients diagnosed with HIV infection. A REDCap “tracker” tool was devised to allow outpatient clinics to report, without any identifiable patient information, whether they saw patients in follow-up. Results: This project resulted in several improvements: (1) Rapid, point-of-care HIV screening is now available in the UNMH adult and pediatric EDs and has subsequently been expanded to UNMH Labor and Delivery. (2) Reflex laboratory confirmatory testing for any positive rapid HIV screen has been implemented, and a nurse-driven protocol for follow-up of these results is in place. (3) A 24/7 Truman Health Services “connect-to-care” phone line is available to providers at UNMH and in the surrounding community to link point-of-care evaluations with outpatient follow-up for patients with a new HIV diagnosis. (4) A network of seven follow-up clinics for HIV treatment and ten follow-up clinics for HIV preventive care in the Albuquerque area is now available to UNMH patients. Utilizing the REDCap “tracker” tool, we can confirm that patients are following up in outpatient clinics. Conclusion: The project was successful in establishing rapid, point-of-care HIV testing in the ED and in streamlining follow-up care for patients newly diagnosed with HIV. The success of the ED screening initiative led to expansion of the rapid testing elsewhere at UNMH. Future plans are in development to quantify the change in HIV screening rates resulting from these improvements using an interrupted time series study design. References: 1. Branson, Bernard, M, and et al. “Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings.” CDC. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm 2. Moyer, VA. “Screening for HIV: U.S. Preventive Services Task Force Recommendation Statement.” Ann Internal Medicine 159, no. 1 (2013): 51–60. 3. “National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. New Mexico - State Health Profile,” https://www.cdc.gov/nchhstp/stateprofiles/pdf/New_Mexico_profile.pdf. 4. Saadatzadeh T, Wilson CG, Salas NM, Walraven C, Sarangarm P, Crandall CS, Crook J, Sarangarm D, Yaple C, Stafford A, Page K, Carvour ML. The IN-STEP Project: Improving Access to HIV Prevention for Patients Evaluated After Sexual Assault Using a Multidisciplinary, Patient-Centered Approach. Poster presented at University of New Mexico Health Sciences Center Quality Improvement and Patient Safety Symposium in February 2019, Albuquerque, NM and the New Mexico HIV & HCV Update Conference in April 2019, Albuquerque, NM. Oral presentation by T. Saadatzadeh at the American College of Physicians Internal Medicine Annual Meeting in April 2019, Philadelphia, PA