1. The Association between Ancillary Services and Clinical and Healthcare Utilization Outcomes for HIV- Infected Children Pediatric AIDS Clinical Trials Unit Meeting New Orleans, Louisiana 25 April 2001

2. Authors Manya Magnus, Norine Schmidt, Barbara Brown, and Patricia Kissinger for the FACES Program at Children’s Hospital, New Orleans

3. Acknowledgements The authors gratefully acknowledge the staff and clients at FACES and HOP for their assistance. A special thanks to FACES volunteer Joe Park, who contributed enormously to the collection of additional data regarding ER and hospital visits. The data for this study were collected as part of the Health Resources and Services Administration (HRSA) grant number 250-OA-13(8); the analyses were supported under HRSA contract number 98-0702(P).

4. Introduction F Evaluation of the association between ancillary services and  clinical outcomes  entry and retention into health care F This study performed under a HRSA contract as an extension of an existing comprehensive evaluation plan at FACES

5. Description of FACES F Located in metropolitan New Orleans F The only provider of comprehensive ancillary services to HIV-infected women and children in the area F The majority of the program’s clients are low- income and from minority groups  Provides a wide range of clinical and supportive services to clients

6. F Services provided by FACES include  intensive case management  home visits  transportation services  referrals for financial assistance  referrals for housing assistance  mental health counseling  substance abuse counseling  psychosocial support  crisis management  medications not covered by other sources

7. F Services, continued  child care  respite care  activities for children  developmental assessments and interventions  concrete items (e.g., formula, diapers, etc.)  funeral assistance  vocational employment and coordination  referrals for legal assistance  health education  peer education/counseling  community advisory board

8. Background F Ryan White Care Act F Provides support for approximately 500,000 people infected or affected by HIV/AIDS who lack insurance or are underinsured F RWCA funds services through “titles” F Received $1.4 Billion in funding for fiscal year 1999; administered by HRSA F Soon up for re-authorization

9. Background F Competitive contract F Eight sites awarded F Only one other maternal-child site F Study completed in January 2000

10. Research question F What is the association between ancillary services, clinical outcomes, and entry and retention into health care?

11. Research question F Neediest clients  least likely to have positive outcomes & most likely to use services F Clients with fewer needs  fewer services  best outcomes F Time F Databases set up to track services and not outcomes

12. Research question F Common problems in evaluation/outcomes research F Prospective studies best F Better study designs: pre-post design, randomized trials F Ethical issues

13. Study Design F Retrospective F Used existing data sources F Study period from 1/1/97 through 12/31/98 F Longitudinal, individual-level data

15. Data Sources

16. Data Analysis F Univariate and bivariate analyses F Multivariate analysis with Generalized Estimating Equations (GEE) F Stata  software (College Station, Texas) was used for all analysis F Bonferonni correction (  =0.006)

17. Data Analysis F Difficulty in using frequency of contacts as proxy for need F To adjust for the confounding effect of need, a dynamic needs adjustment factor was developed F The needs adjustment factor (NAF) included clinical, behavioral, and social stressors and was re-calculated for each six-month interval F The needs adjustment factor was included in the multivariate analysis, along with other confounders

18. Eligibility To be eligible for this study, the child had to: F Be HIV-infected F Have received at least one FACES service during the study period F Receive medical care within the MCLNO system

19. Results F 58 children eligible from FACES F 10 (17%) excluded due to no clinical data available during study period F 6 (10%) excluded due to not being seen within MCLNO system F 42 (72%) children included in study

20. Selected Baseline Characteristics of FACES Children (N=42) CharacteristicPercent 1 to 5 years old50 African-American88 Perinatally infected98 Permanent housing86 Primary caregiver64 No immune suppression (Cat. 1)62 Use of ARV treatment (any)83 On study33

21. Percentage of Children Utilizing FACES Services (N=42)

22. Results* Number of services received: Receipt of more than one transportation service per month was associated with the development of moderate or severe immune suppression OR 4.31, 95% CI 1.98-9.35, p<0.0001 *all ORs are adjusted for age, NAF (calculated for particular outcome) (including immune status), length of time enrolled in primary care and FACES.

23. Results Receipt of any versus no: Ancillary service was associated with: F more than 75% adherence with required appointments OR 4.35, 95% CI 1.85-10.00, p<0.006 F improved retention OR 8.28, 95% CI 2.04-33.60, p<0.006

24. Results Receipt of any versus no: Transportation service was associated with: F Being prescribed an antiretroviral treatment OR 13.55, 95% CI 6.25-29.42, p<0.006 F having one or more ER visit per month OR 6.71, 95% CI 2.35-19.18, p<0.006

25. Results Receipt of any versus no: Case management contact was associated with: F having no ER visits per month OR 4.76, 95% CI 1.64-14.29, p<0.006

26. Results Receipt of any versus no: Neurodevelopmental service was associated with: F being prescribed a protease inhibitor OR 4.86, 95% CI 1.59-14.81, p<0.006 F having one or more ER visit per month OR 6.09, 95% CI 1.92-9.32, p<0.006

27. Results F Number of contacts varied by the level of client needs. Children with higher levels of need F Received more services overall per month (mean 3.63 vs. 2.26, p<0.05) F Received more transportation services per month (mean 0.86 vs. 0.26, p<0.001) than those with lower levels of need

28. A thorn in the side… F What about the finding of increased increased ER visits???

29. Additional Analyses F Additional data were collected to further explore the association between ER visits and hospital visits, and ancillary services

30. Methods F A FACES volunteer abstracted data on all ER and hospital visits analyzed in Component II F Discharge diagnoses for each visit were recorded in narrative form and then coded as one of the following categories:

31. Methods Visits were coded as: F acute HIV-related F non-acute HIV-related F acute non-HIV-related F non-acute non-HIV-related

32. Results There were 24 ER visits: 3 (13%) resulted in a hospital admission 2 (8%) were HIV-related but not acute the remainder (79%) were HIV-related or -unrelated acute and necessary

33. Discussion F Ancillary services are associated with improved retention and several improved clinical outcomes for high-risk, HIV-infected children F Children receive appropriate changes in services as needs change F suitable allocation of resources

34. Limitations F Sample size F Selection bias  selection for services  referral patterns  available medical records F Retrospective design F Use of secondary data F Lack of control group F Some social services are available from multiple sources besides FACES F Blurring of maternal and child service receipt F Complex needs -- difficult to quantify stressors

35. Strengths F One of few evaluations of HIV- and child- specific ancillary service programs F Longitudinal analysis with individual-level data F Needs adjustment factor adjusts for changing needs in a dynamic fashion

36. For more information... Please contact FACES at 504-821-4611 or email manyadm@tulane.edu Please accept our thanks for your attention.