Strategies for Staying Current
in HIV Care: Panel Discussion
Steven P. Bromer, MD
Clinical Professor
University of California San Francisco
San Francisco, California
FORMATTED: 12/04/15
New Orleans, Louisiana: December 15-17, 2015
Learning Objectives
After attending this presentation, participants will
be able to:
 Identify 1-2 sources for live and archived HIV
related CME
 Describe the role of consultation in maintaining
clinical expertise
 List 1-2 resources offered by the AETC program
that can support your clinical role
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Panelists
•
•
•
•
•
Michael S. Saag, MD
David H. Spach, MD
Carolyn Chu, MD, MSc
Ronald Goldschmidt, MD
John Nelson, PhD, CNS, CPNP
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Landon, B. E. (2005). Physician Specialization and the Quality of Care for Human
Immunodeficiency Virus Infection. Archives of Internal Medicine, 165(10), 1133.
Slide 4 of 49
Landon: Specialization and Quality of Care
• JAMA 2005
• RWHAP- funded care settings
• Assessed relationship of quality outcomes
between generalists, with and without HIV
expertise and ID specialists
• 5000 unique patients, multiple sites
Landon, B. E. (2005). Physician Specialization and the Quality of Care for Human
Immunodeficiency Virus Infection. Archives of Internal Medicine, 165(10), 1133.
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Landon: Specialization and Quality of Care
• Generalist with HIV-expertise same
outcomes as ID specialists
• Low volume and non-expert providers did
not perform as well
• Expert generalist should be part of the HIV
workforce
Landon, B. E. (2005). Physician Specialization and the Quality of Care for Human
Immunodeficiency Virus Infection. Archives of Internal Medicine, 165(10), 1133.
Slide 6 of 49
Professional Organization’s
Definition of HIV Specialist
Experience
Training/CME
Expertise
HIVMA
Management of 25
HIV-infected patients
in preceding 36
months
At least 40 hours Board Certification/5
of HIV CME in
years of experience if
preceding 36
no Board Certification
months
AAHIVM
Direct care of at least
20 HIV patients in
preceding 24 months
30 hours of HIVrelated CME
credits in past
24 months
Credentialing Exam
(previously every 2
years, now every 3
years)
Slide 7 of 49
Recent Research: Volume
O’Neill, M., Karelas, G. D., Feller, D. J., Knudsen-Strong, E., Lajeunesse, D., Tsui, D., … Agins, B. D. (2015). The HIV
Workforce in New York State: Does Patient Volume Correlate with Quality? Clinical Infectious Diseases, 61(12),
1871–1877.
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Recent Research: Volume
• 33% of NYS HIV ambulatory care
providers care for <20 patients
• Scores on basic HIV performance
measures, including viral suppression
higher for those providers with > 20
patients (56% vs.77%)
O’Neill, M., Karelas, G. D., Feller, D. J., Knudsen-Strong, E., Lajeunesse, D., Tsui, D., … Agins, B. D. (2015). The HIV
Workforce in New York State: Does Patient Volume Correlate with Quality? Clinical Infectious Diseases, 61(12),
1871–1877.
Slide 9 of 49
Essential Components of HIV Care
Gallant, J. E., Adimora, A. A, Carmichael, J. K., Horberg, M., Kitahata, M., Quinlivan, E. B., … Ryan White Medical Providers Coalition.
(2011). Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of
America and the Ryan White Medical Providers Coalition. Clinical Infectious Diseases 53(11), 1043–50.
Slide 10 of 49
Challenges to Staying Current
1st
High CD4 nadir, or
line ARVs, UD VL
2nd
Low CD4panel,
nadir, multiple
Patient
co-morbidities,150
history
approximately
OIs with
patients, of
FQHC
RWHAP Part C grant
Immunocompromised,
intermittent or no ARVs,
late diagnosis
•
•
•
•
•
•
•
•
•
ARV management/Primary Care
Cure Research
Poly-pharmacy/Co-morbidities
Inflammation
Aging and premature aging
DDX
Social Isolation
Opportunistic Infections
Complex Mental Health/Social needs
Special populations: Women, Co-infection, Adolescent, Illicit Drug Users, Aging
Health Systems Issues: ACA, ADAP, PCMH, Care Teams, MU,
Slide 11 of 49
Staying Current Checklist
Live CME
Self-study/asynchronous resources
Community of practice/peer support
Consultation/mentorship
Supporting colleagues with less
experience/teaching
Slide 12 of 24
Staying Current: IAS-USA CME and
Educational Activities
Michael S. Saag, MD
Member, IAS-USA BOD
Professor of Medicine
Associate Dean for Global Health
University of Alabama at Birmingham
Birmingham, Alabama
FORMATTED: 11/17/2015
New Orleans, Louisiana: December 15-17, 2015
IAS–USA Activities
Slide 14 of 58
HIV Activities Targeted to HIV-Experienced Practitioners
• Live Full-day courses in HIV epicenter cities and archived webcasts
• Cases on the Web (COWs)
• Monthly live webinars
• Topics in Antiviral Medicine™
• Current reviews
• Resistance Mutations in HIV
• Guidelines in HIV
Copies online or at the registration desk
• CROI presentations, abstracts, and posters on www.iasusa.org
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Guidelines in HIV
Slide 16 of 58
Gunthard et al, JAMA, 2014; Marrazzo et al, JAMA, 2014.
IAS–USA Activities
Slide 17 of 58
Visit
www.iasusa.org
Slide 18 of 58
Keeping Current with Distance Learning
David Spach, MD
Principal Investigator, Frontier AETC
Professor of Medicine, Division of Infectious Diseases
University of Washington School of Medicine
HIV Telehealth/ECHO
How do you provide updated materials for telehealth?
Updates for Telehealth/ECHO
• Mini-lectures (15 min) on clinically relevant topics
• Include cases in same session related to lecture topic
• Send out “real-time” relevant updated materials
• Conference Updates (eg, CROI)
AETC National HIV Curriculum
How do you create and manage updated curriculum?
National HIV Curriculum
• Dynamic curriculum
• Content and assessment tools updated
• Links to updated guidelines throughout
• System of flagging updated content
• Use of Content Management System for ease of updating
HIV National Curriculum: Core Competencies Working Group
David Spach, MD
John Nelson, PhD, NP
Sherrillyn Crooks, PA
Jeffrey Beal, MD
Susa Coffey, MD
Fran Cournos, MD
John Faragon, Pharm D
Jason Farley, PhD, NP
Marshall Glesby, MD, PhD
Rebecca Kinney, MD
Tonia Poteat, PhD
Deborah Storm, PhD, RN
Donna Sweet, MD
Information
Portal
⌃
Modular Learning
Applied Exercises
Challenges & Controversies
Question Bank
Media Presentations
Lesson Topic Review
CONTENT
National HIV Curriculum: Progress Tracker
National HIV Curriculum: Question Bank Progress Tracker
HIV: Question Bank
Access as Information Portal
Core Concepts
Reviews
Lectures
Self Assessment
Question Bank
Challenges
&
Controversies
Calculators
Tools
Master Bib
National HIV Curriculum: Organized Content
Experiences from the National Clinician
Consultation Center
Carolyn Chu, MD, MSc
Associate Clinical Professor
Family and Community Medicine
University of California San Francisco
School of Medicine
San Francisco, California
Ronald H. Goldschmidt, MD
Professor of Clinical Family and Community Medicine, Step 9
Family and Community Medicine
University of California San Francisco
School of Medicine
San Francisco, California
FORMATTED: 12/08/15
New Orleans, Louisiana: December 15 to 17
Slide 32 of 49
Patterns by region and caller type
12.12 REGION
%
2.40
18.27
%
South
%
33.75
%
33.75
%
West
PROFESSION
7.61
6.89 %
%
20%
65.50
%
MD/D
O
APN/P
A
Pharm
Other
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Caller case load
- Of HIV Warmline callers who provided
information on monthly caseload:
-
30.8% provide > 50 services/month
28.9% provide 20-49 svcs/month
18.8% provide 10-19 svcs/month
19.7% provide 1-9 svcs/month
1.7% provide < 1/month
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Caller experience/case load
35%
30%
25%
20%
15%
10%
5%
0%
Volume + Length of Career
Volume +…
Low-volume, 1-10 High-volume, 1- Low-volume, > 10 High-volume, >
yrs experience 10 yrs experience yrs experience 10 yrs experience
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Distance-based consultation: special features
- Decision support allows self-directed learning
(options given, multiple care strategies,
individualized)
- “Teachable Moment”
-
“Question behind the question”
Encourages continuity for time-sensitive, highacuity clinical situations (perinatal)
Empowers callers to expand their work
Builds inter-professional teams
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The Clinician Consultation Center (CCC)
…provides clinicians of all experience levels with
confidential, timely, cost-free, expert advice on:
•
HIV/AIDS management (testing, ARVs, co-infection, care)
Warmline 800.933.3413 M-F
9 am – 8 pm
• Occupational and non-occupational exposures
PEPline
•
Pre-exposure prophylaxis (PrEP)
PrEPline 855.448.7737
•
9 am – 2 am
888.448.4911
M-F
11 am – 5 pm
Management of HIV in pregnant mothers and infants
Perinatal HIV Hotline 888.448.8765
Online Consultation: nccc.ucsf.edu
.
24/7
www.ncc.ucsf.edu
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AETC NCRC
John A. Nelson, PhD, CNS, CPNP
Program Director
FORMATTED: 12/08/15
New Orleans, Louisiana: December 15 to 17
AIDS Education & Training Center Program
Regional Centers
National Centers
Clinician Consultation
Center (CCC)
National
Coordinating
Resource Center
(NCRC)
National Evaluation
Center (NEC)
http://aidsetc.org/
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François-Xavier Bagnoud Center
Ways the AETC NCRC Fosters Ongoing Learning
• Support national communities of practice and other working groups
• Support technical assistance work for the AETC Program in multiple areas
including creating and maintaining mailing groups, social media, a quarterly
newsletter, and other mechanisms to facilitate communication, sharing of
resources and AETC Program news
• Serve as the AETC Program’s central web-based resource repository of
training and capacity development resources by housing all AETC Program
resources on www.aidsetc.org
AETC NCRC
www.aidsetc.org
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Staying Current Checklist
Live CME
Self-study/asynchronous resources
Community of practice/peer support
Consultation/mentorship
Supporting colleagues with less
experience/teaching
Slide 43 of 24