The Impact of a ComputerAssisted SelfInterview on the Delivery and Clinical Outcomes of HIV Care

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The Impact of a Computer-Assisted Self-Interview
on the Delivery and Clinical Outcomes of HIV Care
Johns Hopkins University School of Medicine

• Richard D. Moore, MD, MHS
• Beulah P. Sabundayo, PharmD, MPH
• Jeanne Keruly, MS, CRNP
• Greg Lucas, MD, PhD

August 29, 2006 RWCA All Titles Conference
CATS
Computer Adherence Technology Study
Project supported by HRSA Grant H97HA00266
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Audio Computer-Assisted Self-InterviewACASI

• Information technology used primarily in clinical
  research
• Elicits personal/sensitive information
• Shown to provide more valid responses than
  face-to-face interviews
• Medication adherence
• Certain behaviors (illicit drug use, sexual
  behaviors)

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CATS
Computer Adherence Technology Study

• Objective Assess if ACASI in routine clinical
  practice
• Enhances the delivery of HIV care
• Improves HIV clinical outcomes
• Hypothesis ACASI feedback to clinicians will
  inform clinical practice by
• Improve clinician-patient communication
• Early identification of nonadherence
• Identify problems affecting adherence
• Improved identification of medication errors
• Standardize evaluation of side effects
• Identify patient misconceptions
• Promote early treatment decisions

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Study Design

• Randomized clinical trial
• Enrollment 180 subjects starting HAART
• HAART is defined according to DHHS-Kaiser 2002
  Guidelines for Antiretroviral Therapy (HAART) in
  Adults
• 12 month intervention
• 90 subjects randomized to no clinician feedback
  of ACASI
• 90 subjects randomized to clinician feedback of
  ACASI at the time of clinical care visit
• Stratified on HAART (1st vs. salvage)

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Outcomes

• Use of ACASI technology to enhance patient
  services
• Enhancing patient/clinician communication
• Adherence to ARVs
• Identification of depression
• Identification of substance abuse
• Acceptance of ACASI by patients and clinicians
• Clinical outcomes
• HIV-1 RNA suppression at 6 and 12 months
• CD4 lymphocyte change at 6 and 12 months
• Duration of HAART use
• Genotypic resistance

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ACASI Questions Medications

• Medications
• Identify med
• Dosage
• Schedule
• Missed doses
• Reasons for missed doses
• ACTG

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ACASI Questions Depression

• Based on the validated Hospital Anxiety
  Depression Score (HADS)
• 5 questions
• Overall depression score (0-15)
• Possible 5 7
• Probable gt 8

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ACASI Questions Alcohol

• Alcohol usage in past week and month

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ACASI Questions Illicit Drug Use

• Usage in the past month
• Last use
• Cocaine
• Cocaine heroin
• Heroin
• Others

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ACASI Questions Treatment Programs

• Drug or alcohol
• Type of program

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Recruitment and Retention
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Characteristics of Enrolled Subjects (N198)
Mean age (years) 43 Median age (years)
43 Range (years) 24 - 66
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ACASI Performance
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Patient Survey
n1 month 180 n6 month 15 n12 month 162

• Patient ACASI Information Technology Survey
• CHECK ONE BOX FOR EACH QUESTION
• How comfortable did you feel answering questions
  on the computer?
• Very comfortable
• Somewhat comfortable
• Neither comfortable nor uncomfortable
• Somewhat uncomfortable
• Very uncomfortable
• Do you think its easier to tell personal
  information to a computer or directly to your
  doctor?
• Much easier with the computer
• Somewhat easier with the computer
• I dont know
• Somewhat easier with my doctor
• Much easier with my doctor
• Did answering the questions on the computer make
  you think of things that you wanted to talk to
  your doctor about?
• Yes
• No
• I dont know

• If your computer answers were given to your
  doctor, how did that affect your communication
  with your doctor?
• Very helpful
• Somewhat helpful
• Neither helpful nor harmful
• Somewhat harmful
• Very harmful

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Patient Survey
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Patient Survey
Do you think its easier to tell personal
information to a computer or directly to your
doctor?
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Patient Survey
Did answering the questions on the computer make
you think of things that you wanted to talk to
your doctor about?
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Patient Survey
If your computer answers were given to your
doctor, how did that affect your communication
with your doctor?
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Clinician Survey
n1 month 87 n12 month 70

• Provider ACASI Information Technology Survey
• Did the ACASI survey impede or interfere with
  clinic procedures or patient flow?
• No
• Yes
• I dont know
• How did the feedback report(s) from your
  patients interview(s) affect your communication
  with the patient?
• Helpful
• No effect
• Harmful
• What information in the feedback report(s_ was
  helpful in understanding barriers faced by your
  patient? CHECK ALL THAT APPLY
• Patients self-identified medications or dosing
  scheme were different than prescribed
• Patients self-reported adherence with HIV
  medications
• Patients reasons for missed doses
• Patients general knowledge of HIV treatment
• Patients depressive symptoms and score
• Patients drug or alcohol use
• No information was helpful
• Which specific clinical management decisions did
  you make that were influenced by information from
  your patients feedback reports?
• Temporarily discontinued antiretroviral therapy

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Clinician Survey
Did the ACASI survey impede or interfere with
clinic procedures or patient flow?
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Clinician Survey
How did the feedback report(s) from your
patients interview(s) affect your communication
with the patient?
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Clinician and Patient Survey
How did the feedback report(s) affect your
communication?
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Clinician Survey
What information in the feedback report(s) was
helpful in understanding barriers faced by your
patient?
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Clinician Survey
Which specific clinical management decisions did
you make that were influenced by information from
your patients feedback reports?

• Other
• Adherence
• Depression
• Referrals

49
57
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Preliminary Clinical Outcomes
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Preliminary Clinical Outcomes
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Conclusions

• We successfully enrolled and retained a primarily
  African American patient population with a high
  prevalence of comorbidities
• Women and drug users were well-represented
• ACASI was widely accepted by patients and
  clinicians
• Both clinicians and patients felt that the ACASI
  had a positive effect on their communication with
  each other
• Patients were more likely to share sensitive
  information with their clinicians, providing
  opportunities for risk reduction counseling
• ACASI feedback was helpful to clinicians for
  identifying problems with adherence, depression
  and substance abuse

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Future Directions

• Full 12 month analysis pending
• Confounding problems affecting adherence
• Identification of medication errors
• Enhanced adherence support
• Identification of depression
• Identification of substance abuse
• Examine reasons for negative or neutral survey
  responses from patients and clinicians
• Assessment of clinical disease markers

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CATS
Computer Adherence Technology Studyat the Johns
Hopkins Moore Clinic
For more information, please contact Beulah
Sabundayo, PharmD, MPH bsabund1_at_jhmi.edu