Sreekanth K. Chaguturu

Incidence of immune reconstitution syndrome in HIV/tuberculosis-coinfected patients after initiation of generic antiretroviral therapy in India.

This paper describes the incidence of immune reconstitution syndrome (IRS) from the developing world and implications for clinicians. Eleven of 144 HIVand tuberculosis (TB)-coinfected individuals followed for 72 person-years developed IRS within 6 months of initiating generic highly active antiretroviral therapy (HAART). All of the IRS patients were male, with a median age of 29 years; median CD4 at HAART initiation was 123 cells/mm3, and 6-month median CD4 rise was 124 cells/mm3. There was no statistical difference in CD4 rise or CD4 count and duration of TB treatment at HAART initiation between those who did and those who did not develop IRS (P = 0.8380). The median time to development of clinical IRS was 42 days (range 10-89 days). The incidence of IRS in this cohort is 15.2 cases per 100 patient-years. With increased coprevalence of opportunistic infections, especially TB, and increasing access to antiretroviral therapy in the developing world, clinicians in these countries must be able to identify IRS and relieve symptoms without compromising clinical care.

The changing natural history of HIV disease: before and after the introduction of generic antiretroviral therapy in southern India.

The number of individuals seeking treatment for infection with human immunodeficiency virus increased as the cost of highly active antiretroviral therapy (HAART) decreased 20-fold after the introduction of generic HAART in India in the year 2000. The incidence of tuberculosis and opportunistic infections decreased to <2 cases per 100 person-years. Death rates decreased from 25 to 5 deaths per 100 person-years between 1997 and 2003.

The safety, tolerability and effectiveness of generic antiretroviral drug regimens for HIV-infected patients in south India.

We investigated the safety, tolerability and effectiveness of locally produced generic highly active antiretroviral therapy (HAART) regimens with a chart review conducted at YRG CARE, a tertiary HIV referral centre in India. A total of 333 patients had been on Indian-manufactured generic HAART for at least 3 months. In this cohort, generic HAART was safe, well tolerated and effective at increasing CD4 T-lymphocyte counts in patients with advanced HIV, comparable to the experience with proprietary HAART.

ACOs and High-Cost Patients

Since a small percentage of patients account for the majority of health care spending, high-risk care management could substantially reduce costs and improve quality. But heterogeneity in clinical needs complicates efforts to develop integrated strategies.

Dried blood spots are an acceptable and useful HIV surveillance tool in a remote developing world setting.

Enzyme-linked immunosorbent assay and Western blot analysis of dried blood spots (DBS) on filter paper have been shown to be as sensitive and specific as analysis of serum, and therefore may be a cost-effective and culturally appropriate HIV seroprevalence tool in remote areas. This study examines the acceptability of DBS in a tropical, rural population from an outpatient clinic in Andhra Pradesh, India, where participation was offered to every fifth patient seeking general medical care between March and April 2001. All 1413 patients approached for the study agreed to participate and provide a DBS for examination. The overall HIV seroprevalence in this sample was 2.8%. Of the participants, 51.7% were male, 93.2% were between the ages of 18 and 40, 85.3% were married, 29.7% were employed, 47.6% had no education and 73.1% resided in a rural setting. In the univariate analysis, history of genital warts (P=0.01), sexually transmitted disease (P=0.001), premarital sexual intercourse (P=0.002), sexual contact with a commercial sex worker (P=0.003), being employed (P=0.011) and having more than 10 injections for medical purposes (P=0.006) all correlated with being HIV-infected. Given the uniform willingness of these clinic attendees to be tested, we conclude that DBS is a useful, cost-effective tool in HIV serosurveillance in a rural, tropical setting.

Ten Years, Forty Decision Aids, And Thousands Of Patient Uses: Shared Decision Making At Massachusetts General Hospital

Shared decision making is a core component of population health strategies aimed at improving patient engagement. Massachusetts General Hospitals integration of shared decision making into practice has focused on the following three elements: developing a culture receptive to, and health care providers skilled in, shared decision making conversations; using patient decision aids to help inform and engage patients; and providing infrastructure and resources to support the implementation of shared decision making in practice. In the period 2005-15, more than 900 clinicians and other staff members were trained in shared decision making, and more than 28,000 orders for one of about forty patient decision aids were placed to support informed patient-centered decisions. We profile two different implementation initiatives that increased the use of patient decision aids at the hospitals eighteen adult primary care practices, and we summarize key elements of the shared decision making program.

Optimizing high-risk care management.

The most costly 1% of patients account for one-fifth of national health expenditures—accruing average annual expenses of nearly

HIV and obstetric complications and fetal outcomes in Vellore, India.

90 000 per person.1 These individuals typically have several complex, co-occurring conditions for which they often receive poorly coordinated care, driving unnecessary utilization and poor outcomes. Given these characteristics, high-risk care management programs have potential to improve care and reduce costs for this population.2,3 The structure of these programs varies, but most involve care managers who work with panels of high-risk patients to coordinate care across clinicians, engage patients in setting and achieving health-related goals, and monitor and track health outcomes. Although these programs have traditionally been managed by payers or third-party vendors, clinicians and health care organizations are increasingly adopting programs of their own.2,4 High-risk care management is quickly becoming a cornerstone of health reform efforts. Over the past decade, Medicare has funded 6 rounds of demonstration projects aimed at improving care and reducing costs for high-risk patients.5 In the private sector, purchasers are seeking payers that provide these services; by this year, roughly 75% of large employers expect to contract with a health plan that offers disease management services.6 Within care delivery organizations, new payment contracts that tie reimbursement to cost and quality trends are prompting experiments with new delivery strategies for high-risk patients.1 Excitement over the growth and potential of highrisk care management programs are tempered by the unevenresultsofpreviousefforts.Despitesomeisolatedsuccesses, most evaluated high-risk care management programs failed to significantly affect the cost and quality of care provided to their targeted patient populations.4,5 This suggests that prevailing approaches to high-risk care management are not optimally designed. As activity continues to accelerate in this area, it is necessary to consider the optimal approach to organizing and financing these activities. Despite increasing evidence that programs led by clinicians and health care organizations are most effective, the majority of care management programs remain under the purview of payers.4,5 This is likely a key factor behind the lackluster results of previous efforts. However, prevailing regulations support this status quo. Payers are reluctant to cede control of care management programs to care delivery organizations. A frequently cited reason for such reluctance is that transfer of this responsibility would jeopardize National Committee for Quality Assurance (NCQA) health plan accreditation, which requires health plans to provide disease and complex case management services to beneficiaries. The NCQA has processes for delegating medical management responsibilities while maintaining accreditation. However, in discussions with payer colleagues, we have heard that current processes for delegation are cumbersome and could jeopardize accreditation. Continued efforts by the NCQA to simplify and streamline the delegation process are needed. While important, removing regulatory barriers to physician-led care management is only one element of the transformation needed to harness the substantial cost and quality opportunity presented by high-risk care management. Optimizing these programs will require a system-level approach that takes advantage of each stakeholder’s unique capabilities. Simultaneous initiatives from payers and care delivery organizations are unnecessary and wasteful. Drawing on our experience implementing these programs across a large, integrated health system, we propose 3 overarching principles to guide the design and implementation of high-risk care management services. Practice-based: High-risk care management programs are most effective when they are anchored in the practices where patients receive their care. Care managers co-located within practices are able to build strong, trusting relationships with patients that promote patient engagement through planning and adherence. The primacy of in-person contact and integration within clinical practices is underscored by the results of several studies. An analysis of the Medicare demonstration for high-cost beneficiaries found that programs in which care managers had direct, in-person interaction with patients and their physicians reduced expenditures by 7%, whereas those in which payer-based or third-party care managers interacted with patients via telephone had no effect.5 A review of both private and public programs reached similar conclusions, finding that programs that embedded in-person care managers into practices were more effective than those in which communication was outsourced to payers or third-party vendors.4 There is simply no substitute for person-to-person contact. Payer-catalyzed: As care financiers and plan administrators, payers have a fundamental role to play in creating an environment that enables and encourages the delivery of care management services. Most important is developing payment models that promote investment in high-risk care management capacities by clinicians and health care organizations. Traditional feefor-service reimbursement actively hinders experimentation with care management. On the other hand, shared savings arrangements, capitated payments, and per-member, per-month payments for complex longterm care management all afford care delivery organizations with the flexibility to reengineer care and create an environment where success improves financial perVIEWPOINT

Patient Population Loss At A Large Pioneer Accountable Care Organization And Implications For Refining The Program

Antenatal prevalence is more than 1% in parts of India, yet little is known about the complications and fetal outcomes in this region. We reviewed the records of 23,386 women who delivered at the Christian Medical College Hospital in Vellore, India from 2000 through 2002. HIV-infected women were more likely than HIV-uninfected women to have pregnancy-induced hypertension, anaemia, breech presentations, stillborn babies and fetal deaths. HIV-infected women who did not receive mother-to-child transmission prophylaxis or had breech fetal presentation were more likely to have fetal deaths (P = 0.001). HIV prophylaxis and optimal prenatal care should be a priority for HIV-infected pregnant women in resource-limited countries.

Penalizing Success: Is Comprehensive HIV Care Sustainable?

There is an ongoing move toward payment models that hold providers increasingly accountable for the care of their patients. The success of these new models depends in part on the stability of patient populations. We investigated the amount of population turnover in a large Medicare Pioneer accountable care organization (ACO) in the period 2012-14. We found that substantial numbers of beneficiaries became part of or left the ACO population during that period. For example, nearly one-third of beneficiaries who entered in 2012 left before 2014. Some of this turnover reflected that of ACO physicians-that is, beneficiaries whose physicians left the ACO were more likely to leave than those whose physicians remained. Some of the turnover also reflected changes in care delivery. For example, beneficiaries who were active in a care management program were less likely to leave the ACO than similar beneficiaries who had not yet started such a program. We recommend policy changes to increase the stability of ACO beneficiary populations, such as permitting lower cost sharing for care received within an ACO and requiring all beneficiaries to identify their primary care physician before being linked to an ACO.