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A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data.

ABSTRACT: The human immunodeficiency virus (HIV) care cascade is a conceptual model used to outline the benchmarks that reflects effectiveness of HIV care in the whole HIV care continuum. The models can be used to identify barriers contributing to poor outcomes along each benchmark in the cascade such as disengagement from care or death. Recently, the HIV care cascade has been widely applied to monitor progress towards HIV prevention and care goals in an attempt to develop strategies to improve health outcomes along the care continuum. Yet, there are challenges in quantifying successes and gaps in HIV care using the cascade models that are partly due to the lack of analytic approaches. The availability of large cohort data presents an opportunity to develop a coherent statistical framework for analysis of the HIV care cascade. Motivated by data from the Academic Model Providing Access to Healthcare, which has provided HIV care to nearly 200,000 individuals in Western Kenya since 2001, we developed a state transition framework that can characterize patient-level movements through the multiple stages of the HIV care cascade. We describe how to transform large observational data into an analyzable format. We then illustrate the state transition framework via multistate modeling to quantify dynamics in retention aspects of care. The proposed modeling approach identifies the transition probabilities of moving through each stage in the care cascade. In addition, this approach allows regression-based estimation to characterize effects of (time-varying) predictors of within and between state transitions such as retention, disengagement, re-entry into care, transfer-out, and mortality. Copyright © 2017 John Wiley & Sons, Ltd.

SUBMITTER: Lee H

PROVIDER: S-EPMC5735035 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data.

Lee Hana H Hogan Joseph W JW Genberg Becky L BL Wu Xiaotian K XK Musick Beverly S BS Mwangi Ann A Braitstein Paula P

Statistics in medicine 20171122 2

The human immunodeficiency virus (HIV) care cascade is a conceptual model used to outline the benchmarks that reflects effectiveness of HIV care in the whole HIV care continuum. The models can be used to identify barriers contributing to poor outcomes along each benchmark in the cascade such as disengagement from care or death. Recently, the HIV care cascade has been widely applied to monitor progress towards HIV prevention and care goals in an attempt to develop strategies to improve health out ...[more]

PMID: 29164648

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Project description:INTRODUCTION:Adherence to antiretroviral therapy (ART) and retention in treatment programs are required for successful virologic suppression and treatment outcomes. As the number of adolescents living with HIV continues to increase globally, more information about adherence and retention patterns during and through transition from child- to adult-centered care is needed to ensure provision of a high level of care and inform development of targeted interventions to improve patient outcomes in this vulnerable population. In this analysis, we sought to describe long-term trends in adherence, retention, and virologic suppression in adolescents receiving ART at a pediatric HIV clinic in Nigeria through transition to the adult clinic. SETTING:The Jos University Teaching Hospital, United States President's Emergency Plan for AIDS Relief (PEPFAR)-funded HIV clinic in Jos, Plateau State, Nigeria. METHODS:We conducted a retrospective observational longitudinal evaluation of data that had been collected during the course of care in a large pediatric ART program in Nigeria. We used descriptive statistics to define our patient population and quantify retention from ART initiation through adolescence and transition to adult-centered care. Logistic regression was used to evaluate predictors of loss to follow-up. We used medication possession ratio (MPR) to quantify adherence for each year a patient was on ART. To evaluate adherence and virologic suppression, we measured the proportion of patients with ?95% MPR and the proportion with virologic suppression (viral load ?400 copies/mL) within each age cohort, and used bivariate analyses to examine any association between MPR and VL suppression for all person-years observed. RESULTS:A total of 476 patients received at least one dose of ART as an adolescent (ages 10-19 years). The proportions of patients lost to follow-up were: 11.9% (71/597) prior to adolescence, 19.1% (31/162) during adolescence, and 13.7% (10/73) during transition to adult-centered care. While over 80% of patients had ?95% medication adherence in all age groups, their viral load suppression rates through adolescence and post-transition were only 55.6%-64.0%. For patients that successfully transitioned to adult-centered care, we observed 87.7% (50/57) retention at month 12 post-transition, but only 34.6% (9/26) viral load suppression. CONCLUSIONS:Our evaluation found considerable proportions of adolescents lost to follow-up throughout the ART program cascade. We also found discrepancies between the proportions of patients with ?95% MPR and the proportions with VL suppression, suggesting that true medication adherence in this population may be poor. Significant attention and targeted interventions to improve retention and adherence focused on adolescents are needed in order for global programs to achieve 90-90-90 goals.

Project description:BackgroundPatient portals (ie, electronic personal health records tethered to institutional electronic health records) are recognized as a promising mechanism to support greater patient engagement, yet questions remain about how health care leaders, policy makers, and designers can encourage adoption of patient portals and what factors might contribute to sustained utilization.ObjectiveThe purposes of this state of the science review are to (1) present the definition, background, and how current literature addresses the encouragement and support of patient engagement through the patient portal, and (2) provide a summary of future directions for patient portal research and development to meaningfully impact patient engagement.MethodsWe reviewed literature from 2006 through 2014 in PubMed, Ovid Medline, and PsycInfo using the search terms "patient portal" OR "personal health record" OR "electronic personal health record". Final inclusion criterion dictated that studies report on the patient experience and/or ways that patients may be supported to make competent health care decisions and act on those decisions using patient portal functionality.ResultsWe found 120 studies that met the inclusion criteria. Based on the research questions, explicit and implicit aims of the studies, and related measures addressed, the studies were grouped into five major topics (patient adoption, provider endorsement, health literacy, usability, and utility). We discuss the findings and conclusions of studies that address the five topical areas.ConclusionsCurrent research has demonstrated that patients' interest and ability to use patient portals is strongly influenced by personal factors such age, ethnicity, education level, health literacy, health status, and role as a caregiver. Health care delivery factors, mainly provider endorsement and patient portal usability also contribute to patient's ability to engage through and with the patient portal. Future directions of research should focus on identifying specific populations and contextual considerations that would benefit most from a greater degree of patient engagement through a patient portal. Ultimately, adoption by patients and endorsement by providers will come when existing patient portal features align with patients' and providers' information needs and functionality.

Project description:Complex nanoshaped structures (nanoshape structures here are defined as shapes enabled by sharp corners with radius of curvature <5 nm) have been shown to enable emerging nanoscale applications in energy, electronics, optics, and medicine. This nanoshaped fabrication at high throughput is well beyond the capabilities of advanced optical lithography. While the highest-resolution e-beam processes (Gaussian beam tools with non-chemically amplified resists) can achieve <5 nm resolution, this is only available at very low throughputs. Large-area e-beam processes, needed for photomasks and imprint templates, are limited to ~18 nm half-pitch lines and spaces and ~20 nm half-pitch hole patterns. Using nanoimprint lithography, we have previously demonstrated the ability to fabricate precise diamond-like nanoshapes with ~3 nm radius corners over large areas. An exemplary shaped silicon nanowire ultracapacitor device was fabricated with these nanoshaped structures, wherein the half-pitch was 100 nm. The device significantly exceeded standard nanowire capacitor performance (by 90%) due to relative increase in surface area per unit projected area, enabled by the nanoshape. Going beyond the previous work, in this paper we explore the scaling of these nanoshaped structures to 10 nm half-pitch and below. At these scales a new "shape retention" resolution limit is observed due to polymer relaxation in imprint resists, which cannot be predicted with a linear elastic continuum model. An all-atom molecular dynamics model of the nanoshape structure was developed here to study this shape retention phenomenon and accurately predict the polymer relaxation. The atomistic framework is an essential modeling and design tool to extend the capability of imprint lithography to sub-10 nm nanoshapes. This framework has been used here to propose process refinements that maximize shape retention, and design template assist features (design for nanoshape retention) to achieve targeted nanoshapes.

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A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data.

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A state transition framework for patient-level modeling of engagement and retention in HIV care using longitudinal cohort data.

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