ob/gyn chart review - ryanwhiteatl.org · ob/gyn chart review a summary of ob/gyn clinical chart...

OB/GYN CHART REVIEW

A summary of OB/GYN clinical chart review results designed to monitor the quality of care provided by a Ryan White funded OB/GYN primary care site as part of the Atlanta EMA’s quality management plan.

Prepared for Fulton County Government’s Ryan White Part A Program By the Southeast AIDS Training and Education Center

Emory University School of Medicine

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Methodology• Purpose: To examine the extent to which a Ryan White funded primary care site is

providing care that meets quality of care indicators for HIV positive obstetric patients.

• Reviewers: Barbara Blake, RN, PhD, ACRN and Gloria Taylor, DSN, RN

• Electronic Medical Record System: EPIC

• Completed: April 2013

• Extraction Tool: From baseline Quality of Care Measures used in the development of primary care quality management standards and indicators in the EMA, based on Public Health Service Guidelines and acceptable clinical practices as well as quality indicators for providers of pregnant women with HIV. Susan Richardson, MN, MPH, FNP-BC assisted in the creation and accuracy of the tool.

• Patient Chart Selection: Systematic sampling of 2011 HIV positive obstetric clinic patients

• Total Charts Reviewed: 32

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Patient Demographics

Race/Ethnicity

6%(n=2)

50%(n=16) 44%

(n=14)

0%

10%

20%

30%

40%

50%

60%

<=19 20-29 30-39

Black75% (n=24)

White 3% (n=1)

Multi-Racial 13% (n=4)

Other Race9% (n=3)

Age

3

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Clinic History and Engagement

Measures

1. Patient meets eligibility criteria

2. Date of initial OB visit (not shown)

3. Patient was new to clinic during study period

4. Date of first IDP visit (not shown)

5. If not IDP, name of HIV provider prior to coming to Grady (not shown)

6. Name of other provider (not shown)

7. Ever IDP visit

4

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Clinic History and Engagement

Eligibility criteria:• HIV positive• Pregnant• Had at least one medical visit within the

review period• Necessary chart volumes were accessible

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%

100.0%

Yes No

87%(n=28)

13%(n=4)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

25%(n=8)

75%(n=24)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

1. Meets eligibility criteria

3. New to clinic during study period 7. Ever IDP visit

5

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HAB Performance MeasuresHAB Group 1:

Serve as foundational measures for HIV provision of care

Performance Measure EMA Indicator Goal

Prescribed ARV therapy for pregnant women None available

Had > 2 CD4 T-Cell Counts within measurement year 90%

Had > 2 medical visits in an HIV care setting (OB clinic) 85%

HAB Group 2: Important measures that

should seriously be considered for inclusion

in HIV clinical care

Assessed and Counseled for adherence > 2 times at least three months apart

90%

Has completed the HBV vaccination series CDC goal: 45%

HCV screening was performed at least once since diagnosis of HIV

95%

Has received HIV risk counseling within the measurement year

85%

If on ARV therapy, had a fasting lipid panel during measurement year

HIVQUAL 2006 Median: 85%

Had a test for syphilis performed within the measurement year

90%

Had a test with documented results for LTBI since HIV diagnosis

100%

HAB Group 3: “Best practice” areas of

care that lack written clinical guidelines

Had a test for chlamydia within the measurement year None available

Had a test for gonorrhea within the measurement year None available

Received influenza vaccination within the measurement year

None available

Documented pneumococcal vaccine HIVQUAL 2007 Median: 91%

Documented Toxoplasma screen since HIV diagnosis HIVQUAL 2007 Median: 84%

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Clinical Assessment

*Denotes HAB HIV Performance Measure

Measures

1. Patient has (ever) been diagnosed with AIDS

2. Patient is currently on ART*

3. Two medical visits (at least 3 months apart)*

4. Patient is not currently on ART, but has a history of ART

5. Patient has prior ART regimens listed

6. Patient has prior history of resistance testing

7. If not resistant, ART regimen included at least NRTI

8. Problem list

9. Allergies documented

10. No known allergies (NKA/NKDA)

11. Patient was diagnosed with an STI during study period

12. Patient used tobacco during study period 7

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Clinical Assessment

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

41%(n=13)

59%(n=19)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

84%(n=27)

16%(n=5)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

53%(n=17) 47%

(n=15)


2b. Not currently on ART, but history of ART

2a. Currently on ART*

3. Two medical visits (at least 3 months apart)*

1. Ever diagnosed with HIV

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

20%(n=1)

80%(n=4)

8

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Clinical Assessment

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

38%(n=12)

63%(n=20)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

69%(n=22)

31%(n=10)

6a. Prior history of resistance testing

6b. If not resistant, ART regimen includes at least 1 NRTI 7. Problem list

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

5. Prior regimen listed

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

67%(n=12)

33%(n=4) 9

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Clinical Assessment

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

47%(n=15)

53%(n=17)

10. No known allergies (NKA/NKDA)**

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

88%(n=25)

22%(n=7)

9. Allergies documented

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

13%(n=4)

88%(n=28)

11. Diagnosed with STI during study period 12. Used tobacco during study period

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

13%(n=4)

88%(n=28)

**Although 25 charts did not have documented allergies as noted in graph #9, only 15 had NKA/NKDA indicated in the chart.

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Study Period Documentation


Measures

1. Chlamydia, Gonorrhea, Syphilis Screen*

2. Influenza Vaccination*

3. Adherence counseling at every visit*

4. Risk assessment at every visit

5. Risk reduction counseling at every visit*

6. Hepatitis B co-infection

7. Hepatitis C co-infection

8. Hepatitis B past infection with immunity

9. PPD current*

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0%10%20%30%40%50%60%70%80%90%

100%

Yes No

41%(n=13)

59%(n=19)


0%10%20%30%40%50%60%70%80%90%

100%

Yes No

97%(n=31)

3%(n=1)

1. Chlamydia and Gonorrhea screen*

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

97%(n=30)

6%(n=2)

1. Syphilis screen*

2. Received influenza vaccine*

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

3-5. Adherence counseling, risk assessment, risk reduction at every visit*

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0%10%20%30%40%50%60%70%80%90%

100%

Yes No

41%(n=13)

59%(n=19)


6-7. Hep B, Hep C co-infection 8. Hep B past infection with immunity

9. PPD current*

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

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Screens and Tests


Measure Group 1: At any point in time

1. Hepatitis B series*

2. Pneumococcal vaccination*

Measure Group 2: Since HIV diagnosis

3. Hepatitis C screen*

4. Hepatitis A screen

5. Toxoplasmosis screen*

6. LTBI test (TST or IGRA)*

Measure Group 3: Received during study

period or during pregnancy

7. Ultrasound in 1st trimester

8. If ART 1st Trimester, Ultrasound 2nd Trimester

9. Glucose tolerance test done at 20-23 wks

10. Liver enzymes and electrolytes monthly at 28 wksto birth

11. Strep B (vaginal) screen done at 32-36 wks14

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Screens and Tests

Measure Group 4: ART and blood work

during study or throughout pregnancy

12. If ART naïve, baseline resistance testing

13. If on ART at first visit, regimen documented

14. ART regimen at delivery

15. Nevaripine not begun if CD4>250

16. Baseline CBC and chemistries

17. At least 2 CBCs and chemistries (three months apart)

18. First CBCs and chemistries date (not shown)

19. Second CBCs and chemistries date (not shown)

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Screens and TestMeasure Group 2: Since HIV Diagnosis


0%10%20%30%40%50%60%70%80%90%

100%

Yes No

6%(n=2)

94%(n=30)

1-2. Hep B vaccination series, pnuemococcal vaccination*

Measure Group 1: At any point in time

0%10%20%30%40%50%60%70%80%90%

Yes No

81%(n=26)

19%(n=6)

3. Hep C screen*

4. Hep A screen*

0%

10%

20%

30%

40%

50%

60%

70%

80%

Yes No

72%(n=23)

28%(n=9)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

94%(n=30)

6%(n=2)

5. Toxoplasmosis screen*

16

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Screens and Test


Measure Group 2: Since HIV Diagnosis

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

6. LTBI test (TST or IGRA)*

Measure Group 3: Received during study period or pregnancy

0%

10%

20%

30%

40%

50%

60%

70%

Yes No

34%(n=11)

66%(n=21)

7. Ultrasound in 1st trimester

0%

10%

20%

30%

40%

50%

60%

Yes No

53%(n=17) 47%

(n=15)

8. If ART during 1st trimester, ultrasound during 2nd trimester

0%10%20%30%40%50%60%70%80%90%

Yes No

19%(n=6)

81%(n=26)

9. Glucose tolerance done at 20-23 weeks

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Screens and Tests

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

41%(n=13)

81%(n=19)

Measure Group 3: Received during study period or pregnancy

10. Liver enzymes and electrolytes monthly at 28 wks to birth

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

59%(n=19)

41%(n=13)

11. Strep B (vaginal) screen done at 32-36 weeks

Measure Group 4: ART and blood work during study or throughout pregnancy

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

9%(n=3)

91%(n=29)

12. If ART naïve, baseline resistance testing**

**Only 1 patient had NO history of ART (ART naïve), but 3 were tested of the 32 total charts.

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Screens and Tests

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

75%(n=24)

25%(n=8)

13. On ART at first visit

13.1. If on ART at first visit, regimen documented

61%(n=19)

3%(n=1)

3%(n=1)

3%(n=1)

3%(n=1)

3%(n=1)

16%(n=5) 6%

(n=2)02468

101214161820

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Screens and Tests14. ART regimen at delivery

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

100%(n=32)

16. Baseline CBC and chemistries

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

53%(n=17)

47%(n=15)

15. Nevaripine not begun if CD4>250

57%(n=13)

4%(n=1)

4%(n=1)

4%(n=1)

4%(n=1)

4%(n=1)

17%(n=4)

4%(n=1)

02468

101214

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Screens and Tests

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

78%(n=25)

22%(n=7)

17. At least 2 CBC and chemistries (3 months apart)

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CD4 and Viral Load

Measures

1. CD4 and viral load at initial visit

2. Two CD4 cell count tests (at least 3 months apart)*

3. If VL >500-1,000 on ART, resistance testing done

4. VL at 34-36 wks for mode of delivery decision

5. VL every three months until birth* - Only three (9%) charts reviewed indicated having a VL every 3 months until birth

6. VL at first visit

7. VL at delivery


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CD4 and Viral Load

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

31%(n=22)

69%(n=10)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

50%(n=16)

50%(n=16)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

16%(n=5)

84%(n=27)

0%10%20%30%40%50%60%70%80%90%

100%

Yes No

53%(n=17) 47%

(n=15)


1. CD4 and VL at initial visit 2. Two CD4 cell count tests (at least 3 months apart)*

3. If VL > 500-1,000 on ART, resistance testing done 4. VL at 34-36 weeks for mode of delivery decision

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Medications• Nucleoside/Nucleotide Analogue Reverse Transcriptase

Inhibitors (NRTI)

HIV Medication Frequency Percent

Combivir 19 59.4

Emtriva 31 96.9

Epivir 31 96.9

Epzicom 2 6.3

Hivid 0 -

Retrovir 31 96.9

Trizivir 1 3.1

Truvada 7 21.9

Videx EC 0 -

Videx 0 -

Viread 30 93.8

Zerit 0 -

Ziagen 0 -24

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Medications• Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI)

• HIV Inhibitors

• Entry Inhibitors


Intelence 1 3.1

Rescriptor 0 -

Sustiva 0 -

Viramune 0 -


Isentress 3 9.4


Selzentry 0 - 25

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Medications• Fusion Inhibitors

• Multi-Class


Fuzeon 0 -


Atripla 0 -

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Medications

• Protease Inhibitors (PI)


Agenerase 0 -

Aptivus 0 -

Crixivan 0 -

Fortovase 0 -

Invirase 0 -

Kaletra 19 59.4

Lexiva 0 -

Norvir 8 25.0

Prezista 2 6.3

Reyataz 6 18.8

Viracept 1 3.127

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Limitations and Reviewer Observations

• Only portions of patient charts were made available to reviewers• Lab results• Sections of chart that were deemed acceptable to respond to

pre-submitted questions• Full delivery record not available• Observations

• Population came into care late• Some may have been transferred but this information was not made

available and was unable to be reviewed• One incarcerated patient chart• Few appointments recorded across the board considering pregnancy

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ob/gyn chart review - ryanwhiteatl.org · ob/gyn chart review a summary of ob/gyn clinical chart...

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