TrendsandAssocia-onswithPrEPPrescrip-onamong602NYC
AmbulatoryCarePrac-ces,2014-16
PaulM.SalcuniJennySmolenSachinJainJulieMyersZoeEdelstein
NewYorkCityDepartmentofHealthandMentalHygiene
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Background• NYChasoneofthelargestHIVepidemicsintheUS
• 2,493newdiagnosesin2015,disproporIonatelyoccurringamongcertainpopulaIons,including:1• 58%menwhohavesexwithmen• 16%BlackandLaInawomen• 53%peoplelivinginhigh-povertyneighborhoods
• Oralemtricitabine/tenofovir(FTC/TDF)forHIVpre-exposureprophylaxis(PrEP)hasbeenshowntoreduceriskofsexualtransmissionbyupto92%whentakendaily2
• ComprehensiveeffortstoscaleupPrEPprescripIonanduseareunderwayinNYC,focusingonprioritypopulaIonsabove
1NYCDOHMHHIVSurveillanceReport,2015:h_ps://www1.nyc.gov/assets/doh/downloads/pdf/dires/hiv-surveillance-annualreport-2015.pdf2Grantetal,LancetID,2014
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StudyAims• ExaminePrEPprescribingamongasampleofNYCambulatorycarepracIcesusingdatafromauniqueclinicalsurveillancesystemcalledtheHubPopula-onHealthSystem(TheHub)
• Specificallyaimedto:• MeasurequarterlytrendsinPrEPprescripIonrates• IdenIfyassociaIonswithPrEPprescribingbypracIce-levelandpaIent-levelcharacterisIcs
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WhatisTheHub?• AninnovaIvesystemthatconnectstoelectronichealthrecords(EHRs)ofprovidersusingEHRvendoreClinicalWorks
• SecureandconfidenIal–onlyaggregatepaIentcountsarereceivedfromthepracIce
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Hub
• 720 prac-ces• 2,645providersacIvein2016• 2.0Mpa-entswithvisitsin2016
HubpracIcesonaverageover-represent:• Youngwomen(15-29)• Hispanic/LaInoandAsianpersons• Medicaid/MedicarepaIents• Primarycareproviders• Onlypeoplewhoareincare
WhoispartofTheHub?
BuckMDetal,JAmMedInformAssoc,2011.
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Methods• RetrospecIvecohort(Q12014–Q22016)of602ambulatorycarepracIcesusingHubtoqueryEHRs• 38(6%)communityhealthcenters;~22%ofpaIentvisits• 3(<1%)hospitaloutpa-entclinics;~12%ofpaIentvisits• 561(93%)independentprac-ces;~66%ofpaIentvisits
• PracIceinclusioncriteria:• LocatedinNewYorkCity• Contributeddataforallquarters• Documentedin2014and2015:
• Visitsfor≥50paIentsaged≥13• DiagnosisinformaIonfor≥80%ofvisits• MedicaIoninformaIonfor≥20%ofvisits
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Outcome:PrEPprescrip-onalgorithmFTC/TDF
prescrip-on
ICD-9/10codesforpriordiagnosisofHIVorHIV-relatedopportunisIcinfecIons;concomitantprescripIonofotheranIretroviral(s)
ICD-9/10codesforpriordiagnosisofhepaIIsB
ICD-9/10codesfor“contaminatedneedlesIck”or“prophylaxis”
ClassifiedasPrEPprescrip-on
HIVTreatment
ChronicHepBTreatment
PEPProvision
Exclusions
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Dataanalysis
Pa-ent-levelfactors
• Sexmale,female• Age18-29,30andabove• Race/ethnicityAsian,Black,Hispanic,White,other,missing
• QuarterlyPrEPprescripIonratecalculatedper100,000paIentsseen• TrendsandassociaIonswithPrEPprescripIonassessedusinggeneralizedesImaIngequaIons,examining:
*High-povertyneighborhoodsareZIPcodeareaswhere≥20%ofresidentslivebelowthefederalpovertylevel.
Prac-ce-levelfactors
• PracIcetypeCommunityhealthcenter,hospital,independent• PracIcelocaIonManha_an,other• AcIveIDspecialistsYes,no• ProporIonofpaIentsfromhigh-povertyneighborhoods*
RankedbyquarIle
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PrEPprescrip-onratesper100,000pa-entsseenin602ambulatorycareprac-ces,overall,NYC,2014-2016
050
100150200250300350400450
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2014 2015 2016
PrEPprescrip
Ions
per1
00,000paI
entsse
en
418.52,977/711,343
Unadjustedratera6o(RR)1.27(1.24–1.31)perquarter38.9
249/639,469
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PrEPprescrip-onratesper100,000pa-entsseenin602ambulatorycareprac-ces,bysex,NYC,2014-2016
0
200
400
600
800
1000
1200
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2014 2015 2016
PrEPprescrip
Ions
per1
00,000paI
entsse
en
Males Females 1036.42,835/273,555
7.429/393,780 32.4
142/437,788
Adjusted*RRMale:4.6(2.8–7.6)
Female:Ref.
*AdjustedforpaIentageandrace/ethnicity,pracIcelocaIonandtype,proporIonofpracIce’spaIentslivinginhighpovertyZIPs,andnumberofIDspecialists.
89.5220/245,689
Adjusted*RRMale:13.5(8.5–21.6)
Female:Ref.
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PrEPprescrip-onratesper100,000malesseenin602ambulatorycareprac-ces,byagegroup,NYC,2014-2016
0
500
1000
1500
2000
2500
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2014 2015 2016
PrEPprescrip
Ions
per1
00,000paI
entsse
en
18to29 30andabove
131.449/37,288
2297.1974/42,402
82.1171/208,401
805.11,861/231,153
*AdjustedforIme,paIentrace/ethnicity,pracIcelocaIonandtype,numberofIDspecialists,proporIonofpracIce’spaIentslivinginhighpovertyZIPs,andinteracIonbetweenpovertyandIme.
Adjusted*RR18-29:2.8(2.4–3.4)30andabove:Ref.
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0
500
1000
1500
2000
2500
3000
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2014 2015 2016
PrEPprescrip
Ions
per1
00,000paI
entsse
en
White Black Hispanic/La-no API Other 2508.51,396/55,650
189.9117/61,625
112.623/20,428
654.8176/26,880
51.833/63,704 709.5
545/76,81744.0
17/38,671
868.6357/41,100
39.518/45,552 468.5
254/54,210
PrEPprescrip-onratesper100,000malesseenin602ambulatorycareprac-ces,byrace/ethnicity,NYC,2014-2016
*AdjustedforpaIentage,pracIcelocaIonandtype,proporIonofpracIce’spaIentslivinginhighpovertyZIPs,andnumberofIDspecialists.
Adjusted*RRAPI:0.5(0.3–0.8)Black:0.6(0.4–0.9)LaIno:0.5(0.3–0.7)Other:0.7(0.5–0.9)
White:Ref.
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Associa-onswithPrEPprescrip-onrateandprac-ce-levelcharacteris-csamongmalepa-entsin602ambulatorycareprac-ces,NYC,2014–2016
Characteris-cAdjusted*ratera-o
(95%CI)Prac-celoca-onManha_an 8.5(4.0-18.1)Other Ref.Prac-cetypeCHC 4.9(2.5-9.5)Hospital 0.4(0.1-1.8)Independent Ref.Ac-veIDspecialistsbYes 8.4(3.6-19.6)No Ref.CHC=communityhealthcenter;ID=infecIousdiseaseBold=p<0.05
*AdjustedforIme,paIentageandrace/ethnicity,pracIcelocaIonandtype,proporIonofpracIce’spaIentslivinginhighpovertyZIPs,andnumberofIDspecialists. 13
PrEPprescribingbyprac-ceneighborhood,comparedtopovertyandHIVdiagnosisrate
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Limita-ons• PrescripIondatainEHRsareinherentlylimited
• PracIcescoveredbytheHublikelynotrepresentaIveofallambulatorycarepracIcesinNYC• Over-representscertainpaIentgroups• Coveragevariesbyarea(lessrepresentaIvebelowthecitylevel)• MissingsomepracIcesknowntobePrEPprescribers
• TimetrendsandassociaIonsmaynotbegeneralizabletoallNYCpracIces,oroutsideofNYC
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Summary• PrEPprescripIonincreased976%betweenQ12014toQ22016among602ambulatorycarepracIcesinNYC• ByQ22016,malesmadeup95%ofPrEPprescripIons• Amongmales,PrEPprescripIonwasassociatedwith:
• Youngerage• Whiterace/ethnicity• Manha_anpracIcelocaIon• Communityhealthcentersvs.independentpracIces• On-siteIDspecialists• LowerproporIonofpaIentpopulaIonfromhigh-povertyneighborhoods(althoughtheassociaIona_enuatedoverIme)
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Implica-ons• SustainedincreaseinPrEPprescribingsuggestssuccessofcampaignsforpaIentsandproviders• DifferencebysexmoIvatesfocusonwomenandtheirprimarycareproviders,includingOB/GYNs• Lowprescribingtomenofcolor,despiteoverrepresentaIonintheHIVepidemic,mustconInuetobeaddressed• ConInuedoutreachneededfor:
• PracIcesoutsideofManha_an• IndependentpracIces• Non-IDspecialists• PracIcesseeingpaIentsfromhigh-povertyneighborhoods
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AcknowledgementsDivisionofDiseaseControl,BureauofHIV/AIDSZoeEdelstein,JulieMyers,BenjaminTsoi,BisratAbraham,DemetreDaskalakis
DivisionofPreven-onandPrimaryCareJennySmolen,SachinJain,LauraJacobson,RemleNewton-Dame,ShadiChamanyeClinicalWorks&par-cipa-ngproviders
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