Audit Report 2003
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Audit Report 2003

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4 Pages
English

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British HIV AssociationBHIVABRITISH HIV ASSOCIATION Clinical Audit Report 2002–3Registered Charity 1056354 October 2003About the Expanding audit programmeclinical auditpresented at BHIVA’s Autumn 2003HE Brithish HIV Association (BHIVA)committeeConference.clinical audit committee expanded itsDuring the year the committee alsoTwork in 2002–3, by conducting twoThe BHIVA clinical auditworked to consolidate its role, by national audit projects. The first was acommittee began work inadopting terms of reference which havemajor audit covering two main topics:2001. Its aims are:been approved by the BHIVA executive • A survey of clinical practice on • To promote practice inand by working to strengthen links withinitiating antiretroviral treatment andclinical audit in HIV, AIDSlocal clinicians and regional audit groupsreview of case notes of patients whoand related fields.via the establishment of the BHIVA clinicalstarted from naive during• To develop andaudit faculty. The faculty operates throughApril–September 2002.implement a rollinga fully interactive website at• A preliminary survey of arrangements programme of nationalhttp://www.bhiva-clinical-audit.org.ukfor HIV maternity care.clinical audit in HIV andwhich enables clinicians to shareResults of this audit were presented AIDS.information about their own projects at the BHIVA Spring conference in• To facilitate sharing ofand to access the committee’s plans, Manchester in April 2003 and are beingrelevant ...

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British HIV Association
BHIVA
BRITISH HIV ASSOCIATION Clinical Audit Report 2002–3
Registered Charity 1056354 October 2003
About the Expanding audit programme
clinical audit
presented at BHIVA’s Autumn 2003HE Brithish HIV Association (BHIVA)committee
Conference.clinical audit committee expanded its
During the year the committee alsoTwork in 2002–3, by conducting twoThe BHIVA clinical audit
worked to consolidate its role, by national audit projects. The first was acommittee began work in
adopting terms of reference which havemajor audit covering two main topics:2001. Its aims are:
been approved by the BHIVA executive • A survey of clinical practice on • To promote practice in
and by working to strengthen links withinitiating antiretroviral treatment andclinical audit in HIV, AIDS
local clinicians and regional audit groupsreview of case notes of patients whoand related fields.
via the establishment of the BHIVA clinicalstarted from naive during• To develop and
audit faculty. The faculty operates throughApril–September 2002.implement a rolling
a fully interactive website at• A preliminary survey of arrangements programme of national
http://www.bhiva-clinical-audit.org.ukfor HIV maternity care.clinical audit in HIV and
which enables clinicians to shareResults of this audit were presented AIDS.
information about their own projects at the BHIVA Spring conference in• To facilitate sharing of
and to access the committee’s plans, Manchester in April 2003 and are beingrelevant information and
audit results, draft questionnaires and prepared for journal publication.expertise via the BHIVA
other documents. Summary results of The second audit was a case noteClinical Audit Faculty.
the three audits to date are available review of new diagnoses of HIV infection.More information about the
from this site in PowerPoint and AcrobatIntended to follow up on the 2001–2 committee’s work is
PDF formats. The site will be integratedaudit finding that most patients startingavailable at:
into the main BHIVA website at:treatment did so at CD4 counts <200http://www.bhiva-clinical-
http://www.bhiva.org when this is re-cells/µl, but that this largely reflected lateaudit.org.uk
developed.diagnosis. Preliminary results were
Members of the
clinical audit Implications of the
committee
Chairperson: Dr Margaret audit resultsJohnson, BHIVA Chair Elect
Deputy chairperson:
due to late diagnosis. However, a• Commissioners need to address theDr Gary Brook, North Thames
significant minority of those who started Regional Audit Group pressures that rapidly rising HIV
treatment at CD4 <200 cells/µl had beencaseloads are creating for services.Audit co-ordinator:
diagnosed more than 6 months beforeDr Hilary Curtis • Late diagnosis of HIV infection remains
doing so. Possible reasons includea significant problem in the UK, andDr Ray Brettle, Edinburgh
patient choice of non-attendance, raisingcontributes to avoidable disease. RoutineMr Paul Bunting, South Thames
the question of whether more could beRegional Audit Group screening accounted for fewer than half
done to encourage people withDr David Daniels, British of diagnoses, and should be promoted
diagnosed HIV to attend for regularAssociation for Sexual Health and HIV further.
monitoring.Dr Andrew Freedman, Cardiff • GPs and hospital doctors need to be
Professor Brian Gazzard, BHIVA • It is of concern that a substantial propor-alert to the possibility of HIV infection, President
tion of patients started antiretroviralin view of some evidence of delayedDr Eric Montiero, Yorkshire
therapy without all relevant baselinediagnosis even after patients haveRegional Audit Group
tests being performed. This is beingpresented with symptomatic disease.Dr Dushyant Mital, London
addressed in revised national guidelines.Dr Fiona Mulcahy, Dublin • Black-African people are diagnosed later
Dr Colm O’Mahony, Chester than whites. In some cases this may • It appeared that most antenatal services
Dr Anton Pozniak, London reflect the stage at their arrival in the had not reached the national target of
Dr Caroline Sabin, UK, but it suggests a need to encourage 90% uptake for HIV screening, with a
Dr Ann Sullivan, London testing within Black-African communities. significant minority not offering such
Dr Alan Tang, Reading • Two-thirds of patients started treatment screening on an opt-out basis. This is
Dr Jan Welch, London
later than guidelines recommend, at being explored in more detail in the
Dr Ed Wilkins, Manchester
CD4 counts <200 cells/µl. This is mostly 2003–4 national audit.
1 BHIVA Clinical Audit Report 2002–3
BHIVA British HIV AssociationAudit of patients starting HIV treatment
ones. In addition, 34% have ahis audit comprised a fact nearly all of these had CD4
local policy or guidelines onsurvey of clinical practice counts justifying treatment
supporting adherence toTin relation to starting according to the guidelines.
treatment.treatment, and a case-note
Choice of treatment review of patients who started
Timing of treatment A very wide range of differentfor the first time during April–
drug combinations was reported,September 2002. Its main aim Most patients started treatment
but the overwhelming majority was to assess adherence to the late, 66% at CD4 counts
of patients were started BHIVA guidelines applicable at <200 cells/µl including 24%
on treatment regimensthe time. at <50 cells/µl. Most of these
recommended in guidelinespatients were diagnosed less
Questionnaires were sent applicable at the time: 64% than 3 months before starting
in October 2002 to centres on two nucleoside reversetreatment, indicating late
previously identified as providing transcriptase inhibitors (NRTIs)diagnosis rather than delayed
adult HIV care. Completed forms plus a non-nucleoside reversetreatment. However, 10% of
were received from 113 centres transcriptase inhibitor, 10% onpatients who started treatment
with data on 942 patients, of two NRTIs plus a proteaseat CD4 <50 cells/µl and 29%
whom 56% were male and inhibitor (single or boosted), of those who started at CD4
55% Black-African. One striking 13% on three NRTIs and 3% on>50 and <200 cells/µl had been
finding concerned caseloads, zidovudine monotherapy fordiagnosed more than 6 months
with most centres reporting prevention of verticalbefore doing so.
an increase of over 15% in the transmission. The most widely
number of HIV patients under Reasons for treatment used specific combinations were
care over the preceding year. ®Combivir /efavirenz andThe main reason for starting
® /nevirapine. Althoughtreatment was disease Adherence to tenofovir was not licensed forprogression (85% of patients),guidelines first-line use at the time of thefollowed by prevention of
audit, 42 patients (4%) wereThe audit showed strong vertical transmission (12% of Figure 1:
started on this drug.support for BHIVA guidelines, patients, including 10% for Proportion of
patientswith 74% of centres saying their whom it was the sole reason).
Other findingsrecorded aspolicy is to follow the guidelines Patient choice and/or high viral
undergoing
Although not addressed inand a further 13% reporting that load were given as the sole
baseline tests
guidelines at the time, the they have their own guidelines reason for starting treatment for a before starting
case-note review includedwhich supplement the BHIVA small number of patients, but in treatment.
questions on baseline tests
performed before starting
treatment. The results are shown
97%100 96% in Figure 1, and the low rates of
testing recorded are of concern
81% in view of the known adverse
80
effects of HIV therapy.69%
The survey showed that most
56%60
52% clinical centres review patients
soon after starting treatment,
within 1–2 weeks for 63% of40
centres. At two centres, however,
patients were not reviewed
20 until 4–8 weeks after starting
treatment, while 36% of
centres reported that they 0
do not monitor the viral load
until more than 6 weeks after
starting. This is of concern
in view of the need to support
patients in adhering to
Baseline tests
treatment and in managing
potential side effects.
BHIVA Clinical Audit Report 2002–3 2
Blood pressure
Liver function
Serum lipids
Random glucose
Hepatitis B
Hepatitis C
Percentage
BHIVA British HIV Associationyyy
yy
y
yyy
yyy
yyy
yyy
y
y
y
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(17%) of patients being
hospitalised either at the time of
White Black African
diagnosis or during the preceding
year. A further 13% had not
35 been hospitalised but had had
symptoms or conditions, which
30 in retrospect, could have been
related to their HIV infection.
25 The course of events leading up
to diagnosis was not always clear
20 from the audit data, but a
significant minority of patients
15 were diagnosed through routine
screening after having attended
10
clinical services with symptomatic
disease, suggesting earlier
5
opportunities for diagnosis had
been missed.
0
0–50 51–200 201–350 351–500 500+ Although the audit was not
intended to assess outcomes, five
CD4 count (cells/µl) patients were reported to have
died soon after diagnosis and nine
to have been lost to follow-up.
Figure 2: CD4Audit of new diagnoses of at diagnosis in
cells/µl, by
HIV infection ethnicity.
Future
This project involved case-note Overall, 31% of diagnoses BHIVA events
review of patients who were first occurred late, at CD4 <200
10th Anniversary
diagnosed with HIV during cells/µl (11% at CD4 <50
BHIVA Conference
January–March 2003, or were first cells/µl), and 15% of patients
15–17 April 2004seen at participating centres were classified as having CDC
stage C disease at the time ofduring this period having been City Hall, Cardiff
diagnosed elsewhere no more diagnosis. Black-African patients
BHIVA Autumn Conferencethan 2 months earlier. The aim were diagnosed significantly later Figure 3:
8–9 October 2004Circumstanceswas to follow up on the results of than whites (P=0.0003, Figure 2).
Londonof HIVthe first audit conducted in
diagnosis. 2001–2, by exploring possible The circumstances of diagnosis
AN, antenatal;
reasons for late diagnosis. Data are shown in Figure 3. Routine
GUM, genito-
were analysed on 977 patients screening accounted for fewer urinary
submitted from 98 centres, of than half the diagnoses. medicine; Maternity
whom 55% were male, 59% Substantial morbidity occurred NK, not
black African and 33% white. prior to diagnosis, with 162 known. care and HIV
The management of HIV and
2% pregnancy will be the subject of
7% GUM screen the main audit project for
2003–4, but some preliminary
questions on this were included in
AN screen29%
the 2002 survey. In terms of HIV
16% testing policies at local maternity
Other routine screen services, 88% of respondents
reported an ‘opt-out’ approach,
10% ‘opt-in’ and 3% selective.
Only a third of respondents
Test because of concern
reported uptake rates of 90% or
about risk
above (the national target figure
Diagnosis of symptomatic for December 2002), with 9%
disease reporting figures below 60%. It
9% should be noted, however, that
Investigation of other
these figures represent HIV
abnormal signs
clinicians’ perceptions of what is
3%
happening rather than audited34% NK/not stated
patient data.
3 BHIVA Clinical Audit Report 2002–3
BHIVA British HIV Association
Percentage of patientsParticipation and coverage Financial details
One possible issue is that because they had no eligible As in 2001, all BHIVA’s seven major sponsors
the number of centres taking patients. In addition, the (see below) generously supported the 2002
part in the national audit configuration of clinical audit programme by equally contributing a
programme has declined. A services may have changed further £50k.
total of 148 centres responded in some areas. Hence, it is Unlike 2001, this year BHIVA conducted
to the first national audit in unclear whether there has two (one last year) national clinical audits.
2001–2 and 113 to the autumn been a real decline in The budgeted total cost of running two audits
2002 audit of treatment willingness to participate. is £44k. A printed audit report and a display
initiation. The 2003 audit of poster is being prepared and will be sent to
new diagnosis elicited responses The autumn 2002 audit all participating centres and the full BHIVA
from 113 centres, but only 98 membership.of treatment initiation included
submitted patient data. an optional question on the During 2002, BHIVA also commissioned
the set-up and management of a Clinicalcentre’s precise caseload,
The audit committee is defined as the number of adult Audit Faculty, cost £1.3k.
investigating the reasons for HIV patients seen for care Summary of expenditure £000
the declining number of within the preceding 6 months.
Clinical audit coordinator 16
participating centres. However, The 90 centres that answered
Project management and handling 17
there is no denominator on this question reported caring
Data reading, printing and postage 10
which to base a participation for a total of 21,791 patients.
Audit committee expenses 1
rate. Anecdotally, some units The committee plans to ask this
Total 44
combined to submit data question routinely in future
jointly and some may not have audits as a way of monitoring Surplus funds will be used towards future
audits.taken part in the 2002–3 audits coverage.
THANKS TO SPONSORS AND PARTICIPANTS
Contact details
ROCHE PRODUCTS LTD
BHIVA secretariat:
Mediscript Ltd
1 Mountview Court
310 Friern Barnet Lane
London N20 0LD
Tel: 020 8369 5380
Fax: 020 8446 9194
Email address:
Merck Sharp & Dohme Limited
bhiva@bhiva.org
Website:
http://www.bhiva.org
Completing the audit cycle
Clinical audit
Of the 113 centres that took part in the autumn 2002 audit, six reported changes in co-ordinator:
clinical practice as a result of BHIVA’s first national audit in 2001–2. This many seem
Dr Hilary Curtislow, but reflects the generally positive results of the first audit, with most centres
39 Esmond Roadreporting no need for change.
London NW6 7HF
It is too early yet for feedback on whether the audit of treatment initiation has led Tel: 020 7624 2148
to changes in clinical practice. However, its results fed into the work of the writing Fax: 0870 0567 212
committee, which recently revised BHIVA’s treatment guidelines for adults with HIV.
Email: hilary@regordane.netFor example, these guidelines now include recommendations on routine tests and
examinations, partly as a reflection of concern about the audit findings.
BHIVA Clinical Audit Report 2002–3 4
BHIVA British HIV Association