Department of Human
Services
Acute Health Division
Evaluation of the Relocated HIV/AIDS and Infectious Diseases
Services
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5 Findings 5.1
HIV/AIDS Services at The Alfred Hospital
Documentation provided by The Alfred on the effectiveness of the quality of the clinical services provided at the hospital reflects the outcomes of treatment using a range of clinical indicators.(2) The results were based on an audit of HIV/AIDS patients at The Alfred between 1996 and 1998, excluding pre-existing Alfred HIV/AIDS patients. A total of 1,655 patients were on The Alfred database as at July 1998, of whom 526 were pre-existing Alfred patients, 930 transferred from Fairfield, and 199 were newly referred following the transfer. Only 30% of the Infectious Diseases Unit bed-days, and 68% of the HIV/AIDS bed-days at The Alfred are occupied by former Fairfield patients. Over the two-year period since the transfer of patients, participation in antiretroviral treatment increased from 35% to 90% of patients, which compares to a national participation rate of approximately 80%. Over the same period, incident AIDS-related cases fell every quarter from 42 cases in June 1996 to 3 cases in June 1998, a reduction of 93%, also consistent with national outcomes. There was no significant change in the illnesses presenting as AIDS-defining illnesses over this period. Deaths decreased from 21 in the third quarter of 1996 to 6 in the second quarter of 1998, a reduction of 71%. At the same time, HIV RNA in the hospital-associated patient group declined and has remained stable over the past 2 quarters, which has also been associated with an increase in the median 100 CD4 cell/ml. Inpatient admissions have consistently declined over the 2 years, together with a reduction in the multi-day length of stay from 13.9 days to 10 days. The proportion of multi-day to same-day admissions has risen as the disease pattern of HIV/AIDS patients has changed from opportunistic infections to drug toxicity and other illnesses. The analysis by The Alfred concludes that: "The patients attending the HIV service at The Alfred are accessing treatment and there is clear evidence of their improved outcome as measured by reduced AIDS-defined illnesses, deaths, admissions, HIV RNA levels and increased CD4 counts. There is, however, a trend towards more non-AIDS admissions and a trend to more of these due to toxicity. The evidence of persistent albeit low levels of HIV viraemia in this population is also of concern as it is likely to predict the development of antiretroviral resistance to current therapies. Toxicity and resistance pose substantial threats to the ongoing health of this population".(3) Supporting these clinical outcome measures are patient satisfaction surveys conducted by The Alfred, together with anecdotal comments made by a wide range of stakeholders to the consultants, including consumers and community-based service providers. The large majority of those consulted in the course of the review was highly complimentary of the quality of the clinical care provided at The Alfred by medical practitioners, nursing staff and allied health professionals. Criticism of services at The Alfred related more to environmental factors associated with service delivery rather than the quality of clinical care itself. The views of stakeholders are discussed in greater detail in Section 5.1.5. The clinical data on outcomes and the views of stakeholders indicate that the quality of care provided by The Alfred is of a standard at least equivalent to national standards, and meeting the needs of consumers.
The Alfred has established several mechanisms to monitor and assess patient satisfaction with services including six-monthly focus groups, the monthly HIV Care Committee and periodic patient satisfaction surveys. The HIV Care Committee has been the primary vehicle for liaison with consumers and their representative groups, with some 12 groups represented on the Committee. The Committee has met 32 times over the past 2 years, with an average of 8 community representatives attending the meetings, and 8 Alfred representatives. Views among consumer representatives on the effectiveness of the Committee vary, with some considering that it has provided an effective vehicle for the voicing of concerns and lobbying for action, while others felt that it has been slow to respond to change, with a tendency to focus on day-to-day issues rather than service-wide or strategic issues. Patient views on the services provided at The Alfred have been elicited from a range of sources in the course of the review:
Two patient satisfaction surveys conducted by The Alfred in September 1998 sought the views of inpatients and outpatients on services. The key results, as presented in The Alfred's report (4) were: Inpatients: 89%
knew the name of their primary nurse; The vast majority of patients reported that the Allied Health services were excellent. Outpatients: 93%
agreed or strongly agreed that they had confidence in their doctor's
ability to diagnose problems, their thoroughness and skills; Notwithstanding the limitations inherent in patient satisfaction surveys, the results indicate a relatively high level of satisfaction with the services provided at The Alfred. In general terms, these results are consistent with the results of the voluntary survey conducted by the consultants. However, the consultants' survey also revealed instances of strong concerns among some patients about some aspects of services.
Discussions with consumer representatives both individually and in focus groups revealed a range of opinions about the services provided. The overall view expressed was that while The Alfred's services were now at a stage where (in general) they meet the requirements of the service agreement, there have been delays in their implementation, and in many instances have required considerable effort and intervention by consumers for the required services to be implemented. Most agreed that the services have improved significantly over the past 12 months or so. Issues identified as being of greatest concern related to the standard of accommodation in the palliative/continuing care unit, delays in admissions to Ward 7W, the lack of exclusivity to HIV/AIDS facilities, occasional lapses in sensitivity and privacy in some sections of the hospital, and the need for more non-HIV specialists to be more informed about HIV when treating comorbidities. The discussions also identified areas where improvements are required in the range of services available to patients with HIV/AIDS, particularly psychiatric services, drug and alcohol services and gynaecological services. Further details of the views of consumers are discussed in Section 5.1.5.
Survey forms were made available to current patients of The Alfred, as well as responses being sought through a variety of mechanisms available to former and current patients. We emphasise that the survey was not based on a statistical sampling strategy, and comprised voluntary responses by any party who wished to make comment or complete the survey form. Consequently the results may not be representative of the total patient population. However, the results (albeit from a small sample) provide information about some aspects of services that warrant further consideration. A total of 24 survey forms were received relating to HIV/AIDS services provided at The Alfred, together with 1 written submission and 6 telephone calls. Of the responses received, a total of 22 (71%) indicated that they were generally satisfied with the services they received. In the 24 completed survey forms;
A number of the consumers were effusive in their compliments regarding the quality and continuity of care, and the sensitivity of staff to their needs. On the other hand, 6 (25%) respondents were critical of these same dimensions, and expressed disappointment with the care they had received and the accessibility of services. This distribution of positive and negative comments is broadly consistent with the patient survey results. Areas identified which warrant attention (which included comments from some respondents who were generally satisfied) were waiting times for admission to the ward from the emergency area, access to pharmacy services, and excessive waiting times to see non-HIV specialists. The quality of food and access to car parking were other issues that received adverse criticism. It is evident from the range of information sources used to elicit patient views that, while the majority of consumers have indicated that they are satisfied with the services provided, there remains a number who have serious concerns. This diversity of opinion and experiences suggests that there remains work to be done by The Alfred in ensuring consistency not so much in the quality of the clinical services provided, but in the administrative arrangements (particularly waiting times for ward admissions and clinical appointments), the training of staff in issues affecting patients with HIV/AIDS and the need for greater sensitivity when treating or assisting them. At the same time, there is a view that there are a number of deficiencies in the range of services available to patients with HIV/AIDS, particularly psychiatric services, drug and alcohol services, gynaecological services and the experience of non-AIDS specialists in catering for the needs of HIV/AIDS patients when treating their comorbidities. |