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Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities

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ABSTRACT

BACKGROUND

Pilot data suggest that a multifaceted approach may increase HIV testing rates, but the scalability of this approach and the level of support needed for successful implementation remain unknown.

OBJECTIVE

To evaluate the effectiveness of a scaled-up multi-component intervention in increasing the rate of risk-based and routine HIV diagnostic testing in primary care clinics and the impact of differing levels of program support.

DESIGN

Three arm, quasi-experimental implementation research study.

SETTING

Veterans Health Administration (VHA) facilities.

PATIENTS

Persons receiving primary care between June 2009 and September 2011

INTERVENTION

A multimodal program, including a real-time electronic clinical reminder to facilitate HIV testing, provider feedback reports and provider education, was implemented in Central and Local Arm Sites; sites in the Central Arm also received ongoing programmatic support. Control Arm sites had no intervention

MAIN MEASURES

Frequency of performing HIV testing during the 6 months before and after implementation of a risk-based clinical reminder (phase I) or routine clinical reminder (phase II).

KEY RESULTS

The adjusted rate of risk-based testing increased by 0.4 %, 5.6 % and 10.1 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). During phase II, the adjusted rate of routine testing increased by 1.1 %, 6.3 % and 9.2 % in the Control, Local and Central Arms, respectively (all comparisons, p < 0.01). At study end, 70–80 % of patients had been offered an HIV test.

CONCLUSIONS

Use of clinical reminders, provider feedback, education and social marketing significantly increased the frequency at which HIV testing is offered and performed in VHA facilities. These findings support a multimodal approach toward achieving the goal of having every American know their HIV status as a matter of routine clinical practice.

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REFERENCES

  1. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-infected adults and adolescents. Available at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed February 5, 2013.

  2. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1–17.

    PubMed  Google Scholar 

  3. Qaseem A, Snow V, Shekelle P, Hopkins R Jr, Owens DK. Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. Ann Intern Med. 2009;150:125–31.

    Article  PubMed  Google Scholar 

  4. Campsmith ML, Rhodes PH, Hall HI, Green TA. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006. J Acquir Immune Defic Syndr. 2010;53:619–24.

    PubMed  Google Scholar 

  5. Bokhour BG, Solomon JL, Knapp H, Asch SM, Gifford AL. Barriers and facilitators to routine HIV testing in VA primary care. J Gen Intern Med. 2009;24:1109–14.

    Article  PubMed  Google Scholar 

  6. Sundaram V, Lazzeroni LC, Douglass LR, Sanders GD, Tempio P, Owens DK. A randomized trial of computer-based reminders and audit and feedback to improve HIV screening in a primary care setting. Int J STD AIDS. 2009;20:527–33.

    Article  PubMed  CAS  Google Scholar 

  7. Wei C, Herrick A, Raymond HF, Anglemyer A, Gerbase A, Noar SM. Social marketing interventions to increase HIV/STI testing uptake among men who have sex with men and male-to-female transgender women. Cochrane Database Syst Rev. 2011;9, CD009337.

    PubMed  Google Scholar 

  8. Cunningham CO, Doran B, DeLuca J, Dyksterhouse R, Asgary R, Sacajiu G. Routine opt-out HIV testing in an urban community health center. AIDS Patient Care STDS. 2009;23:619–23.

    Article  PubMed  Google Scholar 

  9. Walensky RP, Reichmann WM, Arbelaez C, et al. Counselor- versus provider-based HIV screening in the emergency department: results from the universal screening for HIV infection in the emergency room (USHER) randomized controlled trial. Ann Emerg Med. 2011;58:S126–32.

    Article  PubMed  Google Scholar 

  10. Myers JJ, Modica C, Dufour MS, Bernstein C, McNamara K. Routine rapid HIV screening in six community health centers serving populations at risk. J Gen Intern Med. 2009;24:1269–74.

    Article  PubMed  Google Scholar 

  11. Scott VF, Sitapati A, Martin S, et al. The Howard University Hospital experience with routineized HIV screening: a progress report. Trans Am Clin Climatol Assoc. 2009;120:429–34.

    PubMed  Google Scholar 

  12. Cohan D, Sarnquist C, Gomez E, Feakins C, Maldonado Y, Zetola N. Increased uptake of HIV testing with the integration of nurse-initiated HIV testing into routine prenatal care. J Acquir Immune Defic Syndr. 2008;49:571–3.

    Article  PubMed  Google Scholar 

  13. Goetz MB, Bowman C, Hoang T, et al. Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI Series. Implement Sci. 2008;3:16.

    Article  PubMed  Google Scholar 

  14. Goetz MB, Hoang T, Bowman C, et al. A system-wide intervention to improve HIV testing in the Veterans Health Administration. J Gen Intern Med. 2008;23:1200–7.

    Article  PubMed  Google Scholar 

  15. Goetz MB, Hoang T, Henry SR, et al. Evaluation of the sustainability of an intervention to increase HIV testing. J Gen Intern Med. 2009;24:1275–80.

    Article  PubMed  Google Scholar 

  16. Goetz MB, Hoang T, Henry SR, et al. Exportability of an intervention to increase HIV testing. Jt Comm J Qual Patient Saf. 2011;37:553–9.

    PubMed  Google Scholar 

  17. Veterans Health Administration NLB Human Resources Committee. 2005 Facility Complexity Model. Available at http://vaww.vanod.med.va.gov/resources/VANOD/Indicators/Complexity_Report_2005.doc. Accessed February 5, 20132.

  18. Testing for Human Immunodeficiency Virus in Veterans Health Administration Facilities. Available at http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2056. Accessed February 5, 2013.

  19. Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J. Opinion leaders vs. Audit and feedback to implement practice guidelines: delivery after previous cesarean section. JAMA. 1991;265:2202–7.

    Article  PubMed  CAS  Google Scholar 

  20. Jamtvedt G, Young J, Kristoffersen D, O’brien M, Oxman A. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006;19, CD000259.

    Google Scholar 

  21. Thomson O’Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2005;CD000125. Doi: 10.1002/14651858.CD000125.

  22. Fauci AS. AIDS: let science inform policy. Science. 2011;333:13.

    Article  PubMed  Google Scholar 

  23. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997;157:408–16.

    PubMed  CAS  Google Scholar 

  24. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–51.

    Article  PubMed  Google Scholar 

  25. Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2000;CD000409.

  26. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2003;CD000259.

  27. Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform. 2005;38:189–99.

    Article  PubMed  Google Scholar 

  28. Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005;352:570–85.

    Article  PubMed  CAS  Google Scholar 

  29. Paltiel AD, Weinstein MC, Kimmel AD, et al. Expanded screening for HIV in the United States—an analysis of cost-effectiveness. N Engl J Med. 2005;352:586–95.

    Article  PubMed  CAS  Google Scholar 

  30. Goetz MB, Rimland D. Effect of expanded HIV testing programs on the status of newly diagnosed HIV-infected patients in two Veterans Health Administration Facilities: 1999–2009. JAIDS. 2011;57:e23–5.

    Article  PubMed  Google Scholar 

  31. Goetz MB and Rimland D. Linkage to care of newly diagnosed HIV-infected patients in two VA Facilities. 49th Annual Meeting of the Infectious Diseases Society of America. 2011; Boston, MA. Abstract 478.

  32. Øvretveit J. Understanding the conditions for improvement: research to discover which context influences affect improvement success. Qual Saf Health Care. 2011;In press.

  33. Anaya HD, Chan K, Karmarker U, Asch SM, Goetz MB. Budget impact analysis of HIV testing in the VA healthcare system. Value Health. 2012;In Press.

  34. Chen JC, Goetz MB, Feld JE, et al. A provider participatory implementation model for HIV testing in an ED. Am J Emerg Med. 2011;29:418–26.

    Article  PubMed  Google Scholar 

  35. Anaya HD, Hoang T, Golden JF, et al. Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing. J Gen Intern Med. 2008;23:800–7.

    Article  PubMed  Google Scholar 

  36. Anaya HD, Bokhour B, Feld J, Golden JF, Asch SM, Knapp H. Implementation of routine rapid HIV testing within the US Department of Veterans Affairs Healthcare System. J Healthc Qual. 2012;34:7–14.

    Article  PubMed  Google Scholar 

  37. Conners EE, Hagedorn HJ, Butler JN, et al. Evaluating the implementation of nurse-initiated HIV rapid testing in three Veterans Health Administration substance use disorder clinics. Int J STD AIDS. 2012;23:799–805.

    Article  PubMed  CAS  Google Scholar 

  38. Millett GA, Crowley JS, Koh H, et al. A way forward: the National HIV/AIDS Strategy and reducing HIV incidence in the United States. J Acquir Immune Defic Syndr. 2010;55(Suppl 2):S144–7.

    Article  PubMed  Google Scholar 

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ACKNOWLEDGEMENTS

We acknowledge and are grateful for the invaluable support for this project that was provided by Ana Goffin, Barbara Kertz, Thomas Giordano, MD, and Scott Sherman, MD, MPH, as well as the providers and leadership in the many VHA medical facilities that participated in this study. This project was supported by a research grant to Drs. Goetz and Asch by the Health Services Research & Development Service (SDP 08–002).

Conflicts of Interest

Allen Gifford: royalties for authorship of Living Well With HIV And AIDS, Ball Publishing Co. Steven Asch: unrestricted travel grant from Trinity Pharmaceuticals. The other authors declare that they do not have any conflicts of interest.

Author information

Authors and Affiliations

  1. Infectious Diseases Section (111-F), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA

    Matthew Bidwell Goetz MD

  2. David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Matthew Bidwell Goetz MD

  3. General Medicine (111G), VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, Los Angeles, CA, 90073, USA

    Tuyen Hoang PhD, Herschel Knapp PhD, MSSW, Jane Burgess RN, MS & Michael D. Fletcher MHP, BA

  4. VA Bedford Center for Health Quality, Outcomes & Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA, 01730, USA

    Allen L. Gifford MD

  5. Boston University Schools of Public Health and Medicine, Boston, MA, USA

    Allen L. Gifford MD

  6. VA Palo Alto Health Care System, Palo Alto, CA, USA

    Steven M. Asch MD, MPH

  7. Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, CA, USA

    Steven M. Asch MD, MPH

Authors
  1. Matthew Bidwell Goetz MD
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  2. Tuyen Hoang PhD
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  3. Herschel Knapp PhD, MSSW
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  4. Jane Burgess RN, MS
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  6. Allen L. Gifford MD
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  7. Steven M. Asch MD, MPH
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the QUERI-HIV/Hepatitis Program

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Correspondence to Matthew Bidwell Goetz MD.

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Goetz, M.B., Hoang, T., Knapp, H. et al. Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities. J GEN INTERN MED 28, 1311–1317 (2013). https://doi.org/10.1007/s11606-013-2420-6

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  • DOI: https://doi.org/10.1007/s11606-013-2420-6

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