Testing for HIV is a high priority for the VA, as earlier case identification reduces both mortality and the cost of treatment by keeping patients with this treatable chronic infection out of the hospital, and encourages reduction of risk behaviors thus preventing further transmission. Unfortunately, many at risk VA patients are not tested for HIV infection. In studies conducted by QUERI-HIV and the Public Health Strategic Healthcare Group (PHSHG) only between 30 and 50% of patients with known, documented risk factors have undergone HIV testing.
We surveyed providers and managers as to the barriers to increasing HIV testing rates. We found that lack of accountability, low prioritization, the time needed to discuss sensitive issues, and organizational barriers to pre and post test counseling ranked among the most important. To improve HIV testing rates for higher than average risk patients, we will implement an integrated program utilizing proven quality improvement techniques in VISN 22.
The specific goals for this project were: 1) To evaluate the effect of interventions designed to improve HIV screening and testing rates in VISN 22. 2) To refine the intervention using an iterative process evaluative technique. 3) To develop a "Business Case" analysis of HIV testing rates in other VISNs. 4) To develop an exportable model for increasing HIV testing rates in other VISNs.
This project was built upon the successful foundational pilot work that was supported by Locally Initiated Project funds (Supplemental QLP HIV-AIDS, HIV 04-386) and QUERI-HIV core funds. In this work, we pilot tested a series quality improvement interventions to increase the rates of HIV testing in the VA Greater Los Angeles and San Diego Healthcare Systems; the 3 other VISN22 facilities served as controls.
The specific interventions were: 1.) clinical reminders, i.e., a real time, context-specific, computerized clinical reminder for HIV testing of individual patients; 2.) audit/feedback, i.e., a retrospective summary of group and provider-specific HIV screening for groups of at-risk patients; 3.) provider activation via established academic detailing and social marketing methodology; and 4.) organizational change to remove barriers to performance of HIV testing. The outcomes of this intervention are being evaluated qualitatively (i.e., via surveys of providers) and quantitatively (assessment of HIV testing rates in facilities that do or do not receive the intervention).
We implemented this research plan in a quasi-experimental manner in the VA San Diego and Greater Los Angeles Healthcare System followed by time-series experiments involving the VA Las Vegas and Loma Linda facilities; VA Long Beach served as a control.
During the first year of the intervention (during which time sites A & B were active intervention sites and sites C, D & E served as controls) , the cumulative rate at which at risk individuals had ever been tested for HIV infection increased from 16 - 22% to 24 - 34% at the active intervention facilities (A & B; p < 0.05). In contrast, the cumulative rate of testing at the control facilities was 14 - 18% and did not change.
During the subsequent year, the provider activation program was deintensified at sites A & B; the full intervention was introduced in sites C & D; site E remained in the control arm. During this year, the cumulative rates of testing further increased to 28 - 37% at facilities A & B (p < 0.05). Meanwhile, after implementation at facilities C & D, the rates of cumulative HIV testing increased from 14% to 20.1% (facility C, month 3) and from 23% to 29.4% (facility D, month 4). .Analyses of the sustainability of the intervention indicated that selective deintensification of provider activation programs was followed by reduced rates of HIV testing that nevertheless remained well above baseline among new patients. The test acceptance rate increased throughout the study period, suggesting that providers either became more proficient at encouraging patients to be tested or offered testing only to selected patients.
Business case modeling indicated that for a facility has 20,000 at-risk patients, there was a $75,000 - $167,000 increase in the costs of HIV testing in the first quarter, which later diminished as the pool of untested patients decreased. Overall the costs associated with expansion of HIV testing programs represent a small fraction of the estimated outpatient costs of HIV care, which for a facility that cares for 100 - 400 patients, amount to $200 - $800,000/quarter.
We have demonstrated that an integrated quality improvement project can increase rates of HIV testing. Our sustainability analysis indicates that attenuation of the provider activation program is associated with a diminution of the rates of HIV testing which nonetheless remained well above the baseline rates. Based on the success of this project, we have designed a regional, multi-VISN project to confirm, extend and refine the interventions that were proven to be successful in this multi-station, single VISN trial. The goals of this next project, which is being conducted in partnership with the VA Public Health Strategic Healthcare Group and with support of SDP 08-002) are to:
- Evaluate two alternative refined versions of the intervention to improve HIV testing rates in two geographically varied VISNs. This will make use of a study design in which stations will be randomized to receive differing levels of formal provider activation.
- Identify regional variations as well as neglected populations and identify remediation strategies. Particular attention will be paid to OIF/OEF veterans who are at highest risk soon after their return from service.
- Further evaluate service-specific implementation costs of this program, by generalizing the business case model developed for VISN 22.
- Identify organizational requisites (e.g., structure, training) for the success of this intervention.
The work accomplished under the aegis of SDP 08-002 will allow us to shape the next phase of the project, for which we are already in the planning stages with the VA Public Health Strategic Healthcare Group, namely the dissemination of the program to other VISNs. The net result will lead to earlier identification and treatment of HIV-infected patients and consequent improved medical outcomes for these persons.
Finally, an additional impact of this program is that HIV testing has now been approved as a Performance Measure by the VISN 22 Quality Performance Improvement Committee, thus providing long-term institutional support for sustaining the interventions that were put in place by this project and providing ongoing local incentives to maintain the observed improvements in HIV testing rates.
- Groessl EJ, Weingart KR, Gifford AL, Asch SM, Ho SB. Development of the hepatitis C self-management program. Patient education and counseling. 2011 May 1; 83(2):252-5.
- Goetz MB, Hoang T, Henry SR, Knapp H, Anaya HD, Gifford AL, Asch SM, QUERI-HIV/Hepatitis Program. Evaluation of the sustainability of an intervention to increase HIV testing. Journal of general internal medicine. 2009 Dec 1; 24(12):1275-80.
- Bokhour BG, Solomon JL, Knapp H, Asch SM, Gifford AL. Barriers and facilitators to routine HIV testing in VA primary care. Journal of general internal medicine. 2009 Oct 1; 24(10):1109-14.
- Dookeran NM, Burgess JF, Bowman CC, Goetz MB, Asch SM, Gifford AL. HIV screening among substance-abusing veterans in care. Journal of substance abuse treatment. 2009 Oct 1; 37(3):286-91.
- Hoang T, Goetz MB, Yano EM, Rossman B, Anaya HD, Knapp H, Korthuis PT, Henry R, Bowman C, Gifford A, Asch SM. The impact of integrated HIV care on patient health outcomes. Medical care. 2009 May 1; 47(5):560-7.
- Pyne JM, Asch SM, Lincourt K, Kilbourne AM, Bowman C, Atkinson H, Gifford A. Quality indicators for depression care in HIV patients. AIDS Care. 2008 Oct 1; 20(9):1075-83.
- Goetz MB, Bowman C, Hoang T, Anaya H, Osborn T, Gifford AL, Asch SM. 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. Implementation science : IS. 2008 Mar 19; 3:16.
- Justice AC, Dombrowski E, Conigliaro J, Fultz SL, Gibson D, Madenwald T, Goulet J, Simberkoff M, Butt AA, Rimland D, Rodriguez-Barradas MC, Gibert CL, Oursler KA, Brown S, Leaf DA, Goetz MB, Bryant K. Veterans Aging Cohort Study (VACS): Overview and description. Medical care. 2006 Aug 1; 44(8 Suppl 2):S13-24.
- Goetz MB. Linkage to Care of Newly Diagnosed HIV-infected Patients in Two VA Facilities. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2011 Oct 20; Boston, MA.
- Anaya H, Chan K, Goetz MB, Karmarkar US, Asch SM. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care Within the United States Department of Veterans Affairs. Poster session presented at: American Conference for the Treatment of HIV; 2011 Apr 7; Denver, CO.
- Knapp H, Goetz MB, Needleman J, Kominski G, Asch SM. Expanding HIV Rapid Testing Via Point-of-Care Paraprofessionals. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 29; Chicago, IL.
- Anaya H, Goetz MB, Karmarkar U, Asch SM. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care Within the United States Department of Veterans Affairs. Poster session presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL.
- Gidwani RA, Goetz MB, Needleman J, Kominski G, Mattocks K, Samet JH, Justice A, Gandhi N, Asch SM. A Budget Impact Analysis of Implementing Rapid HIV Screening in VA Emergency Departments. Paper presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
- Goetz MB, Hoang T, Henry SR, Knapp H, Anaya H, Swan L, Burgess J, Gifford A, Asch SM. Regional Rollout of a Program to Improve HIV Testing Rates. Paper presented at: Retroviruses and Opportunistic Infections Annual Conference; 2009 Feb 12; Baltimore, MD.
- Henry SR, Hoang T, Goetz MB, Bell-Lewis LS, Asch SM. Disparities in HIV Clinic Appointment Adherence: Factors Associated with Missed HIV Clinic Appointments. Poster session presented at: VA QUERI National Meeting; 2008 Dec 10; Phoenix, AZ.
- Anaya HD, Goetz MB, Asch SM, Karmarkar U. Using Capacity Planning Models to Estimate Organizational Costs of HIV Care within the United States Department of Veterans Affairs. Paper presented at: HIV Diagnosis, Prevention, and Access to Care National Annual Summit; 2008 Nov 20; Washington, DC.
- McInnes DK, Yano EM, Asch SM, Gifford AL. Understanding characteristics associated with efforts to increase rates of HIV testing in Veterans Administration primary care clinics. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 10; Washington, DC.
- Goetz MB, Hoang T, Henry SR, Knapp H, Anaya H, Osborn T, Gifford A, Asch S. Implementation and Evaluation of a VISN-based Program to Improve HIV Screening and Testing: Two-Year Outcomes. Presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
- Bowman C, Hoang T, Saleem J, Gifford A, Goetz M, Asch S. Evaluating sustained use of quality improvement interventions in VHA HIV care. Paper presented at: AcademyHealth Annual Research Meeting; 2006 Jun 1; Seattle, WA.
- Goetz MB, Rossman B, Hoang T, Anaya HD, Burgess J, Volpp B, Osborn T, Bowman C, Gifford A, Asch S. Development and implementation of a clinical reminder for HIV testing. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.