Early diagnosis of HIV infection allows for the timely initiation of highly effective, life-prolonging antiretroviral therapy. Unfortunately, many patients -- including those with known risk of HIV infection -- are not tested. Therefore, in collaboration with VA Clinical Public Health, we implemented and evaluated an integrated program utilizing proven quality improvement techniques in VISN 22. The components of this program contained four known quality improvement interventions: Clinical Reminders (CR), Provider Activation, Provider Feedback and Organizational Change. This program resulted a tripling of HIV testing rates. Based on this success, we extended this quality improvement project to three other VISNs.
The primary objective is to implement a multi-modal intervention -- proven to improve HIV testing rates -- in geographically dispersed VISNs to evaluate the generalizability and the resources necessary for success. Other objectives are to identify regional variations, neglected populations and strategies to remediate these issues; to evaluate implementation costs; and to identify organizational requisites for success.
We matched VA facilities on complexity level and randomized participating sites to receive one of two levels of assistance in project implementation with National Arm Sites receiving greater degree of provider activation assistance from the national research team than do Local Arm Sites. Control Arm sites receive no intervention.
The quantitative evaluation assessed pre and post intervention HIV testing rates across study sites. We assessed the effectiveness of risk-based versus routine reminders for HIV testing. The qualitative evaluation will assess intervention success in terms of identified organizational factors, implementation tactics and key barriers. Using implementation costs, economic evaluation will validate and refine our implementation business model.
We found that HIV testing rates increased based on the level and extent of provider activation. Based on a six month pre and post intervention period, the adjusted rate of routine HIV testing increased by 1.1% in the Control Arm, 6.3% in the Local Arm and 9.2% in the National Arm. The adjusted rate of risk-based HIV testing increased by 0.4% in the Control Arm, 5.6% in the Local Arm and 10.1% in the National Arm. Not only was the rate of testing higher in Routine testing, but also the number of veterans tested was about 5 times greater than in Risk-based testing. At study end, 70 - 80% of patients had been offered an HIV test.
This study has demonstrated the generalizable effectiveness of a multimodal implementation of the proven intervention for HIV testing, and has shed light on how to scale-up routine HIV testing. The implementation package increased HIV testing rates across multiple healthcare facilities with heterogeneous patient populations and facility structure. Implementation of this program increased the rate of risk-based testing two to three-fold and increased routine testing three to four-fold. In contrast, HIV testing rates did not meaningfully increase in control facilities despite the VHA-wide encouragement of routine testing, and removal of requirements to obtain written informed consent and perform pre- and post-test counseling. These findings are consistent with prior observations that policy change without active advocacy or other interventions (e.g., decision support, social marketing) is often insufficient to change clinical practice.
These results have informed the development of programs led by our operational partners in the VA Clinical Public Health to further promote HIV testing and to encourage VA facilities to voluntarily implement a clinical reminder to promote HIV testing. VA Clinical Public Health has found that the rates of HIV testing are significantly higher among those VA facilities that have utilized this tool, thus providing further evidence of the generalizability across the VA of the interventions we have developed and implemented in partnership with VA Clinical Public Health.
- Goetz MB, Hoang T, Kan VL, Rimland D, Rodriguez-Barradas MC, Asch SM. Rates and Predictors of Newly Diagnosed HIV Infection Among Veterans Receiving Routine Once-Per-Lifetime HIV Testing in the Veterans Health Administration. Journal of acquired immune deficiency syndromes (1999). 2015 Aug 15; 69(5):544-50.
- Bokhour BG, Saifu H, Goetz MB, Fix GM, Burgess J, Fletcher MD, Knapp H, Asch SM. The role of evidence and context for implementing a multimodal intervention to increase HIV testing. Implementation science : IS. 2015 Feb 13; 10(1):22.
- Goetz MB, Hoang T, Kan VL, Rimland D, Rodriguez-Barradas M. Development and validation of an algorithm to identify patients newly diagnosed with HIV infection from electronic health records. AIDS Research and Human Retroviruses. 2014 Jul 1; 30(7):626-33.
- Goetz MB, Hoang T, Knapp H, Burgess J, Fletcher MD, Gifford AL, Asch SM, QUERI-HIV/Hepatitis Program. Central implementation strategies outperform local ones in improving HIV testing in Veterans Healthcare Administration facilities. Journal of general internal medicine. 2013 Oct 1; 28(10):1311-7.
- Goetz MB, Hoang T, Knapp H, Henry SR, Anaya H, Chou AF, Gifford AL, Asch SM, HIV/HCV QUERI Program. Exportability of an intervention to increase HIV testing in the Veterans Health Administration. Joint Commission Journal on Quality and Patient Safety. 2011 Dec 1; 37(12):553-9.
- Knapp H, Fletcher M, Taylor A, Chan K, Goetz MB. No clinic left behind: providing cost-effective in-services via distance learning. Journal for healthcare quality : official publication of the National Association for Healthcare Quality. 2011 Sep 1; 33(5):17-24.
- Knapp H, Chan K, Anaya HD, Goetz MB. Interactive internet-based clinical education: an efficient and cost-savings approach to point-of-care test training. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 2011 Jun 1; 17(5):335-40.
- Goetz MB, Hoang T, Knapp H, Burgess J, Fletcher MD, Gifford AL, Asch SM. Patient, Provider, and Facility Factors Associated with HIV Testing and Refusal. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
- Goetz MB, Hoang T, Knapp H, Burgess J, Goffin A, Kertz B, Fletcher MD, Gifford AL, Asch SM. Successful Generalization of a Program to Improve HIV Testing. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
- Henry SR, Saifu H, Bokhour B, Fix G, Goetz MB, Knapp H, Fletcher MD, Burgess J, Asch SM. Barriers and facilitators to implementing a multimodal intervention to increase HIV testing. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
- Bokhour B, Henry SR, Saifu H, Fix G, Goetz MB, Knapp H, Fletcher MD, Burgess J, Asch SM. Barriers and facilitators to implementing a multimodal intervention to increase HIV testing. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2012 May 9; Buena Vista, FL.
- Goetz MB, Hoang T, Henry SR, Knapp H, Anaya H, Burgess J, Gifford AL, Asch SM. Multi-Regional Evaluation of a Program to Promote HIV Testing. Paper presented at: Treatment of HIV (ACTHIV) American Conference; 2010 May 20; Denver, CO.