Veterans Health Administration is the largest provider of care for persons with HIV in the United States, with ~26,000 Veterans in care. VHA has historically concentrated care for Veterans with HIV in infectious diseases specialty clinics. This specialty-centered model has provided high-quality HIV care, but does not provide accessible care for Veterans with HIV in rural and outlying urban areas. The telehealth collaborative care (TCC) model seeks to improve access for these Veterans. TCC is a shared-care model that integrates HIV specialty care delivered by clinical video telehealth (CVT) with primary care by teams in VHA clinics serving rural and outlying areas. In addition to using CVT to deliver HIV specialty care, TCC includes processes to improve care coordination between specialty and primary care teams, and use of a registry to promote population management across sites. As part of its Promising Practices initiative, the VHA Office of Rural Health (ORH) is currently supporting expansion of the TCC model as a quality improvement initiative in four VHA facilities. This provides an opportunity to evaluate the impact of TCC on clinical outcomes and healthcare utilization.
The objective of this proposal is to complete a cluster-randomized program evaluation of the TCC quality improvement initiatives to determine: 1) TCC effectiveness, and 2) the influence of TCC on healthcare utilization. We hypothesize that compared to usual care (i.e. driving to the HIV clinic for all care), TCC will lead to non-inferior HIV viral control, while improving retention in care and hypertension control.
Evaluation includes 1,686 Veterans who are actually in care for HIV infection in the Dallas, Houston, San Antonio, and Atlanta VAs, and who live nearer to one of 28 primary care clinics than to an HIV clinic. Due to limited capacity to establish TCC in all primary care clinics simultaneously through local quality improvement initiatives, clinics were randomly assigned to establish TCC during the first-year vs. second-year of the ORH initiative. Measures of clinical effectiveness and healthcare utilization will be compared between TCC and usual care during the first year using data routinely gathered during care and included in VHA's Corporate Data Warehouse (CDW).
Preliminary findings include a relationship between geographic access to care (ie travel time to HIV specialty clinic) and retention in care (RIC, at least two visits in year at least 60 days apart) in the year prior to telehealth implementation (RIC = 86% among Veterans < 1 hour drive to clinic, 58% 1-2 hours, and 54% if > 2 hours, p<0.001). In the first year of intervention, 120 of 920 (13%) Veterans living in the service area of a telehealth clinic had at least one telehealth visit. Telehealth use increased with increasing travel time saved (i.e. travel time to telehealth clinic minus travel time to HIV clinic; 8.3% among those saving < 30 minutes vs. 28.0% among those saving > 60 minutes, p <0.001)). In Intention to Treat (ITT) analyses during year one, unadjusted RIC was greater among Veterans living in the service area of a telehealth clinic compared to a control clinic (76.5% vs. 72.3%, p=0.05).
Understanding the impact of TCC on clinical outcomes and healthcare utilization will inform future policies regarding broader implementation of the TCC model both within and outside VHA.
- Ohl ME, Richardson K, Rodriguez-Barradas MC, Bedimo R, Marconi V, Morano JP, Jones MP, Vaughan-Sarrazin M. Impact of Availability of Telehealth Programs on Documented HIV Viral Suppression: A Cluster-Randomized Program Evaluation in the Veterans Health Administration. Open forum infectious diseases. 2019 Jun 1; 6(6):ofz206.