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CDA 11-211
Improving Access and Outcomes for Rural Veterans with HIV
Michael Ohl MD MSPH
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: October 2012 - September 2017

BACKGROUND/RATIONALE:
Approximately 12-16% of the 27,000 veterans in care for HIV infection in the United States live in rural areas and have limited access to specialized health care. Our prior work demonstrated that, compared to their urban counterparts, rural veterans with HIV infection entered care with more advanced illness and experienced higher mortality.

OBJECTIVE(S):
The long term research objective of this career development award was to develop, evaluate, and implement innovative delivery models to improve the accessibility, quality, and outcomes of care for rural veterans with HIV. Specific aims were to: 1) further determine rural - urban variation in HIV care quality and intermediate outcomes, and identify gaps in care for rural veterans; 2) identify barriers to care for rural veterans with HIV and obtain stakeholder input on design of an improved delivery model; and 3) develop and evaluate an innovative delivery model for rural veterans with HIV that employs existing VA telehealth resources.

METHODS:
We employed a series of mixed methods during three incremental projects to achieve these aims. In aim 1 we applied secondary analysis of VA HIV registry and other administrative data to identify gaps in care for rural veterans with HIV. In aim 2 we employed qualitative methods and interviews with veterans, VA providers, and administrators to identify opportunities to improve care for rural veterans with HIV. In aim 3 we applied these findings to develop, pilot test, and evaluate innovative, telehealth-based delivery models for rural veterans with HIV.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This work increased our understanding of gaps in care for rural veterans, and strategies for overcoming these gaps. In addition to improving access and outcomes of care for rural veterans with HIV, this may inform care systems for rural veterans with other chronic conditions requiring ongoing specialized care. Thus, this work directly addresses the VA operation mandate and HSR&D research priority to improve access to care for rural veterans.

PUBLICATIONS:

Journal Articles

  1. Ohl ME, Carrell M, Thurman A, Weg MV, Pharm TH, Mengeling M, Vaughan-Sarrazin M. "Availability of healthcare providers for rural veterans eligible for purchased care under the veterans choice act". BMC health services research. 2018 May 29; 18(1):315.
  2. van Epps P, Maier M, Lund B, Howren MB, Beck B, Beste L, Skolnik A, Vaughan-Sarrazin M, Ohl ME. Medication Adherence in a Nationwide Cohort of Veterans Initiating Pre-exposure Prophylaxis (PrEP) to Prevent HIV Infection. Journal of acquired immune deficiency syndromes (1999). 2018 Mar 1; 77(3):272-278.
  3. Vaughan Sarrazin MS, Ohl ME, Richardson KK, Asch SM, Gifford AL, Bokhour BG. Patient and Facility Correlates of Racial Differences in Viral Control for Black and White Veterans with HIV Infection in the Veterans Administration. AIDS Patient Care and Stds. 2018 Mar 1; 32(3):84-91.
  4. Goto M, McDanel JS, Jones MM, Livorsi DJ, Ohl ME, Beck BF, Richardson KK, Alexander B, Perencevich EN. Antimicrobial Nonsusceptibility of Gram-Negative Bloodstream Isolates, Veterans Health Administration System, United States, 2003-2013. Emerging Infectious Diseases. 2017 Nov 1; 23(11):1815-1825.
  5. Goto M, Schweizer ML, Vaughan-Sarrazin MS, Perencevich EN, Livorsi DJ, Diekema DJ, Richardson KK, Beck BF, Alexander B, Ohl ME. Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014. JAMA internal medicine. 2017 Oct 1; 177(10):1489-1497.
  6. Mosher H, Zhou Y, Thurman AL, Sarrazin MV, Ohl ME. Trends in Hospitalization for Opioid Overdose among Rural Compared to Urban Residents of the United States, 2007-2014. Journal of hospital medicine. 2017 Nov 1; 12(11):925-929.
  7. McDanel JS, Roghmann MC, Perencevich EN, Ohl ME, Goto M, Livorsi DJ, Jones M, Albertson JP, Nair R, O'Shea AMJ, Schweizer ML. Comparative Effectiveness of Cefazolin Versus Nafcillin or Oxacillin for Treatment of Methicillin-Susceptible Staphylococcus aureus Infections Complicated by Bacteremia: A Nationwide Cohort Study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2017 Jul 1; 65(1):100-106.
  8. Schafer KR, Albrecht H, Dillingham R, Hogg RS, Jaworsky D, Kasper K, Loutfy M, MacKenzie LJ, McManus KA, Oursler KA, Rhodes SD, Samji H, Skinner S, Sun CJ, Weissman S, Ohl ME. The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions. Journal of acquired immune deficiency syndromes (1999). 2017 May 1; 75(1):35-44.
  9. Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, Ohl ME. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open forum infectious diseases. 2017 Feb 3; 4(1):ofx005.
  10. Richardson KK, Bokhour B, McInnes DK, Yakovchenko V, Okwara L, Midboe AM, Skolnik A, Vaughan-Sarrazin M, Asch SM, Gifford AL, Ohl ME. Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care. Journal of the National Medical Association. 2016 Sep 22; 108(4):201-210.e3.
  11. Moeckli J, Stewart KR, Ono S, Alexander B, Goss T, Maier M, Tien PC, Howren MB, Ohl ME. Mixed-Methods Study of Uptake of the Extension for Community Health Outcomes (ECHO) Telemedicine Model for Rural Veterans With HIV. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2017 Jun 1; 33(3):323-331.
  12. Barnett PG, Schmitt SK, Yu W, Goetz MB, Ohl ME, Asch SM. How Will New Guidelines Affect CD4 Testing in Veterans With HIV? Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016 Jul 1; 63(1):96-100.
  13. Korthuis PT, McGinnis KA, Kraemer KL, Gordon AJ, Skanderson M, Justice AC, Crystal S, Goetz MB, Gibert CL, Rimland D, Fiellin LE, Gaither JR, Wang K, Asch SM, McInnes DK, Ohl ME, Bryant K, Tate JP, Duggal M, Fiellin DA, Veterans Aging Cohort Study. Quality of HIV Care and Mortality Rates in HIV-Infected Patients. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016 Jan 15; 62(2):233-9.
  14. Yehia BR, Rebeiro P, Althoff KN, Agwu AL, Horberg MA, Samji H, Napravnik S, Mayer K, Tedaldi E, Silverberg MJ, Thorne JE, Burchell AN, Rourke SB, Rachlis A, Mayor A, Gill MJ, Zinski A, Ohl M, Anastos K, Abraham AG, Kitahata MM, Moore RD, Gebo KA, North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD). Impact of age on retention in care and viral suppression. Journal of acquired immune deficiency syndromes (1999). 2015 Apr 1; 68(4):413-9.
  15. Chang H, Tate J, Justice AC, Ohl ME. Medicare and Medicaid enrollment and outside hospitalizations among HIV-infected and uninfected veterans engaged in VA care: a retrospective cohort study. BMC health services research. 2015 Jan 22; 15(1):27.
  16. Ohl ME, Richardson KK, Goto M, Vaughan-Sarrazin M, Schweizer ML, Perencevich EN. HIV quality report cards: impact of case-mix adjustment and statistical methods. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Oct 15; 59(8):1160-7.
  17. Ohl ME, Rosenthal GE. Advancing telecare for pain treatment in primary care. JAMA. 2014 Jul 16; 312(3):235-6.
  18. Ohl ME, Richardson K, Kaboli PJ, Perencevich EN, Vaughan-Sarrazin M. Geographic access and use of infectious diseases specialty and general primary care services by veterans with HIV infection: implications for telehealth and shared care programs. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2014 Apr 6; 30(4):412-21.
  19. Goto M, Ohl ME, Schweizer ML, Perencevich EN. Accuracy of administrative code data for the surveillance of healthcare-associated infections: a systematic review and meta-analysis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Mar 1; 58(5):688-96.
  20. Schweizer ML, Reisinger HS, Ohl M, Formanek MB, Blevins A, Ward MA, Perencevich EN. Searching for an optimal hand hygiene bundle: a meta-analysis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2014 Jan 1; 58(2):248-59.
  21. Keith McInnes D, Shimada SL, Rao SR, Quill A, Duggal M, Gifford AL, Brandt CA, Houston TK, Ohl ME, Gordon KS, Mattocks KM, Kazis LE, Justice AC. Personal health record use and its association with antiretroviral adherence: survey and medical record data from 1871 US veterans infected with HIV. AIDS and behavior. 2013 Nov 1; 17(9):3091-100.
  22. Greysen SR, Horwitz LI, Covinsky KE, Gordon K, Ohl ME, Justice AC. Does social isolation predict hospitalization and mortality among HIV+ and uninfected older veterans? Journal of the American Geriatrics Society. 2013 Sep 1; 61(9):1456-63.
  23. Ohl M, Dillon D, Moeckli J, Ono S, Waterbury N, Sissel J, Yin J, Neil B, Wakefield B, Kaboli P. Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. Journal of general internal medicine. 2013 Sep 1; 28(9):1165-73.
  24. Ohl M, Lund B, Belperio PS, Goetz MB, Rimland D, Richardson K, Justice A, Perencevich E, Vaughan-Sarrazin M. Rural residence and adoption of a novel HIV therapy in a national, equal-access healthcare system. AIDS and behavior. 2013 Jan 1; 17(1):250-9.
  25. Ohl ME, Perencevich E, McInnes DK, Kim N, Rimland D, Akgun K, Fiellin DA, Skanderson M, Wang K, Justice A. Antiretroviral adherence among rural compared to urban veterans with HIV infection in the United States. AIDS and behavior. 2013 Jan 1; 17(1):174-80.
  26. Ohl M, Schweizer M, Graham M, Heilmann K, Boyken L, Diekema D. Hospital privacy curtains are frequently and rapidly contaminated with potentially pathogenic bacteria. American journal of infection control. 2012 Dec 1; 40(10):904-6.
  27. Schweizer M, Graham M, Ohl M, Heilmann K, Boyken L, Diekema D. Novel hospital curtains with antimicrobial properties: a randomized, controlled trial. Infection control and hospital epidemiology. 2012 Nov 1; 33(11):1081-5.
  28. Ohl M, Tate J, Duggal M, Skanderson M, Scotch M, Kaboli P, Vaughan-Sarrazin M, Justice A. Rural residence is associated with delayed care entry and increased mortality among veterans with human immunodeficiency virus infection. Medical care. 2010 Dec 1; 48(12):1064-70.
  29. Ohl M, Harris A, Nurudtinova D, Cai X, Drohobyczer D, Overton ET. Do brief screening questions or provider perception accurately identify persons with low health literacy in the HIV primary care setting? AIDS Patient Care and Stds. 2010 Oct 1; 24(10):623-9.
CYBR

  1. Grewenow R, Tuepker A, Ohl M. Integrating VA Specialty and Primary Care and Improving the Referral Process. [Cyberseminar]. 2012 Dec 19.
Conference Presentations

  1. Appenheimer AB, Bokhour BG, McInnes DK, Richardson K, Midboe A, Gifford AL, Asch S, Dvorin K, Thurman A, Vaughan-Sarrazin M, Ohl M. Testing Un-learning and Substitution Strategies to De-implement Antipsychotics in Nursing Homes. Poster session presented at: ID Week Annual Conference; 2016 Oct 26; New Orleans, LA.
  2. McDanel JS, Roghmann MC, Perencevich EN, Ohl M, Goto M, Livorsi D, Jones MP, Albertson J, Nair R, O'Shea AM, Schweizer ML. Comparative Effectiveness of Third Generation Cephalosporins versus Penicillinase-Stable Penicillins for Treatment of Methicillin-Susceptible Staphylococcus aureus Infections Complicated by Bacteremia: A Nationwide Cohort Study. Poster session presented at: ID Week Annual Conference; 2015 Oct 9; San Diego, CA.
  3. Ohl M, Richardson KK, Swan H, McInnes K, Yakovchenko V, Okwara L, Midboe A, Bokhour B. HIV Viral Control and Comorbidity Control are not Highly Correlated at the Level of the HIV Clinic. Paper presented at: ID Week Annual Conference; 2015 Oct 9; San Diego, CA.
  4. Richardson KK, Swan H, McInnes K, Yakovchenko V, Okwara L, Midboe A, Bokhour B, Ohl M. Racial Disparities Extend to Common Comorbidities among Persons in Care for HIV Infection. Paper presented at: ID Week Annual Conference; 2015 Oct 9; San Diego, CA.
  5. McDanel J, Roghmann MC, Perencevich EN, Ohl M, Goto M, Livorsi D, Jones MP, Albertson J, Nair R, O'Shea AM, Schweizer ML. Comparative Effectiveness of Cefazolin versus Penicillinase-Stable Penicillins for Treatment of Methicillin-Susceptible Staphylococcus aureus Infections Complicated by Bacteremia: A Nationwide Cohort Study. Oral Presentation. Paper presented at: ID Week Annual Conference; 2015 Oct 8; San Diego, CA.
  6. Moeckli J, Ono SS, Stewart K, Alexander B, Ohl M. Does the Specialty Care Access Network-Extension for Community Health Outcomes (SCAN-ECHO) Model Apply to HIV Care? Experience from Three Facilities. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  7. Goto M, Ohl M, Schweizer ML, Perencevich EN, Vaughan-Sarrazin MS. How should we risk-adjust hospital outcomes for blood stream infections? A nationwide cohort study of Staphylococcus aureus bacteraemia. Paper presented at: European Congress of Clinical Microbiology and Infectious Diseases; 2015 Apr 25; Copenhagen, Denmark.
  8. Ono SS, Moeckli J, Ohl M. Delivering HIV Care in VA: Three Place, Three Narratives. Paper presented at: American Anthropological Association Annual Meeting; 2014 Dec 6; Washington, DC.
  9. Goto M, Schweizer ML, Perencevich EN, Ohl M. Hospital-Level Variation in Mortality among Patients with Staphylococcus aureus Bacteremia: a Nationwide Cohort Study. Poster session presented at: ID Week: A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2014 Oct 10; Philadelphia, PA.
  10. Ohl M, Richardson KK, Goto M, Vaughan-Sarrazin MS, Schweizer ML, Perencevich EN. HIV Quality Report Cards: Impact of Case-Mix Adjustment and Statistical Methods. Paper presented at: ID Week: A Joint Meeting of IDSA, SHEA, HIVMA, and PIDS; 2014 Oct 9; Philadelphia, PA.
  11. Perencevich EN, Yin J, Goto M, Ohl M, Schweizer ML, Carrel M. Higher Incidence of Community-Associated Staphylococcus aureus and MRSA Bacteremia in Southern Latitudes among 104 United States (US) Hospitals: Retrospective Cohort Study. Oral Presentation. Paper presented at: European Society of Clinical Microbiology and Infectious Diseases Annual European Congress of Clinical Microbiology and Infectious Diseases; 2014 May 13; Barcelona, Spain.
  12. Goto M, Schweizer ML, Perencevich EN, Ohl M. Hospital Characteristics Associated with Higher Staphylococcus aureus Bacteremia Mortality in Veterans Affairs Healthcare System: A Retrospective Cohort Study. Poster session presented at: European Society of Clinical Microbiology and Infectious Diseases Annual European Congress of Clinical Microbiology and Infectious Diseases; 2014 May 10; Barcelona, Spain.
  13. Moeckli J, Ono SS, Ohl M, Bolton R, Bokhour B. Caring for Rural Veterans with HIV. Paper presented at: Society for Applied Anthropology Annual Meeting; 2014 Mar 9; Albuquerque, NM.
  14. Hynes D, Young A, Ohl M, Houston T, Goldstein M. Virtual HIV Care Teams in a Rural Setting. Presented at: American Medical Informatics Association Annual Symposium; 2013 Nov 17; Washington, DC.
  15. Schweizer ML, Reisinger HS, Ohl M, Formanek M, Blevins A, Ward M, Perencevich EN. Searching for an Optimal Hand Hygiene Bundle: a Meta-Analysis. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2013 Oct 4; San Francisco, CA.
  16. Moeckli J, Ono SS, Dillon D, Ohl M. Decentering HIV Specialty Care. Paper presented at: American Anthropological Association Annual Meeting; 2012 Nov 16; San Francisco, CA.
  17. Ohl M, Dillon D, Sissel J, Waterbury N. Telehealth Collaborative Care: A Model Medical Home for Persons with HIV Infection in Rural and Low Prevalence Settings. Poster session presented at: Infectious Diseases Society of America Annual Meeting; 2012 Oct 18; San Diego, CA.
  18. Ohl M, Perencevich EN, McInnes D, Kim N, Fielin D, Skanderson M, Wang K, Justice A. Antiretroviral Adherence among Rural Compared to Urban Veterans with HIV Infection in the United States. Paper presented at: Infectious Diseases Society of America Annual Meeting; 2012 Oct 18; San Diego, CA.


DRA: Infectious Diseases, Health Systems
DRE: Technology Development and Assessment, Epidemiology
Keywords: Career Development
MeSH Terms: none

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