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Results of a National Comparative HIV Quality-Improvement Initiative Within the VA Healthcare System

Anaya H, Asch SM, Bowman C, Freemont A, Bozzette SA. Results of a National Comparative HIV Quality-Improvement Initiative Within the VA Healthcare System. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC.

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Objectives: As in many conditions, HIV care processes fall short of best practice recommendations. As part of the Veteran's Administration Quality Enhancement Research Initiative (QUERI), we sought to implement and evaluate two quality improvement mechanisms with potential for improving HIV care: real-time computerized clinical reminders (CR), and a collaborative intensive quality improvement program, based on the Institute for Healthcare Improvement Breakthrough Series (IQS). The presence of an electronic medical record with pre-existing reminder software and a registry of HIV patients facilitated both interventions.Methods/Approach: 16 VA facilities nationwide were matched by organizational complexity and antiretroviral use in a 4-arm quasi-experiment. All veterans reported to the VA's Immunology Case Registry (ICR) in the 16 sites were targets of the interventions. To ensure completeness, these data were supplemented by project-specific local computer extraction routines. We measured essential care processes in a 'high accountability' patient population that had at least 2 annual visits to a facility's HIV clinic (range: 381-1104 patients per year per interventional arm). The control arm received only facility-level feedback. The remaining arms received in addition CR, IQS, and CR+IQS. Baseline processes were calculated between May, 2000 and April 2001; post-interventional processes were measured between August, 2001 and August 2002. Measured essential care processes were based on well accepted guidelines and included antiretroviral therapy; hepatitis A, B, C, syphilis and toxoplasmosis screening; CD4, viral load and lipid monitoring; and Mycobacterium Avium-Intracellulare Complex (MAC) and Pneumocystis (PCP) prophylaxis. Qualitative interviews evaluated provider satisfaction and costs.Results/Findings: Relative to the control, CR study arm had positive changes from baseline in 3 of 11 indicators; the IQS arm for 1 of 11, and the CR+IQS arm for 3 of 11 indicators. IQS alone was never effective when CR was not. CR showed positive changes for monitoring (1 of 4 indicators) and screening (2 of 5). These results persisted after adjusting for clustering at facility level, race/ethnicity, age, HIV risk, income, average CD4 count, and percentage of HIV visits. Qualitative results show that implementation costs were relatively small (average CR-$6K; IQS-$30K), as were time burdens. Participation was found to increase work satisfaction. IQS and CR participation was viewed as a positive, low burden experience. Collectively, the interventions improved many HIV clinical endpoints (4/11). The relative effectiveness of clinical reminders and intensive quality support varied by endpoint, but CRs were most effective for screening and monitoring.Implications: In the presence of an electronic medical record and a disease registry, CR and IQS interventions have their place in HIV quality improvement programs, although CRs overall appear to be more generally useful. CR's effectiveness is highest for low periodicity, low importance processes (e.g., screening and routine lab monitoring). Quality managers should choose QI methods based both on their assessments of organizational needs and the nature of the clinical process to be improved.

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