- VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations
This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase.
Date: March 7, 2018
- Evidence Review Identifies Modest Mortality Disparities among Racial and Ethnic Minority Groups in VA Healthcare
To support VA’s efforts to better understand the scale and determinants of disparities in racial and ethnic mortality – and to develop interventions to reduce disparities, investigators from the VA Evidence-based Synthesis Program (ESP) Coordinating Center in Portland, OR conducted an evidence review of mortality disparities specific to VA. Findings showed that although VA’s equal access healthcare system has reduced many racial/ethnic mortality disparities still present in the private sector, modest mortality disparities persist mainly for black Veterans with conditions that include: stage 4 chronic kidney disease, colon cancer, diabetes, HIV, rectal cancer, and stroke. There also were modest disparities in mortality for American Indian and Alaska Native Veterans undergoing major non-cardiac surgery, and for Hispanic Veterans with HIV or traumatic brain injury.
Date: March 1, 2018
- Racial Disparities in HIV Quality of Care that May Extend to Common Comorbid Conditions
To more fully understand patterns of racial disparities in the quality of care for persons with HIV infection, this study examined a national cohort of Veterans in care for HIV in the VA healthcare system during 2013. Findings showed that racial disparities were identified in quality of care specific to HIV infection – and in the care of common comorbid conditions. Blacks were less likely than whites to receive combination antiretroviral therapy (90% vs. 93%) or to experience viral control (85% vs. 91%), hypertension control (62% vs. 68%), diabetes control (86% vs. 90%), or lipid monitoring (82% vs. 85%). Although performance on quality measures was generally high, racial disparities in HIV care for Veterans remain problematic and extend to comorbid conditions. Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.
Date: September 22, 2016
- New Guidelines May Significantly Decrease Cost for Testing Immune Function in Veterans with HIV
In 2012, the Department of Health and Human Services recommended CD4 testing in patients with HIV every 3 to 6 months – except in patients with consistently suppressed virus and sustained CD4 cell count, who could be tested every 6 to 12 months. In 2014, updated guidelines recommended that in individuals with viral suppression, CD4 testing be considered either optional or annual, depending on the cell count. This study evaluated how these recommendations might affect Veterans with HIV who receive care from the largest provider of HIV care in the United States – the VA healthcare system. Findings showed that VA providers decreased the frequency of CD4 testing by 11% between 2009 and 2012, reducing the direct cost of testing by $196,000 per year. While VA has made substantial progress in reducing the frequency of optional CD4 testing, it could be reduced a further 29% by full implementation of new treatment guidelines, with an expected annual savings of $600,000. Reduced CD4 monitoring also would likely reduce patient anxiety with little or no impact on quality of care.
Date: July 1, 2016
- Consequences of Notifying VA Patients about Potential Exposure to Large-Scale Adverse Events
This study sought to determine the intended and unintended consequences of patient notification following a large-scale adverse event (LSAE) within the VA healthcare system, which systematically looks for LSAEs, tracks potentially exposed patients, and communicates with them after LSAE notification. Findings showed that more than two-thirds of potentially exposed patients returned for HCV, HBV, and HIV testing following the receipt of an LSAE notification letter, which was associated with a 72 to 76 percentage point increase in testing.
Among Veterans who sought testing, 57% were tested in the 30 days following notification, and 74% were tested within 60 days. The vast majority (>98%) completed testing in a VA facility; less than 2% were tested at a non-VA facility paid by purchased care or Medicare (when eligible). Among older Veterans, notification was associated with higher odds of increased VA outpatient use in the following 3 months, but decreased odds of using VA healthcare in the subsequent 9 months. Compared to white Veterans, African American Veterans were significantly less likely to return to VA for follow-up testing.
Date: May 1, 2015
- Pilot Study Implements HIV Rapid-Testing in Homeless Shelters
Investigators in this pilot study developed and implemented an HIV rapid-testing/linkage-to-care initiative between VA and local government in Los Angeles County (LAC) to provide rapid testing in homeless shelters – and to link individuals with HIV to care. The initiative was considered a success, with stakeholders noting that the collaboration had prompted their participation in testing within homeless shelters. For example, stakeholders stated that once VA investigators were able “to solidify and secure those shelters, it was easy for us to come in… all that groundwork was done,” showing that different levels of government (i.e., federal, county, city) can work collaboratively to implement HIV testing. During the 26-month duration of the initiative, counselors made 189 visits and administered 817 tests (4.5% were to Veterans), identifying seven preliminary HIV-positive individuals. Five were confirmed and linked to care, one did not return for results, and the other refused linkage to care. Cost analysis showed that the cost per HIV-positive individual was $5,714, with costs highest during the first six months. The initiation and support provided by VA was a catalyst in allowing other agencies to concentrate resources. Investigators note this model can be adapted as a “plug and play” intervention, for the most part.
Date: January 1, 2015
- Multimodal Intervention Increases HIV Testing in VA Primary Care
Investigators with VA/HSR&D’s HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites. Findings showed that the use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency with which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold. Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.
Date: April 19, 2013
- VA HIV and Hepatitis C Telemedicine Clinics Improve Patient Outcomes among Rural Veterans
Among a rural-dwelling study sample, HIV and hepatitis C telemedicine clinics were associated with improved access, high patient satisfaction, and a reduction in health visit-related time. Clinic completion rates (proxy for access) were higher for telemedicine (76%) than for in-person visits (61%). Of the 43 Veterans in the study, 30 (70%) completed a telemedicine-facilitated survey. More than 95% of these Veterans rated telemedicine at the highest level of satisfaction and preferred telemedicine to in-person visits. Veterans estimated that total health visit time was 340 minutes less for telemedicine compared to in-person visits. The majority of perceived time reduction was related to travel.
Date: April 1, 2012
- Intervention to Increase HIV Testing Can Be Successfully Implemented by Non-Research Staff
This study reports on the one-year results of implementing a program that doubled HIV testing rates in at-risk Veterans receiving care at two VAMCs in two other VA facilities where the research team played a much smaller part in the intervention implementation. Findings showed that the annual rate of HIV testing among at-risk Veterans increased by 6% and 16% after the end of the first year for the two sites to which the project was newly exported, and where non-research staff were responsible for implementation. In contrast, for the original two implementation sites where research staff played a major role, testing rates increased by 9% and 12%. There was no change in the rate of testing at the one control site that did not participate in the project. Authors note that even with differences between the original and “export” sites (e.g., strength of academic affiliations, emphasis on specialized services), the successful implementation and similar increases in HIV testing rates across patient and sub-facility levels provides further support for the generalizability of the intervention.
Date: December 1, 2011
- Veterans in Favor of Internet-Provided HIV Screening Information
This study examined patient and provider perceptions of Internet-based outreach to increase HIV screening among Veterans who use the VA healthcare system. Findings showed that both Veterans and providers thought that HIV screening outreach provided electronically via the personal health record (PHR – MyHealtheVet) would improve patient access to health information, with important educational value. Providers believed that it would reinforce messages they give to their patients. Veterans could envision instances in which information provided electronically might be better than verbal information from their doctor because it would be in lay language and readily available. Veterans also believed that electronic outreach would motivate them to be proactive about their health. Most felt that electronic messages would remind them to be screened, or at least contemplate getting screened. Regarding stigma attached to an electronic message about HIV, providers expressed substantially more concerns than Veterans. Providers also expected increased workload from the electronic outreach, and suggested adding primary care resources and devising methods to smooth the flow of patients getting screened.
Date: August 15, 2011
- Routine, Oral, Rapid HIV Testing in VA Emergency Departments Financially Equivalent to Usual Care
Using a dynamic decision analysis model, this study examined the budget impact of implementing a routine oral HIV rapid-testing program in a VA emergency department (ED) versus the impact of following ‘usual’ care. Findings show that a routine oral HIV screening program using a rapid testing approach is financially equivalent to following a usual care approach within the VA healthcare system. Assuming a 1% prevalence of the disease and an 80% acceptance of testing, the total cost of HIV rapid-testing was $1,418,088 versus $1,320,338 for ‘usual care.’ While the HIV rapid-testing program had substantial screening costs, they were offset by lower inpatient expenses associated with earlier identification of disease. The higher treatment costs for ‘usual care’ patients were largely due to inpatient stays, reflecting more hospitalizations for these patients due to opportunistic infections. Given that early detection of HIV and linkage to treatment is associated with better health outcomes – and non-targeted testing does not result in a greater budget impact than usual care – the authors suggest that this analysis provides support for the implementation of a routine oral rapid testing program within VA.
Date: January 27, 2011
- Collaborative Care Intervention Improves Depression in Veterans with HIV
The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
Date: January 10, 2011
- Rates of Liver Cancer and Cirrhosis Increase Significantly among Veterans with Hepatitis C Virus
This study identified all Veterans with hepatitis C virus (HCV) who visited any of 128 VA medical centers over a 10-year period to examine the prevalence of cirrhosis, hepatic decompensation, and hepatocellular cancer, as well as risk factors that may be associated with an accelerated progression to cirrhosis. The number of Veterans diagnosed with HCV increased over the ten years from 17,261 to 106,242. Over the same time period, among HCV patients, the prevalence of cirrhosis increased from 9% to 18.5%, while the prevalence of liver cancer increased approximately 19-fold (from 0.07% to 1.3%). Regarding risk factors among HCV-infected Veterans, the proportion of patients with co-existing diabetes increased from 12% in to 23%, while the number of patients with HIV, hepatitis B virus, or a diagnosis of alcohol use declined slightly.
Date: December 22, 2010
- Nurse-Initiated Rapid HIV Testing was Cost-Effective and Increased Screening Rates among Veterans
Nurse-initiated routine screening (i.e. recommending HIV testing to all Veterans) with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results among Veterans – and was cost-effective compared with traditional risk-based HIV testing strategies. When benefits to sexual partners from reduced transmission was considered, rapid testing with streamlined counseling was even more favorable. Traditional risk-based HIV counseling and testing resulted in the lowest costs and effectiveness.
Date: March 4, 2010
- Chronic Kidney Failure Associated with Increased Mortality among Veterans with HIV and Hepatitis C Virus
Compared with their mono-infected counterparts, Veterans with HIV who were co-infected with HCV had significantly higher rates of chronic kidney disease (14% vs. 11%) and mortality. HCV co-infection independently increased the likelihood of death by nearly 25%, after adjusting for other important HIV- and HCV-related factors. Co-infected Veterans also were less likely to have received highly active antiretroviral therapy (HAART) at baseline. Authors suggest that efforts should be targeted toward optimizing medical care for mono- and co-infected Veterans, including HAART therapy, HCV antiviral therapy, and treatment of comorbid medical conditions.
Date: February 1, 2010
- Predictors Associated with Use of Complementary/Alternative Medicine in Men with HIV
This study sought to describe the types, frequency, and intensity of complementary/alternative medicine (CAM) use among men living with HIV infection in southern California and northern Florida/southern Georgia, and to identify predictors of CAM use and intensity. Findings show that the majority of men with HIV infection in this study (69%) reported some CAM use. The most frequently cited types of CAM use were drug or dietary supplements (71%) and spiritual therapies (66%). CAM use was almost three times higher in California compared to Florida/Georgia, and was also greater in men who reported depression or more health-promoting behaviors. The odds of CAM use intensity increased with greater symptom frequency and more health-promoting behaviors. In addition, vitamins, dietary supplements, and herbs were used by the majority of men in this study. The authors suggest that high levels of CAM use among men with HIV infection should alert healthcare providers to assess CAM use and to incorporate CAM-related patient education into their clinical practices.
Date: November 1, 2009
- Low Rates of HIV Screening among Veterans with Substance Use Disorders
This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
Date: October 1, 2009
- Improving Provider-Patient Communication about Routine HIV Testing in VA
This study sought to understand patient and provider perspectives on the adoption of routine HIV testing within the VA healthcare system. Findings show that Veterans and providers agreed that the implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling would benefit both Veterans and public health. Veterans wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested; they also believed that routine testing would help de-stigmatize HIV. Six steps for providers to use in communicating about routine testing also were identified, such as raising the topic of HIV testing, reassuring the Veteran that he/she is not showing clinical signs of the disease, and responding to Veteran questions about HIV.
Date: October 1, 2009
- Effective Clinical Decision Support Tool for HIV Symptom Management
This pilot study produced a clinical decision support tool called TEMS that was developed to: elicit information about symptoms at routine clinic visits; organize information to emphasize what is most useful for clinical care; present information at the point-of-care; and recommend clinical responses based on that information. TEMS was implemented as part of VA’s electronic medical record at one VA medical center, to increase provider awareness of and response to common HIV symptoms. Investigators then studied the tool’s feasibility in routine care within a weekly HIV clinic, comparing a 4-week intervention period with a 4-week control period. Findings show that TEMS was accepted by Veterans and their providers and did not substantially impede workflow. In addition, there was a trend toward including a greater number of symptoms in the progress notes documented during the intervention period compared to the control period.
Date: July 1, 2009
- Veterans with HIV Treated at Clinics with Integrated Specialty Services More Likely to Achieve Better Outcomes
The most common way HIV clinics address patients with comorbidities is by integrating non-infectious disease providers (e.g., psychiatrists and social workers) into HIV primary care. This retrospective cohort study evaluated the association between Integrated HIV Care and patient outcomes among 1018 Veterans with HIV who received care at five VA facilities from 2000-2006. Findings show that Veterans who visited HIV clinics with more integrated specialty services were more likely to achieve viral suppression. In particular, Veterans visiting clinics that offered hepatitis, psychiatric, psychological, and social services in addition to primary care and HIV specialty services were three times more likely to achieve viral suppression than Veterans visiting clinics that offered only primary care and HIV specialty services. Results also showed that 93% of Veterans in this study had one or more comorbid conditions, with a mean of 3.2 comorbidities. Authors suggest that resources should be allocated to integrate sub-specialty services into HIV primary care clinics, and that providers should direct patients toward these clinics and retain them in care.
Date: May 1, 2009
- Assessing Accuracy and Completeness of Research Data
VA benefits from one of the most highly developed health information systems in the world, which includes the Immunology Case Registry (ICR) that was designed to monitor costs and quality of HIV care, and the Decision Support System (DSS) that was developed to monitor utilization and costs of Veterans in care. This study compared ICR and DSS datasets, which share overlapping laboratory data from the same VA electronic record system. Findings show that six of the laboratory tests for HIV patients that were studied demonstrated remarkably similar amounts of overlap (68% to 72%) between the two datasets, showing that ICR and DSS are both good sources of data for these tests. However, several other tests demonstrated much lower proportions of overlap (between 20% and 31%). These findings indicate that validation of laboratory data should be conducted prior to its use in quality and efficiency projects.
Date: January 1, 2009
- Quality Indicators to Help Treat Veterans with HIV and Depression
Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
Date: October 1, 2008