We demonstrate that implementation of an integrated package of quality improvement interventions that utilized decision support, academic detailing and audit feedback resulted in a doubling of HIV testing for a population of at-risk individuals who had not previously been tested at 2 large VHA HCSs. No change in HIV testing occurred at the 3 control HCSs. These results were robust with dramatic increases in the likelihood of being tested for HIV being observed across patient-level, provider-level, and subfacility-level factors. Furthermore, the rate of positive HIV tests remained constant despite the doubled rate of testing. In aggregate, the percentage of tests, which resulted in new diagnoses of HIV infection was 0.46% in the pre-intervention year versus 0.45% in the post-intervention year and thus well within the range at which the costs of HIV testing is less than $50,000 per quality-adjusted life year when the societal benefits of testing are considered 2
Our intervention relied on several components. First, we implemented a real-time computerized clinical reminder to identify patients with risk factors associated with HIV infection. Previous work has shown that the use of clinical reminders in individual patients when combined with audit/feedback and organizational changes improves vaccination, cardiovascular risk reduction, and breast and colorectal cancer screening rates.24–26,43–49
However, the use of clinical reminders alone is generally insufficient to achieve and sustain a transformation of group norms and maximize quality improvement.28–30,43,50–52
. Consequently, we also implemented a multi-faceted provider activation program that included academic detailing and social marketing with the aim of increasing the priority with which providers view HIV testing, routinizing the test ordering process, and encouraging providers to routinely test at risk patients HIV.28–30,32–34
. We also provided clinic level feedback to health care providers regarding the rate at which HIV screening and testing was performed.31
Several of our interventions were specifically designed to address congressionally mandated legal requirements that VHA patients provide written informed consent for HIV testing and that providers document pre- and posttest counseling.35
As a consequence, many VHA providers have regarded HIV testing to be a time-consuming process that cannot be readily accomplished in the setting of a busy outpatient clinic.53
In response, we developed a streamlined script for HIV pretest counseling that reduces the time required for HIV pretest counseling to 2–3 minutes.38
We also addressed the processes of posttest counseling to specifically allow for telephone notification of negative test results. Studies from other clinical settings including urgent care clinics, emergency departments, and STD clinics have previously shown that HIV testing rates increase after implementation of similar measures.39–41
Our study confirms these results and extends their applicability to a geographically dispersed system of primary care clinics.
The strengths of our study include a quasi-experimental design in which the effect of the intervention was clearly demonstrated in comparison of pre- to post-increases in HIV testing at the intervention HCSs with no pre- to post-changes at the control HCSs. This was very much a real-world effectiveness study that examined the impact of our intervention in an unselected population of at-risk veterans receiving care in a routine clinical setting.
Limitations of our work include the fact that the intervention relied heavily on the quality improvement infrastructure in the VHA, including the electronic medical record, clinical reminder software, and familiarity with performance measurements. This makes it difficult to generalize the intervention to health care systems that do not currently have access to these tools. However, such tools are becoming increasingly common and some components of the intervention, such as provider activation, do not require the infrastructure of an integrated health care system. Another limitation of the design was that we were unable to quantitatively dissect the contributions of the individual elements of our intervention. To address this critical issue, we are undertaking a qualitative process (or formative) evaluation to better understand the influences that impact the success of the intervention; specifically, by identifying contextually relevant factors (i.e., facilitators and barriers) and assessing the degree that behaviors leading to improved testing performance become part of routine practice.54
Areas of particular interest will be to formally evaluate the contribution of nurse-based vs physician-based HIV testing and evaluation as well as the role of intensive provider activation as this is the most costly and time-consuming activity. Finally, since the intervention facilities were selected for convenience and not randomly, this may have biased the results. In this regard, it is relevant that there were little difference in the distribution of patient, provide, subfacility- and facility-level factors between the intervention and control facilities (Table ).
In summary, we found that the coordinated use of computerized real-time clinical reminders, audit/feedback, provider activation, and removal of systemic barriers significantly increases HIV testing rates and thus allows early diagnosis and treatment for these vulnerable patients. These findings support a multimodal approach toward achieving the CDC’s goal of having every American aged 13–64 regardless of the presence of known risk factors know their HIV status as a matter of routine clinical practice. If sustained, dissemination of this program holds promise of substantial benefit to the VA, the largest single HIV provider in the United States and potentially in other jurisdictions where logistical barriers such as obtaining written informed consent impede implementation of routine opt-out HIV testing as recommended by the CDC.55