PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-6 (6)
 

Clipboard (0)
None

Select a Filter Below

Journals
Authors
more »
Year of Publication
Document Types
1.  The Impact of Integrated HIV Care on Patient Health Outcomes 
Medical care  2009;47(5):560-567.
Background
Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have co-morbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers.
Objective
Evaluate effect of Integrated HIV Care on suppression of HIV replication.
Research Design
A retrospective cohort study of HIV patients from five Veterans Affairs healthcare facilities 2000–2006.
Subjects
Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART.
Measures
We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of Integrated HIV Care utilization. We evaluated effect of Integrated HIV Care utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis.
Results
The 1,018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had co-morbidities with mean 3.2 co-morbidities per patient (S.D.=2.0); 52% achieved viral suppression in median 231 days (S.D.=411.6). Patients visiting clinics which offered hepatitis, psychiatric, psychological and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (Hazard ratio=3.1, p<.001).
Conclusions
Patients who visited Integrated HIV Care clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.
doi:10.1097/MLR.0b013e31819432a0
PMCID: PMC3108041  PMID: 19318998
2.  Cost-Effectiveness of Strategies to Improve HIV Testing and Receipt of Results: Economic Analysis of a Randomized Controlled Trial 
Background
The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results.
Objective
To examine the costs and benefits of strategies to improve HIV testing and receipt of results.
Design
Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature.
Setting/target population
Primary-care patients with unknown HIV status.
Interventions
Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling.
Main measures
Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness.
Key results
Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by $53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of $36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses.
Conclusions
In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1265-5) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1265-5
PMCID: PMC2869414  PMID: 20204538
HIV; cost-benefit analysis; highly active antiretroviral therapy; transmission; nurse-initiated HIV screening; HIV rapid testing; Streamlined counseling
3.  Evaluation of the Sustainability of an Intervention to Increase HIV Testing 
Journal of General Internal Medicine  2009;24(12):1275-1280.
ABSTRACT
BACKGROUND
Sustainability—the routinization and institutionalization of processes that improve the quality of healthcare—is difficult to achieve and not often studied.
OBJECTIVE
To evaluate the sustainability of increased rates of HIV testing after implementation of a multi-component intervention in two Veterans Health Administration healthcare systems.
DESIGN
Quasi-experimental implementation study in which the effect of transferring responsibility to conduct the provider education component of the intervention from research to operational staff was assessed.
PATIENTS
Persons receiving healthcare between 2005 and 2006 (intervention year) and 2006 and 2007 (sustainability year).
MEASUREMENTS
Monthly HIV testing rate, stratified by frequency of clinic visits.
RESULTS
The monthly adjusted testing rate increased from 2% at baseline to 6% at the end intervention year and then declined reaching 4% at the end of the sustainability year. However, the stratified, visit-specific testing rate for persons newly exposed to the intervention (i.e., having their first through third visits during the study period) increased throughout the intervention and sustainability years. Increases in the proportion of visits by patients who remained untested despite multiple, prior exposures to the intervention accounted for the aggregate attenuation of testing during the sustainability year. Overall, the percentage of patients who received an HIV test in the sustainability year was 11.6%, in the intervention year 11.1%, and in the pre-intervention year 5.0%
CONCLUSIONS
Provider education combined with informatics and organizational support had a sustainable effect on HIV testing rates. The effect was most pronounced during patients’ early contacts with the healthcare system.
doi:10.1007/s11606-009-1120-8
PMCID: PMC2787938  PMID: 19798538
HIV testing; provider education; sustainability; VA hospitals
4.  A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration 
Journal of General Internal Medicine  2008;23(8):1200-1207.
Background
Although the benefits of identifying and treating asymptomatic HIV-infected individuals are firmly established, health care providers often miss opportunities to offer HIV-testing.
Objective
To evaluate whether a multi-component intervention increases the rate of HIV diagnostic testing.
Design
Pre- to post-quasi-experiment in 5 Veterans Health Administration facilities. Two facilities received the intervention; the other three facilities were controls. The intervention included a real-time electronic clinical reminder that encourages HIV testing, and feedback reports and a provider activation program.
Patients
Persons receiving health care between August 2004 and September 2006 who were at risk but had not been previously tested for HIV infection
Measurements
Pre- to post-changes in the rates of HIV testing at the intervention and control facilities
Results
At the two intervention sites, the adjusted rate of testing increased from 4.8% to 10.8% and from 5.5% to 12.8% (both comparisons, p < .001). In addition, there were 15 new diagnoses of HIV in the pre-intervention year (0.46% of all tests) versus 30 new diagnoses in the post-intervention year (0.45% of all tests). No changes were observed at the control facilities.
Conclusions
Use of clinical reminders and provider feedback, activation, and social marketing increased the frequency of HIV testing and the number of new HIV diagnoses. These findings support a multimodal approach toward achieving the Centers for Disease Control and Prevention’s goal of having every American know their HIV status as a matter of routine clinical practice.
doi:10.1007/s11606-008-0637-6
PMCID: PMC2517965  PMID: 18452045
diagnosis; HIV testing; quality improvement
5.  Improving HIV Screening and Receipt of Results by Nurse-Initiated Streamlined Counseling and Rapid Testing 
Background
HIV testing is cost-effective in unselected general medical populations, yet testing rates among those at risk remain low, even among those with regular primary care. HIV rapid testing is effective in many healthcare settings, but scant research has been done within primary care settings or within the US Department of Veteran’s Affairs Healthcare System.
Objectives
We evaluated three methods proven effective in other diseases/settings: nurse standing orders for testing, streamlined counseling, and HIV rapid testing.
Design
Randomized, controlled trial with three intervention models: model A (traditional counseling/testing); model B (nurse-initiated screening, traditional counseling/testing); model C (nurse-initiated screening, streamlined counseling/rapid testing).
Participants
Two hundred fifty-one patients with primary/urgent care appointments in two VA clinics in the same city (one large urban hospital, one freestanding outpatient clinic in a high HIV prevalence area).
Measurements
Rates of HIV testing and receipt of results; sexual risk reduction; HIV knowledge improvement.
Results
Testing rates were 40.2% (model A), 84.5% (model B), and 89.3% (model C; p = <.01). Test result receipt rates were 14.6% (model A), 31.0% (model B), 79.8% (model C; all p = <.01). Sexual risk reduction and knowledge improvement did not differ significantly between counseling methods.
Conclusions
Streamlined counseling with rapid testing significantly increased testing and receipt rates over current practice without changes in risk behavior or posttest knowledge. Increased testing and receipt of results could lead to earlier disease identification, increased treatment, and reduced morbidity/mortality. Policymakers should consider streamlined counseling/rapid testing when implementing routine HIV testing into primary/urgent care.
doi:10.1007/s11606-008-0617-x
PMCID: PMC2517869  PMID: 18421508
nurse-initiated HIV screening; HIV rapid testing; streamlined counseling
6.  Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI Series 
Background
We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis – a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.
Methods
Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA.
Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide decision support; audit/feedback as a clinical information system, and appropriate changes in delivery system design. These activities are complemented by academic detailing and social marketing interventions to achieve provider activation.
Results
Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3–5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.
Discussion
This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).
doi:10.1186/1748-5908-3-16
PMCID: PMC2335105  PMID: 18353185

Results 1-6 (6)