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1.  Comparative Logic Modeling for Policy Analysis: The Case of HIV Testing Policy Change at the Department of Veterans Affairs 
Health Services Research  2011;46(5):1628-1645.
Objective
Logic models have been used to evaluate policy programs, plan projects, and allocate resources. Logic Modeling for policy analysis has been used rarely in health services research but can be helpful in evaluating the content and rationale of health policies. Comparative Logic Modeling is used here on human immunodeficiency virus (HIV) policy statements from the Department of Veterans Affairs (VA) and Centers for Disease Control and Prevention (CDC). We created visual representations of proposed HIV screening policy components in order to evaluate their structural logic and research-based justifications.
Data Sources and Study Design
We performed content analysis of VA and CDC HIV testing policy documents in a retrospective case study.
Data Collection
Using comparative Logic Modeling, we examined the content and primary sources of policy statements by the VA and CDC. We then quantified evidence-based causal inferences within each statement.
Principal Findings
VA HIV testing policy structure largely replicated that of the CDC guidelines. Despite similar design choices, chosen research citations did not overlap. The agencies used evidence to emphasize different components of the policies.
Conclusion
Comparative Logic Modeling can be used by health services researchers and policy analysts more generally to evaluate structural differences in health policies and to analyze research-based rationales used by policy makers.
doi:10.1111/j.1475-6773.2011.01283.x
PMCID: PMC3207196  PMID: 21689094
Evidence-based practice; HIV; health policy; Centers for Disease Control and Prevention (U.S.); Veterans Affairs (U.S.)
2.  Feasibility and Acceptability of a Real-Time Adherence Device among HIV-Positive IDU Patients in China 
AIDS Research and Treatment  2013;2013:957862.
We collected data on feasibility and acceptability of a real-time web-linked adherence monitoring container among HIV-positive injection drug users (IDU) in China. “Wisepill” uses wireless technology to track on-time medication dosing. Ten patients on antiretroviral therapy (ART) at the Guangxi CDC HIV clinic in Nanning, China, used Wisepill for one ART medication for one month. We monitored device use and adherence and explored acceptability of the device among patients. Mean adherence was 89.2% (SD 10.6%). Half of the subjects reported a positive overall experience with Wisepill. Seven said that it was inconvenient, supported by comments that it was large and conspicuous. Five worried about disclosure of HIV status due to the device; no disclosures were reported. Twelve signal lapses occurred (5.4% of prescribed doses), of which one was due to technical reasons, nine to behavioral reasons (both intentional and unintentional), and two to unclear reasons. Although the technical components must be monitored carefully, and acceptability to patients presents challenges which warrant further exploration, the Wisepill device has potential for adherence interventions that deliver rapid adherence-support behavioral feedback directly to patients, including IDU. The use of wireless technology appears uniquely promising for providing time-sensitive communication on patient behavior that can be harnessed to maximize the benefits of HIV treatment.
doi:10.1155/2013/957862
PMCID: PMC3730150  PMID: 23956851
3.  Living with HIV: Responses to a Mantram Intervention Using the Critical Incident Research Method 
Abstract
Objectives
The objective of this study was to identify and describe ways that a spiritually based intervention of silently repeating a mantram—sacred word or phrase—was used as a coping strategy for managing human immunodeficiency virus (HIV) disease.
Design
The design was a qualitative research method, the critical incident technique.
Settings/location
The study was conducted at an academically affiliated Veterans Affairs Hospital in southern California.
Subjects
The subjects were outpatient adults living with HIV (n=32) who were receiving care through HIV clinics, community agencies, and HIV providers.
Interventions
Subjects who participated in the intervention arm of a randomized controlled trial that tested the efficacy of a 5-weekly group mantram intervention were interviewed 2 months postintervention. Follow-up telephone interviews were specifically aimed at identifying instances of mantram use, and also participant perceptions of intervention usefulness or nonusefulness.
Outcome measures
The outcome measures comprised categorization and comparison of the types and frequency of incidents reported, describing ways that the intervention was “helpful” or “not helpful” in managing stressors of HIV disease.
Results
Participants reported a total of 185 incidents. Analysis and classification of the incidents resulted in eight mutually exclusive categories, including Increasing calm and/or peace, Mastering the technique, Changing my viewpoint, Increasing personal awareness, Adjusting behaviors, Managing physical symptoms, Increasing spirituality, and Enhancing relationships.
Conclusions
This study shows support for the benefits of the mantram intervention for adults with HIV. Additionally, the spiritually based mantram repetition intervention was found to be more helpful in providing a convenient, portable tool for managing a wide range of situations related to living with HIV disease.
doi:10.1089/acm.2009.0489
PMCID: PMC3264955  PMID: 22268972
4.  PILOT STUDY DEMONSTRATING EFFECTIVENESS OF TARGETED EDUCATION TO IMPROVE INFORMED CONSENT UNDERSTANDING IN AIDS CLINICAL TRIALS 
AIDS care  2011;23(11):1382-1391.
Assessing and improving informed consent understanding is equally important as obtaining consent from participants in clinical trial research, but developing interventions to target gaps in participants’ informed consent understanding remains a challenge. We used a randomized controlled study design to pilot test an educational intervention to improve actual informed consent understanding of new enrollees in the Adult AIDS Clinical Trial Group (AACTG). Questionnaires were administered to 24 enrollees to assess their baseline understanding on eight elements of informed consent associated with AIDS clinical trials. Enrollees who scored 18/21(85%) or less were randomly assigned to in-person, targeted education (intervention) or delayed education (control). Two follow-up assessments were administered. Repeated measures ANOVA was performed to determine intervention effectiveness in improving actual informed consent understanding over time. Actual understanding improved at the immediate post-intervention time point with a significant score difference of 2.5 when comparing the intervention and delayed groups. In addition, there was a significant score difference of 3.2 when comparing baseline to 3-month follow-up for the two groups, suggesting a statistically significant intervention effect to improve actual understanding of the basic elements of informed consent. The findings demonstrated that one-time targeted education can improve actual informed consent understanding one week after the intervention, but retention of these concepts may require periodic monitoring to ensure comprehension throughout the course of a clinical trial.
doi:10.1080/09540121.2011.565031
PMCID: PMC3205427  PMID: 22022848
HIV; AIDS; Informed Consent; Ethics Research; Clinical Trial; Intervention Studies
5.  Pilot Randomized Trial of the Effect of Wireless Telemonitoring on Compliance and Treatment Efficacy in Obstructive Sleep Apnea 
Background
Obstructive sleep apnea (OSA) is a prevalent and serious medical condition characterized by repeated complete or partial obstructions of the upper airway during sleep and is prevalent in 2% to 4% of working middle-aged adults. Nasal continuous positive airway pressure (CPAP) is the gold-standard treatment for OSA. Because compliance rates with CPAP therapy are disappointingly low, effective interventions are needed to improve CPAP compliance among patients diagnosed with OSA.
Objective
The aim was to determine whether wireless telemonitoring of CPAP compliance and efficacy data, compared to usual clinical care, results in higher CPAP compliance and improved OSA outcomes.
Methods
45 patients newly diagnosed with OSA were randomized to either telemonitored clinical care or usual clinical care and were followed for their first 2 months of treatment with CPAP therapy. CPAP therapists were not blinded to the participants’ treatment group.
Results
20 participants in each group received the designated intervention. Patients randomized to telemonitored clinical care used CPAP an average of 4.1 ± 1.8 hours per night, while the usual clinical care patients averaged 2.8 ± 2.2 hours per night (P = .07). Telemonitored patients used CPAP on 78% ± 22% of the possible nights, while usual care patients used CPAP on 60% ± 32% of the nights (P = .07). No statistically significant differences between the groups were found on measures of CPAP efficacy, including measures of mask leak and the Apnea-Hypopnea Index. Patients in the telemonitored group rated their likelihood to continue using CPAP significantly higher than the patients in the usual care group. Patients in both groups were highly satisfied with the care they received and rated themselves as “not concerned” that their CPAP data were being wirelessly monitored.
Conclusions
Telemonitoring of CPAP compliance and efficacy data and rapid use of those data by the clinical sleep team to guide the collaborative (ie, patient and provider) management of CPAP treatment is as effective as usual care in improving compliance rates and outcomes in new CPAP users. This study was designed as a pilot—larger, well-powered studies are necessary to fully evaluate the clinical and economic efficacy of telemonitoring for this population.
doi:10.2196/jmir.9.2.e14
PMCID: PMC1874716  PMID: 17513285
Continuous positive airway pressure therapy; CPAP; sleep apnea syndromes; treatment compliance; telemedicine; randomized controlled trial
6.  Hepatitis C Testing Practices and Prevalence in a High-risk Urban Ambulatory Care Setting 
Journal of viral hepatitis  2010;18(7):474-481.
Approximately 3.2 million persons are chronically infected with the hepatitis C virus (HCV) in the U.S; most are not aware of their infection. Our objectives were to examine HCV testing practices to determine which patient characteristics are associated with HCV testing and positivity, and to estimate the prevalence of HCV infection in a high-risk urban population. The study subjects were all patients included in the baseline phase of the Hepatitis C Assessment and Testing Project (HepCAT), a serial cross-sectional study of HCV screening strategies. We examined all patients with a clinic visit to Montefiore Medical Center from 1/1/08 to 2/29/08. Demographic information, laboratory data and ICD-9 diagnostic codes from 3/1/97 – 2/29/08 were extracted from the electronic medical record. Risk factors for HCV were defined based on birth date, ICD-9 codes and laboratory data. The prevalence of HCV infection was estimated assuming that untested subjects would test positive at the same rate as tested subjects, based on risk-factors. Of 9579 subjects examined, 3803 (39.7%) had been tested for HCV and 438 (11.5%) were positive. The overall prevalence of HCV infection was estimated to be 7.7%. Risk factors associated with being tested and anti-HCV positivity included: born in the high-prevalence birth-cohort (1945-64), substance abuse, HIV infection, alcohol abuse, diagnosis of cirrhosis, end-stage renal disease, and ALT elevation. In a high-risk urban population, a significant proportion of patients were tested for HCV and the prevalence of HCV infection was high. Physicians appear to use a risk-based screening strategy to identify HCV infection.
doi:10.1111/j.1365-2893.2010.01327.x
PMCID: PMC2990787  PMID: 20497311
7.  Update in HIV Medicine for the Generalist 
doi:10.1007/s11606-010-1580-x
PMCID: PMC3077485  PMID: 21140297
HIV/AIDS; prevention; screening
9.  Living with Hepatitis C: Qualitative Interviews with Hepatitis C-infected Veterans 
Journal of General Internal Medicine  2008;23(12):1959-1965.
Background
Chronic hepatitis C (HCV) infection affects millions of people in the USA and prevalence rates are higher in US veterans. The consequences of HCV infection include reduced quality of life, liver damage, and reduced longevity.
Objective
Our objective was to describe the experiences of US veterans living with chronic HCV infection and use this information in the development of an HCV self-management intervention.
Methods
Twenty-two male HCV-infected veterans completed qualitative interviews. Participants were recruited via flyers and hepatitis C clinic providers at a major VA medical center. Participants were asked about their medical history, being diagnosed with HCV, and general experiences living with HCV.
Results
The study gathered the following findings: the impact of HCV on interpersonal relationships was pronounced, recovery from substance use disorders and getting care for HCV were connected, receiving the HCV diagnosis was more troubling to non-IV drug users, participants had misconceptions about HCV and its treatment, psychological problems were prevalent as were barriers to participating in antiviral treatment and HCV care in general.
Conclusion
The themes derived from our analysis indicate that affected veterans may benefit from interventions or support to improve HCV-related health education, social/relationship issues, psychological issues, and exploration of the connection between substance use recovery and motivation to get care for HCV infection.
doi:10.1007/s11606-008-0790-y
PMCID: PMC2596521  PMID: 18807097
hepatitis C; HCV; veterans; treatment; impact
10.  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
11.  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
12.  Measuring persistence of implementation: QUERI Series 
As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the "need for further research" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses.
This article is one in a Series of articles documenting implementation science frameworks and approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).
doi:10.1186/1748-5908-3-21
PMCID: PMC2390585  PMID: 18430200
13.  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
14.  Underdiagnosis of Depression in HIV 
OBJECTIVE
To determine the sociodemographic and service delivery correlates of depression underdiagnosis in HIV.
DESIGN
Cross-sectional survey.
PATIENTS/PARTICIPANTS
National probability sample of HIV-infected persons in care in the contiguous United States who have available medical record data.
MEASUREMENTS AND MAIN RESULTS
We interviewed patients using the Composite International Diagnostic Interview (CIDI) survey from the Mental Health Supplement. Patients also provided information regarding demographics, socioeconomic status, and HIV disease severity. We extracted patient medical record data between July 1995 and December 1997, and we defined depression underdiagnosis as a diagnosis of major depressive disorder based on the CIDI and no recorded depression diagnosis by their principal health care provider in their medical records between July 1995 and December 1997. Of the 1,140 HIV Cost and Services Utilization Study patients with medical record data who completed the CIDI, 448 (37%) had CIDI-defined major depression, and of these, 203 (45%) did not have a diagnosis of depression documented in their medical record. Multiple logistic regression analysis revealed that patients who had less than a high school education (P < .05) were less likely to have their depression documented in the medical record compared to those with at least a college education. Patients with Medicare insurance coverage compared to those with private health insurance (P < .01) and those with ≥3 outpatient visits (P < .05) compared to <3 visits were less likely to have their depression diagnosis missed by providers.
CONCLUSIONS
Our results suggest that providers should be more attentive to diagnosing comorbid depression in HIV-infected patients.
doi:10.1046/j.1525-1497.2003.20938.x
PMCID: PMC1494868  PMID: 12823652
depression; HIV; diagnosis
15.  Propensity of HIV Patients to Seek Urgent and Emergent Care 
OBJECTIVE
To assess the propensity of HIV-infected adults to seek care for common symptoms, and to determine whether they would seek care in the emergency department (ED) or with their primary care provider.
DESIGN
Cross-sectional interview study.
SETTING
Patients in care in the 48 contiguous United States.
PARTICIPANTS
A nationally representative group of HIV- infected adults selected using multistage probability sampling.
MEASUREMENTS
Subjects were interviewed between January 1996 and April 1997. Patients with advanced disease (past AIDS diagnosis and/or CD4 cell count <200/μL) and early disease were asked how they would seek care for key HIV-associated symptom complexes. Three advanced disease and 3 early disease symptom scenarios were used.
MAIN RESULTS
Most advanced disease patients (78% to 87%) would seek care right away from the ED or primary care provider for the symptoms asked. Most early disease patients (82%) would seek care right away for new respiratory symptoms; fewer would do so for headache (46%) or oral white patches (62%). In a multivariate model, independent predictors of propensity to use the ED for advanced disease symptoms included African-American ethnicity (adjusted odds ratio [OR], 2.5; 95% confidence interval [95% CI], 1.8 to 3.4); less education (adjusted OR, 1.4; 95% CI, 1.1 to 1.7); drug dependence (adjusted OR, 1.4; 95% CI, 1.1 to 1.7); annual income less than $5,000 (adjusted OR, 1.5; 95% CI, 1.0 to 2.3); and lower psychological well-being (adjusted OR, 0.9; 95% CI, 0.9 to 1.0). In early disease, the following independently predicted ED use: African American (adjusted OR, 4.7; 95% CI, 3.1 to 7.1) or Hispanic ethnicity (adjusted OR 2.4; 95% CI, 1.4 to 4.3), female gender (adjusted OR, 1.6; 95% CI, 1.2 to 2.2), annual income less than $5,000 (adjusted OR, 1.8; 95% CI, 1.1 to 3.0), and lower psychological well-being (adjusted OR, 0.9; 95% CI, 0.8 to 1.0).
CONCLUSIONS
Many patients would use the ED instead of same-day primary care for several common symptoms of HIV disease. African Americans, the poor, and patients with psychological symptoms had a higher propensity to use the ED.
doi:10.1046/j.1525-1497.2000.91136.x
PMCID: PMC1495714  PMID: 11119179
patient HIV infection; emergency department utilization; acceptance of health care; health services accessibility

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