Limits...
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.

Goetz MB, Bowman C, Hoang T, Anaya H, Osborn T, Gifford AL, Asch SM - Implement Sci (2008)

Bottom Line: 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.We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2).Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).

View Article: PubMed Central - HTML - PubMed

Affiliation: Infectious Diseases Section (111-F), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA. Matthew.Goetz@va.gov

ABSTRACT

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).

No MeSH data available.


Related in: MedlinePlus

Sample Audit/Feedback letter. The original report identifies the station and sub-stations by name rather than as "Station A" and sub-stations 1–11. The data provided in this letter indicate the number of persons with identified HIV risk factors who were tested for HIV or who were indicated to have refused HIV testing. No patient had previously been tested for HIV. These results, which represent incident HIV testing and refusal rates, differ from the data given in the results section that indicates the cumulative proportion of patients with identified HIV risk factors who had ever been tested. Achievement of 100% on the Y axis would indicate that all at-risk patients were offered HIV testing as denoted by records indicating that HIV testing was performed or refused by the patient.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2335105&req=5

Figure 2: Sample Audit/Feedback letter. The original report identifies the station and sub-stations by name rather than as "Station A" and sub-stations 1–11. The data provided in this letter indicate the number of persons with identified HIV risk factors who were tested for HIV or who were indicated to have refused HIV testing. No patient had previously been tested for HIV. These results, which represent incident HIV testing and refusal rates, differ from the data given in the results section that indicates the cumulative proportion of patients with identified HIV risk factors who had ever been tested. Achievement of 100% on the Y axis would indicate that all at-risk patients were offered HIV testing as denoted by records indicating that HIV testing was performed or refused by the patient.

Mentions: We designed an audit-feedback system, wherein healthcare providers are informed of group performance in regard to HIV screening rates in at-risk patients. A meta-analysis of 85 trials demonstrates that the use of audit-feedback is effective in improving practice, especially when baseline adherence is low [35]. We have distributed audit-feedback reports (Figure 2) to senior medical center-level clinical managers, outpatient clinic managers, and primary care team leaders at the Los Angeles and the San Diego VA stations. The contents of the reports have been discussed during academic detailing visits to primary care team meetings, and in the social marketing campaign. Informal provider feedback regarding the content of these reports has been positive.


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.

Goetz MB, Bowman C, Hoang T, Anaya H, Osborn T, Gifford AL, Asch SM - Implement Sci (2008)

Sample Audit/Feedback letter. The original report identifies the station and sub-stations by name rather than as "Station A" and sub-stations 1–11. The data provided in this letter indicate the number of persons with identified HIV risk factors who were tested for HIV or who were indicated to have refused HIV testing. No patient had previously been tested for HIV. These results, which represent incident HIV testing and refusal rates, differ from the data given in the results section that indicates the cumulative proportion of patients with identified HIV risk factors who had ever been tested. Achievement of 100% on the Y axis would indicate that all at-risk patients were offered HIV testing as denoted by records indicating that HIV testing was performed or refused by the patient.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2335105&req=5

Figure 2: Sample Audit/Feedback letter. The original report identifies the station and sub-stations by name rather than as "Station A" and sub-stations 1–11. The data provided in this letter indicate the number of persons with identified HIV risk factors who were tested for HIV or who were indicated to have refused HIV testing. No patient had previously been tested for HIV. These results, which represent incident HIV testing and refusal rates, differ from the data given in the results section that indicates the cumulative proportion of patients with identified HIV risk factors who had ever been tested. Achievement of 100% on the Y axis would indicate that all at-risk patients were offered HIV testing as denoted by records indicating that HIV testing was performed or refused by the patient.
Mentions: We designed an audit-feedback system, wherein healthcare providers are informed of group performance in regard to HIV screening rates in at-risk patients. A meta-analysis of 85 trials demonstrates that the use of audit-feedback is effective in improving practice, especially when baseline adherence is low [35]. We have distributed audit-feedback reports (Figure 2) to senior medical center-level clinical managers, outpatient clinic managers, and primary care team leaders at the Los Angeles and the San Diego VA stations. The contents of the reports have been discussed during academic detailing visits to primary care team meetings, and in the social marketing campaign. Informal provider feedback regarding the content of these reports has been positive.

Bottom Line: 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.We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2).Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).

View Article: PubMed Central - HTML - PubMed

Affiliation: Infectious Diseases Section (111-F), VA Greater Los Angeles Healthcare System, Los Angeles, California, USA. Matthew.Goetz@va.gov

ABSTRACT

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).

No MeSH data available.


Related in: MedlinePlus