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Use of Clinical informatics in a Study to Improve HIV Testing 

Matthew B. Goetz, M.D.

Clinical Coordinator, QUERI-HIV/Hepatitis 

Chief, Infectious Diseases, VA Greater Los Angeles Healthcare System

Professor of Clinical Medicine, David Geffen School of Medicine at UCLA 

Mention partnership with 13B

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Outline of this Presentation
        - HIV Testing:  Background
        - Interventions to Promote HIV Testing:

The VISN 22 Project
        - Results of the VISN 22 Implementation Project
        - Next Steps

Implementation and Evaluation in VISN 3 and 16

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HIV testing in the VA

Background

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Background
        - Benefits of earlier diagnosis of HIV infection

 mortality and  hospitalizations

 engagement in high risk behaviors yielding  further transmission. 
        - Many HIV infected patients do not know their status

CDC:  21% of the 1.1 million HIV+ persons in the US are unaware 

50- 70% of VA patients with risk factors have not been tested
        - CDC recommends HIV testing for all adults ≤ age 65 
        - American College of Physicians (ACP) recommends HIV testing for all adults (no age cut-off) 
        - CDC and ACP exception if HIV prevalence known to be < 0.1%

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Testing for HIV is Cost Effective

QALY with consideration of HIV transmission

Testing in VA is cost effective

even at very low HIV prevalence

CDC recommends routine offer of HIV testing if prevalence of undiagnosed infection is > 0.1%

$50,000/QALY

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

0

0.2

0.4

0.6

0.8

1

Prevalence (%)

Incremental Cost Effectiveness 

($/QALY)

QALY without consideration of HIV transmission

NEJM.  2005; 352:570.  NEJM.  2005:352:  586

0.1

Sanders GD, Bayoumi AM, Sundaram V, et al.   Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med. 2005; 352:570-85.

Paltiel AD, Weinstein MC, Kimmel AD, et al.   Expanded screening for HIV in the United States--an analysis of cost-effectiveness. N Engl J Med. 2005; 352:586-95.

CDC recommendation:  MMWR 2006;55(RR-14):1-17

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Undiagnosed HIV Infection in VA Outpatients  Seroprevalence in 6 Sites 2000 - 2002

CDC recommends routine offer of HIV testing if prevalence of undiagnosed infection is > 0.1%

Owens DK, et al.  Am J Public Health.  2007; 97:2173-8 

One site had prevalence of 2.81* (1.7 – 4.3%)

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Undiagnosed HIV Infection in VA Outpatients vs Age:  Seroprevalence in 6 Sites 2000 - 2002

Owens DK, et al.  Am J Public Health.  2007; 97:2173-8 

CDC recommends routine offer of HIV testing if prevalence of undiagnosed infection is > 0.1%

One site had prevalence of 2.81* (1.7 – 4.3%)

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Benefits of Highly Active Antiretroviral Therapy (HAART)

Intervention	Survival gain

Cancer chemotherapy	10 months

Coronary artery by-pass	20 months

HAART-HIV	180 months

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Current Impediments to HIV Testing in the VA 
        - Organizational barriers

Informed consent & pre-test counseling requirements

Constraints on provider time

Limited opportunity for timely, in-person post-test notification

Uncertain capacity to manage newly diagnosed patients
        - Provider behaviors

Incomplete recognition of HIV risk factors 

Reliance on trained counselors to order HIV tests 

Discomfort with HIV counseling

Lack of prioritization of HIV testing

Potential elimination of required written informed consent would remove only ONE barrier to HIV testing in the VA

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Promoting Better HIV Testing

Interventions to Promote HIV Testing

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Interventions to Promote HIV Testing
        - Organizational changes

Reinforce use of standardized VHA HIV informed consent

Promote streamlined counseling & nurse-based counseling

Permit telephonic notification of patients with negative test results

Assure assistance in counseling & HIV clinic f/u for new HIV+ pts
        - Provider activation  

Academic detailing & social marketing:  promote desired behaviors
        - Decision support:  context-specific electronic clinical reminder to assist providers in recognizing at-risk patients

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Context-Specific Triggers that Prompt HIV Testing Electronic Clinical Reminder

Hepatitis B core antibody positive	Lab result: +

Hepatitis B surface antigen positive	Lab result: +

Hepatitis C Virus antibody positive 	Lab result: +

Hepatitis C infection	ICD-9 code

Hepatitis C risk factors 	Health factors  

Sexually transmitted diseases	ICD-9 codes

Drug abuse	ICD-9 codes

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Electronic prompt for identification and testing of patients at-risk for HIV infection

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Interventions to Promote HIV Testing
        - Organizational changes

Reinforce use of standardized VHA HIV informed consent

Promote streamlined counseling & nurse-based counseling

Permit telephonic notification of patients with negative test results

Assure assistance in counseling & HIV clinic f/u for new HIV+ pts
        - Provider activation  

Academic detailing & social marketing:  Promote desired behaviors
        - Decision support:  context-specific electronic clinical reminder to assist providers in recognizing at-risk patients
        - Audit-feedback:  

Clinic level progress reports

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December 2007

Dear Site X Healthcare Primary Care Provider,

The VA is evaluating the effectiveness of a clinical reminder-based intervention for increasing HIV testing rates for veterans at risk for HIV.  This is consistent with the increased emphasis being placed on HIV testing by the CDC (http://www.cdc.gov/hiv/topics/testing/resources/factsheets/healthcare.htm).

Since implementation of this intervention at Las Vegas in March 2007, there has been a substantial and significant increase in rate at which HIV testing is being performed in at-risk patients.  The proportion of at-risk patients who had ever been tested for HIV infection increased from 21% prior to the intervention to 30%% during the most recent quarter. 

However the rate at which patients refuse HIV testing varies greatly across clinics and is far greater than the rate of actual HIV testing.  The following figure compares the rates of testing and test refusal in the two quarters since implementation of this program.

Patient preference must, of course determine whether HIV testing is performed.  In particular, Federal law still requires patients to provide written informed consent for HIV testing.  However, we would like you to please continue to make actual HIV testing a priority among your at-risk patients.  The success of this intervention is not possible without your continued contributions to this important health issue.  

Please contact Herschel Knapp PhD at Herschel.Knapp@va.gov if you have any questions or concerns about this project.

Thanks for doing the right thing for your at-risk patients – and keep up the good work!

Matt Goetz, MD and Herschel Knapp, PhD, for the QUERI-HIV VISN 22 HIV testing reminder evaluation team.

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Promoting Better HIV Testing

The VISN 22 Project

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Methods - Intervention & Evaluation
        - Prospective, controlled quasi-experimental implementation in VISN22 (southern CA and NV)

Year 1: intervention - 2 stations; control-  3 stations

Year 2: sustainability - 2 stations; intervention - 2 stations,              control - 1 station
        - Primary endpoints:  Pre- versus post-intervention

Rate of evaluation for HIV infection in at-risk patients 

Rate of performance of HIV testing in at-risk patients

In the first year, the project was implemented at 2 of the 5 stations in VISN 22, in the second year, the sustainability of the intervention was evaluated in the original two stations and the effect of the intervention was evaluated in two other stations while the fifth station remained a control.

We have previously demonstrated that implementation of this multi-modal intervention significantly increased HIV testing rates in at-risk individuals who receive care at two VHA medical facilities (7).  In particular, the adjusted rate of HIV testing per clinical encounter increased from 4.8% to 10.8% and from 5.5% to 12.8% over a one year period in two active intervention sits (both comparisons p<0.001), but while there was not change in three control facilities. 

We now report on the one year results of implementing this program in two other VHA facilities and on the HIV testing rates during the second year after implementation of this program in the original two facilities.  These data support the generalizability of this approach to improving HIV testing rates and maintenance of the gains that were achieved in the first year of the intervention.  Together these results provide a strong basis for further assessing the effectiveness, generalizability and costs of this program.

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Implementation Plan – VISN 22
        - Network presentation  

Network Director, Chief Medical Officer, Executive Committee, Quality Improvement Council
        - Local team identification

HIV lead clinician, primary care champion
        - Installation of HIV testing clinical reminder
        - Review of local policies
        - Local research approval
        - Facility presentations

Facility and Primary Care leadership
        - Presentation at primary care meetings

Review of local feedback processes

Network presentations :  Chief Medical Officer, Executive Committees, etc

Local team identification :  HIV lead clinician, primary care champion

Installation of HIV testing clinical reminder

Review of local policies

Authorization to order HIV tests or perform counseling

Management of HIV consent documentation

Laboratory test reporting

Provision for telephonic notification

Research approval

Central IRB, local site R&D Committee

Facility presentations:  Facility and Primary Care leadership

Presentation at primary care meetings

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Clinical Reminder Report
        - Design:  pre-specified reports
        - User selectable elements

Time period of interest

Clinic stop code

Station or substation
        - Available statistics

The number of patients seen 

The number of patients for whom the reminder was triggered

The number of patients triggered for whom the reminder was not resolved
        - Access to reports is generally through facility CACs

Fileman reports can be run at the local level to extract information regarding responses to individual elements of the Clinical reminders as captured in “fixed text” health factors

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Clinical Reminder Reports

Advantages
        - Minimal data security concerns:

Reports contain aggregated clinical data 

Do not contain patients’ or providers’ personal information
        - Real time data
        - Can be run  with minimal user input

Disadvantages
        - No access to covariates of interest 

Age, gender, income, race/ethnicity, marital status etc. 

Detailed analyses cannot be performed

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VISN 22 Data Warehouse
        - Includes all VISN 22 lab., demographic & health factor data

Advantage

Health factor data (“fixed text”) are not contained in AAC

Ability to perform multivariate analyses

Disadvantage

Data are “usually” updated monthly – delay in access
        - Data are directly exported from local sites

Disadvantage:  lab tests names differ across facilities

Extra programming to aggregate data

Advantage:  no errors due to derived variables
        - Provides real SSN vs Scrambled SSN in AAC

Disadvantage:  increased data security concerns

Talk- this data source was used for this study

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Results of VISN 22 Implementation

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VISN 22:  Pre- vs Post Incident HIV Testing Rate

Program implementation increases HIV testing rates two – three fold at all sites

			Intervention Year

				Control

	Site A	Site B	Site C	Site D	Site E

0%

10%

20%

30%

40%

50%

60%

70%

80%

-1

1

2

-1

1

2

-1

1

-1

1

2

-1

1

Reminder Resolution (%)

HIV testing

HIV evaluation without testing

Across the 5 HCS, baseline yearly rates of HIV testing among previously untested, at-risk persons were 2.3 – 6.7%.  During the year after program implementation these yearly rates increased by 9.3% - 12.4% for HCS A&B vs 5.8 – 16% for HCS C&E.  There was no change in the testing rate at the control facility (HCS D).. 

Site A = GLA

Site B = SD

Site C = LL

Site D = LB

Site E = LV

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VISN22:  Pre- vs Post-InterventionCumulative HIV Testing Rate

			Intervention Year

				Control

	Site A	Site B	Site C	Site D	Site E

Program implementation yields ~2-fold increase in cumulative HIV testing rates

Evaluation of the aggregate rate of HIV screening (i.e., results that include screening for HIV infection prior to the baseline year) indicate that the aggregate rate of having been tested for HIV infection rose from 17 – 20% to 21 – 34% and that the rate of overall screening increased from 13 – 23% to 50 – 74% from baseline to year one across the four control sites.  Again, continued increases in the aggregate rate of HIV testing were observed from year 1 to year 2 for HCS A and HCS B.  In contrast, the prevalent rate of testing increased from 7.0 – 8.3% and the prevalent rate of screening increased from 8.2 – 9.5% in the control HCS. 

Site A = GLA

Site B = SD

Site C = LL

Site D = LV

Site E = LB

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Post vs Pre Odds Ratio of HIV Testing Analysis of Patient Level Factors

Goetz MB et al. J Gen Intern Med.  2008; 23:1200-1207. 

Age

Income

Ethnicity

Marital status

Homeless

HCV Risk Fx

HCV Infection

HBV Infection

Prior STD

Illicit Drug Use

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Post vs Pre Odds Ratio of HIV Testing Analysis of Provider and Facility Level Factors

Goetz MB et al. J Gen Intern Med.  2008; 23:1200-1207. 

Provider

testing exp.

Patient 

Load

Prevalence ofat-risk pts.

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Sustainability of VISN 22 Implementation

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VISN 22:  Project Sustainability(Provider Activation Program De-emphasized in Year 2)

In aggregate, increased testing is appears to be sustainable

			Intervention Year

				Control

	Site A	Site B	Site C	Site D	Site E

Goetz MB et al.  Submitted for publication. 

0%

10%

20%

30%

40%

50%

60%

70%

80%

-1

1

2

-1

1

2

-1

1

-1

1

2

-1

1

Reminder Resolution (%)

HIV testing

HIV evaluation without testing

Across the 5 HCS, baseline yearly rates of HIV testing among previously untested, at-risk persons were 2.3 – 6.7%.  During the year after program implementation these yearly rates increased by 9.3% - 12.4% for HCS A&B vs 5.8 – 16% for HCS C&E.  There was no change in the testing rate at the control facility (HCS D).. 

Site A = GLA

Site B = SD

Site C = LL

Site D = LB

Site E = LV

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Adjusted HIV Testing Rates

Time series shows attenuation of sustainability

Goetz MB et al.  Submitted for publication. 

The testing rate increased during the intervention year (M1 – 12) but then declined during the sustainability year (M13 – 24) in both patient groups.  At M 24, the rate had returned to baseline for Returning Patients.

To gain further insight as to how HIV testing rates varied among new and returning patients we next analyzed HIV testing rates by the order of visits (i.e. first visit, second visit, etc.) among all patients seen during the two year study period. 

month	adjusted testing rate	(Tuyen “data for figures 1-3.xls” 3/31/09)

0	2	

1	3.93	

2	4.3	

3	4.44	

4	4.68	

5	5.01	

6	5.04	

7	5.29	

8	5.31	

9	5.64	

10	5.45	

11	5.81	

12	6	

13	6.01	

14	6.19	

15	5.76	

16	5.41	

17	5.55	

18	5.34	

19	5.12	

20	4.76	

21	4.86	

22	4.63	

23	4.44	

24	4.14	

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Adjusted HIV Testing Rates by Visit Number

After stratification by visit, time series shows sustained effect on testing

Goetz MB et al.  Submitted for publication. 

When corrected for visit number, the testing rate increased throughout the study period.  Changes in the distribution of the patient population over time explained the attenuation of the rate of HIV testing in the overall population.  No clinical or facility characteristics were found that differed between persons who were or were not tested by the 5th visit. 

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Adjusted HIV Test & Refusal Rates

Overtime, fewer patients refuse offers of HIV testing

Goetz MB et al.  Submitted for publication. 

To assess changes in provider expertise in offering HIV testing, we analyzed temporal changes in the proportion of patients who, when offered a test, agreed to testing.  As shown the proportion of patients who accepted offers of HIV testing increased throughout the study period

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Quarterly Costs of Expanded HIV TestingModel Based on Results in GLA and SD

	Baseline	Quarter 1	Quarter 2	Quarter 3

	8%	13%	8%	13%	8%	13%

Assumes 20,000 at risk patients, with 36% previously screened

3% baseline quarterly testing rate with increase to 8% vs 13%

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Incident Rate of HIV Testing (Month -1 to 5)vs Timing of Provider Activation Program

Substantial increases in HIV testing preceded implementation of the provider activation campaign at HCS E 

The intervention in HCS E differed from that at the other sites as the provider activation component of the program was not implemented until four months after institution of all other components.  This was done in an effort to ascertain the contribution of this, the most labor- and time-intensive component of the intervention.   As shown in Figure 2, despite the absence of the provider activation component of the intervention there was an immediate increase in the HIV test and test offer rate from a baseline value of 1.4% to 7.1% in the first month after implementation of the intervention.  This was greater than the increase that was seen in HCS A and HCS B in the first month of the intervention at those sites, which had the benefit of having had full implementation of the provider activation campaign.  Monthly data regarding the first 4 months of the intervention in HCS C were not available.  

  Of note, despite the absence of the provider activation campaign, there was an immediate increase of the program in LV where a 6.6% increase in the cumulative testing rate and a 42% increase in the HIV test offer rate occurred prior to the onset of the provider activation program. 

Site E = LV

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Summary of Results
        - Implementation of this multi-modal intervention more than doubled HIV testing rates in 4 VISN 22 facilities
        - Increases in testing were accompanied by increases in HIV case identification (data not shown)
        - At the two original sites, the increase in HIV testing rates were sustained over a two year period of time
        - Marginal costs = $40,000 - $70,000 per quarter
        - Uncertain contribution of provider activation program

Marginal costs with nurse-based testing, from VISN 22 business case evaluation

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Current Work

Extension to VISNs 3 & 16

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Goals of Current Project
        - Assess generalizability and acceptability of the intervention to VA facilities with differing structural characteristics

Patient workload		HIV prevalence

Academic affiliation	 	Differing care models

Availability of consultants and other tertiary services
        - Evaluate the added value of “provider activation” (academic detailing, social marketing) campaigns

Facilities randomized to receive extensive (“national sites”) vs modest (“local sites”) support for conduct of “provider activation” program

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Implementation Plan (1)

At all sites the national project team will
        - Meet with facility leadership, e.g., COS and leadership of nursing, laboratory service, ambulatory care and primary care programs
        - Promote program at primary care team meetings
        - Provide written and electronic educational materials
        - Provide feedback reports regarding clinic-specific rates of HIV testing 

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Implementation Plan (2)
        - At sites assigned to National Activation

Year 1:  National project staff will provide extensive support the provider activation campaign

Year 2*:  Local staff will be responsible for program maintenance
        - At sites assigned to Local Activation

Year 1:  Local staff will be encouraged to conduct their own provider education activities

Year 2*:  Local staff will be provided with more formal training to conduct provider activation campaign

*	Year 2 activities are contingent on year 1 results

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Evaluation Plan
        - Quantitative data on HIV testing rates from the Austin Information Technology Center (AITC)
        - Qualitative data from interviews with local site investigators, clinical champions and other key personnel

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Quantitative Analysis
        - Evaluation of the effect of the clinical reminder

Change in HIV testing at Local Activation vs Control sites
        - Evaluation of the effect of provider activation 

Change in HIV testing at Local vs National Activation sites
        - Identification of patient, provider, substation, and station-level factors associated with HIV testing 
        - Evaluation of HIV test offer rates

Control sites (stations) are in VISN 1

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Data Source: Austin Information Technology Center (AITC)
        - Includes all VA laboratory & demographic data
        - Does not include health factor data
        - Laboratory data are “cleaned” prior to inclusion in database

Algorithm searches for key words within local lab test names

Local lab names grouped together under a common identifier

Grouping done according to specified algorithm

No “look-up” table available for review
        - Scrambled SSN vs real SSN in VISN 22 data warehouse

Advantage:  increased data security

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Summary
        - Justification

HIV care is less effective and more costly when HIV is diagnosed late

HIV prevalence in VA exceeds the CDC threshold for testing

Testing for HIV is cost-effective

Not cost-free but is an excellent use of healthcare dollars
        - Outcome

A program that includes organizational change, clinical reminder, audit-feedback, and provider activation can increase HIV testing rates
        - Next Steps

Assess generalizability & contribution of “provider activation” component

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