MultiVISN Quality Improvement MultiVISN Quality Improvement Improving HIV Testing RatesImproving HIV Testing Rates

Herschel Knapp, Ph.D.Herschel Knapp, Ph.D.

BackgroundBackground

Many HIV infected patients do not know their statusMany HIV infected patients do not know their status

• CDC: 21% of the 1.1 million HIV+ persons in the US are unaware 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 tested50 - 70% of VA patients with risk factors have not been tested

50% of newly diagnosed patients have < 200 CD4 cells50% of newly diagnosed patients have < 200 CD4 cells

• High risk of AIDS-related complicationsHigh risk of AIDS-related complications

• Less likelihood of immune recoveryLess likelihood of immune recovery

• Patients often have multiple, missed opportunities for early Patients often have multiple, missed opportunities for early

testingtesting

Benefits of Knowing HIV StatusBenefits of Knowing HIV Status

Increases the benefits of anti-retroviral therapyIncreases the benefits of anti-retroviral therapy

• Increased immune recoveryIncreased immune recovery

• Increased length of lifeIncreased length of life

• Increased quality of lifeIncreased quality of life

Lower viral loads reduce risk of transmissionLower viral loads reduce risk of transmission

Knowledge of infection reduces risky behaviorKnowledge of infection reduces risky behavior

What is the MultiVISNWhat is the MultiVISNQuality Improvement Project?Quality Improvement Project?

ObjectiveObjective

• Improve healthcare of veteransImprove healthcare of veterans

GoalGoal

• Identify HIV positive veterans and refer for careIdentify HIV positive veterans and refer for care

MeansMeans

• Decision supportDecision support

• Policy support Policy support

• Staff engagementStaff engagement

• Multimedia resourcesMultimedia resources

Success to DateSuccess to Date

VISN 22VISN 22

Los Angeles, Loma Linda, San Diego,Los Angeles, Loma Linda, San Diego,

and Southern Nevada VA facilitiesand Southern Nevada VA facilities

More than 200% increase inMore than 200% increase in

HIV testing among at-risk patientsHIV testing among at-risk patients

0%

5%

10%

15%

20%

25%

-1 1 2 -1 1 2 -1 1 -1 1 2 -1 1

HIV

Tes

tin

g R

ate

Program implementation increases HIV testing rates two – threefold at all sitesProgram implementation increases HIV testing rates two – threefold at all sites

Intervention YearIntervention YearControlControl

Site ASite A Site BSite B Site CSite C Site DSite D Site ESite E

Yearly HIV Testing RateYearly HIV Testing Rate Pre- / Post-Intervention Pre- / Post-Intervention

QUERI-HIV ComponentsQUERI-HIV Components

Clinical ReminderClinical Reminder

HIV Clinical Reminder TriggersHIV Clinical Reminder Triggers

Hepatitis B / C infection or risk factorsHepatitis B / C infection or risk factors Substance abuseSubstance abuse Sexually transmitted diseaseSexually transmitted disease

Needn’t wait for HIV Clinical Reminder to offer a testNeedn’t wait for HIV Clinical Reminder to offer a test Not a performance measureNot a performance measure Site-wide (not provider) level of analysisSite-wide (not provider) level of analysis

Trigger for 10% - 15% of patientsTrigger for 10% - 15% of patients

Patient MediaPatient Media

Provider MediaProvider Media

Verbal ConsentVerbal Consent

As of 8/17/2009, written informed consent NO LONGER REQUIRED.As of 8/17/2009, written informed consent NO LONGER REQUIRED.

Verbal consent is sufficient.Verbal consent is sufficient. HIV clinical reminder automatically pastes an entry in the NOTES:HIV clinical reminder automatically pastes an entry in the NOTES:

The patient has verbally consented to HIV testing.The patient has verbally consented to HIV testing.

An HIV antibody test has been ordered.An HIV antibody test has been ordered.

Quarterly statistical Quarterly statistical feedbackfeedback• HIV testing rateHIV testing rate• Rate of clinical reminder Rate of clinical reminder

resolutionresolution

New materials & New materials & methods as neededmethods as needed

Ongoing SupportOngoing Support

Tips for Proposing HIV TestingTips for Proposing HIV Testing

Asymptomatic patients are unlikely to request a test; Asymptomatic patients are unlikely to request a test;

they’re waiting for us to offer the test.they’re waiting for us to offer the test.

Tips for Proposing HIV TestingTips for Proposing HIV Testing

Would you like a Would you like a freefree HIV test? HIV test?

As a veteran, you’re As a veteran, you’re entitledentitled to an HIV test. to an HIV test.

In addition to doing some tests to check for In addition to doing some tests to check for

cholesterol, diabetes, etc., we’re now offering cholesterol, diabetes, etc., we’re now offering

HIV testing. Would you like us to check for HIV HIV testing. Would you like us to check for HIV

infection?infection?