Skip to main content

Advertisement

SpringerLink
Log in

A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2

Similar content being viewed by others

References

  1. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-infected adults and adolescents. Available at http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed February 9, 2008.

  2. 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.

    Article  PubMed  CAS  Google Scholar 

  3. 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.

    Article  PubMed  CAS  Google Scholar 

  4. Yeni PG, Hammer SM, Hirsch MS, et al. Treatment for adult HIV infection: 2004 recommendations of the International AIDS Society—USA Panel. JAMA. 2004;292:251–65.

    Article  PubMed  CAS  Google Scholar 

  5. Goetz MB, Morreale A, Berman S, et al. Effect of highly active anti-retroviral therapy (HAART) on outcomes in Veterans Affairs Medical Centers (VAMC). Clin Infect Dis. 1997;25:396.

    Google Scholar 

  6. Palella FJ, Delaney KM, Moorman AC, Loveless MO, Fuhrer J, Satten GA. Declining morbidity and mortality among patients with advance human immunodeficiency virus infection. N Engl J Med. 1998;338:853–60.

    Article  PubMed  Google Scholar 

  7. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med. 2000;342:921–9.

    Article  PubMed  CAS  Google Scholar 

  8. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446–53.

    Article  PubMed  Google Scholar 

  9. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20:1447–50.

    Article  PubMed  Google Scholar 

  10. Paltiel AD, Walensky RP, Schackman BR, et al. Expanded HIV screening in the United States: effect on clinical outcomes, HIV transmission, and costs. Ann Intern Med. 2006;145:797–806.

    PubMed  Google Scholar 

  11. Perlin JB. Need for routine Human Immunodeficiency Virus (HIV) risk assessment and testing. Under Secretary for Health’s Information Letter. IL 10-2005-017. Available at http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1302. Accessed February 9, 2008.

  12. Anonymous. Screening for HIV: recommendation statement. Ann Intern Med. 2005;143:32–7.

    Google Scholar 

  13. Anonymous. Periodic health examination, 1992 update: 3. HIV antibody screening. Canadian Task Force on the Periodic Health Examination. CMAJ. 1992;147:867–76.

    Google Scholar 

  14. American Academy of Family Physicians. HIV Infection. Available at http://www.aafp.org/online/en/home/clinical/clinicalrecs/hiv.html. Accessed April 4, 2008.

  15. Anonymous. ACOG committee opinion number 304, November 2004. Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Obstet Gynecol. 2004;104:1119–24.

    Google Scholar 

  16. Anonymous. Human immunodeficiency virus (HIV) infection. American College of Physicians and Infectious Diseases Society of America. Ann Intern Med. 1994;120:310–9.

    Google Scholar 

  17. Aberg JA, Gallant JE, Anderson J, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2004;39:609–29.

    Article  PubMed  Google Scholar 

  18. Anonymous. Adolescents and human immunodeficiency virus infection: the role of the pediatrician in prevention and intervention. Committee on Pediatric AIDS and Committee on Adolescence. Pediatrics. 2001;107:188–90.

    Article  Google Scholar 

  19. Owens DK, Sundaram V, Lazzeroni LC, et al. HIV testing of at risk patients in a large integrated health care system. J Gen Intern Med. 2007;22:315–20.

    Article  PubMed  Google Scholar 

  20. Chou R, Huffman LH, Fu R, Smits AK, Korthuis PT. Screening for HIV: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;143:55–73.

    PubMed  Google Scholar 

  21. Cases of HIV infection and AIDS in the United States, 2003. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2003report/pdf/2003SurveillanceReport.pdf. Accessed February 9, 2008.

  22. Gandhi NR, Skanderson M, Gordon K, Concato J, Justice AC. Delayed Presentation for HIV Care Among Veterans: An Opportunity for Intervention. Conf Retroviruses Opportunistic Infect. 2006;13:Abstract 924

  23. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348:2218–27.

    Article  PubMed  Google Scholar 

  24. Asch SM, McGlynn EA, Hogan MM, et al. Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med. 2004;141:938–45.

    PubMed  Google Scholar 

  25. Patterson ES, Doebbeling BN, Fung CH, Militello L, Anders S, Asch SM. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform. 2005;38:189–99.

    Article  PubMed  Google Scholar 

  26. Patterson ES, Nguyen AD, Halloran JP, Asch SM. Human factors barriers to the effective use of ten HIV clinical reminders. J Am Med Inform Assoc. 2004;11:50–9.

    Article  PubMed  Google Scholar 

  27. Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J. Opinion leaders vs. audit and feedback to implement practice guidelines: Delivery after previous cesarean section. JAMA. 1991;265:2202–7.

    Article  PubMed  CAS  Google Scholar 

  28. Thomson O’Brien MA, Oxman AD, Haynes RB, Davis DA, Freemantle N, Harvey EL. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2005;CD000125. DOI 10.1002/14651858.CD000125.

  29. Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2000;CD000409.

  30. Jamtvedt G, Young JM, Kristoffersen DT, Thomson O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2003;CD000259.

  31. Jamtvedt G, Young J, Kristoffersen D, O’brien M, Oxman A. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006;19;CD000259.

  32. Collins B, Hawks J, Davis R. From theory to practice: Identifying authentic opinion leaders to improve care. Managed Care. 2000;9:56–62.

    PubMed  CAS  Google Scholar 

  33. Solomon D, Van Houten L, Glynn R, et al. Academic detailing to improve use of broad spectrum antibiotics at an academic medical center. Arch Intern Med. 2001;161:1897–902.

    Article  PubMed  CAS  Google Scholar 

  34. Lefebvre RC, Rochlin L. Social marketing. In: Lewis FM, Rimer BK, eds. Health Behavior and Health Education: Theory, Research, and Practice. 2nd ed. Jossey-Bass; 1988.

  35. VA Policy on Confidential HIV Testing and Counseling. Available at http://www.hiv.va.gov/vahiv?page=prtop02-ov-02#S2X. Accessed February 9, 2008.

  36. Robson J, Boomla K, Fitzpatrick S, et al. Using nurses for preventive activities with computer assisted follow up: a randomised controlled trial. BMJ. 1989;298:433–6.

    Article  PubMed  CAS  Google Scholar 

  37. Pre-Test Counseling and Consent for HIV Testing. VHA-10-0121. Available at http://www.publichealth.va.gov/documents/vha-10-0121-fill.pdf. Accessed February 9, 2008.

  38. Anaya, HD, Golden J, Asch SM. Improving HIV Screening by Nurse Rapid Testing/Streamlined Counseling. Unpublished Work.

  39. Kendrick SR, Kroc KA, Withum D, Rydman RJ, Branson BM, Weinstein RA. Outcomes of offering rapid point-of-care HIV testing in a sexually transmitted disease clinic. J Acquir Immune Defic Syndr. 2005;38:142–6.

    Article  PubMed  Google Scholar 

  40. Spielberg F, Branson BM, Goldbaum GM, Kurth A, Wood RW. Designing an HIV counseling and testing program for bathhouses: the Seattle experience with strategies to improve acceptability. J Homosex. 2003;44:203–20.

    Article  PubMed  Google Scholar 

  41. Tsu RC, Burm ML, Gilhooly JA, Sells CW. Telephone vs. face-to-face notification of HIV results in high-risk youth. J Adolesc Health. 2002;30:154–60.

    Article  PubMed  Google Scholar 

  42. Perry SW, Jacobsberg LB, Fishman B, Weiler PH, Gold JW, Frances AJ. Psychological responses to serological testing for HIV. AIDS. 1990;4:145–52.

    Article  PubMed  CAS  Google Scholar 

  43. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136:641–51.

    PubMed  Google Scholar 

  44. Austin SM, Balas EA, Mitchell JA, Ewigman BG. Effect of physician reminders on preventive care: meta-analysis of randomized clinical trials. Proc Annu Symp Comput Appl Med Care. 1994;121–4:121–4.

  45. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. J Am Med Inform Assoc. 1996;3:399–409.

    PubMed  CAS  Google Scholar 

  46. Hulscher ME, Wensing M, van der Weijden T, Grol R. Interventions to implement prevention in primary care. Cochrane Database Syst Rev. 2001;CD000362.

  47. Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JThMv, Assendelft WJJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev. 2005;CD001481. DOI 10.1002/14651858.CD001481.

  48. Saleem JJ, Patterson ES, Militello L, Render ML, Orshansky G, Asch SM. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc. 2005;12:438–47.

    Article  PubMed  Google Scholar 

  49. Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330:765.

    Article  PubMed  Google Scholar 

  50. Berwick DM. Developing and testing changes in delivery of care. Ann Intern Med. 1998;128:651–66.

    PubMed  CAS  Google Scholar 

  51. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002;288:1909–14.

    Article  PubMed  Google Scholar 

  52. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775–9.

    Article  PubMed  Google Scholar 

  53. Centers for Disease Control and Prevention. Advancing HIV Prevention. Interim Technical Guidance for Selected Interventions. Available at http://www.cdc.gov/Hiv/topics/prev_prog/AHP/resources/guidelines/pdf/AHPIntGuidfinal.pdf. Accessed February 9, 2008.

  54. Stetler CB, Legro MW, Wallace CM, et al. The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med. 2006;21I(Suppl 2):S1–8.:S1–S8.

    Google Scholar 

  55. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55:1–17.

    PubMed  Google Scholar 

Download references

Acknowledgments

This project was supported by a research grant to Drs. Goetz and Asch by the Veterans Health Administration Health Services Research & Development Service (SDP 06–001).

Conflicts of Interest

Matthew Bidwell Goetz: consultancy with Monogram Biosciences, grant support from Gilead Pharmaceuticals, GlaxoSmithKline; Henry D. Anaya: stock ownership in Trinity Biotechnology, which develops biomarker devices, one of which is a test for the HIV virus, and educational support in the form of unrestricted grants from both Trinity Biotechnology and OraSure Technologies; Allen Gifford: royalties for authorship of Living Well With HIV And AIDS, Ball Publishing Company; Steven Asch: unrestricted travel grant from Trinity Pharmaceuticals. The other authors have no conflicts of interest.

Author information

Authors and Affiliations

  1. Infectious Diseases Section (111-F), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Matthew Bidwell Goetz MD & Barbara Rossman PhD

  2. David Geffen School of Medicine, UCLA, Los Angeles, CA, USA

    Matthew Bidwell Goetz MD & Steven M. Asch MD, MPH

  3. General Medicine (111G), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA

    Tuyen Hoang PhD, Herschel Knapp PhD, Henry Anaya PhD & Steven M. Asch MD, MPH

  4. VA San Diego Healthcare System, San Diego, CA, USA

    Candice Bowman PhD & Robert Smith MD

  5. VISN 22, Long Beach, CA, USA

    Teresa Osborn RN, MSN

  6. VA Bedford Center for Health Quality, Outcomes & Economic Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA

    Allen L. Gifford MD

  7. Boston University Schools of Public Health and Medicine, Boston, MA, USA

    Allen L. Gifford MD

Authors
  1. Matthew Bidwell Goetz MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tuyen Hoang PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Candice Bowman PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Herschel Knapp PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Barbara Rossman PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Robert Smith MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Henry Anaya PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Teresa Osborn RN, MSN
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Allen L. Gifford MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Steven M. Asch MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

The QUERI-HIV/Hepatitis Program

Corresponding author

Correspondence to Matthew Bidwell Goetz MD.

Appendix

Appendix

Triggers for the HIV testing Clinical Reminder

Hepatitis C Infection:

ICD-9 codes

070.41, 070.44, 070.51, 070.54, 070.6, 070.70, 070.71, 070.9, 571.40, 571.41, 571.49, 571.5, 571.8, 571.9, 573.3, 573.8, V02.62

Laboratory tests

Positive HCV antibody test or HCV viral load test

VHA-defined Hepatitis C Risk Factors:

Excessive alcohol use, injection drug use, lack of housing, multiple sexual partners, tattoos, body piercing, receipt of blood/blood products before 1992, unequivocal blood exposure (e.g., in combat), hemodialysis, or unexplained liver disease (including abnormal serum alanine aminotransferase levels). These data are collected through the VHA hepatitis C risk factors dataset.

Hepatitis B Infection:

ICD-9 codes

070.20, 070.21, 070.22, 070.23, 070.3, 070.30, 070.31, 070.32, 070.33, 070.52

Laboratory tests

Positive HBV core antibody test or positive surface antigen

Sexually-transmitted Disease: Includes Gonorrhea, Chlamydia, Syphilis, Herpes

ICD-9 codes

054.10, 054.11, 054.12, 054.13, 054.19, 098.xx, 099.40, 099.41, 099.50, 099.51, 099.52, 099.53, 099.54, 099.55, 099.56, 099.59, 099.8, 099.9, 090.0, 090.1, 090.2, 090.3, 090.40, 090.41, 090.42, 090.49, 099.56, 090.5, 090.6, 090.7, 090.9, 091.0, 091.1, 091.2, 091.3, 091.4, 091.50, 091.51, 091.52, 091.61, 091.61, 091.69, 091.7, 091.81, 091.82, 091.84, 091.89, 091.9, 092.0, 092.9, 093.0, 093.1, 093.20, 093.21, 093.22, 093.23, 093.24, 093.81, 093.82, 093.89, 093.9, 094.0, 094.1, 094.2, 094.3, 094.51, 094.52, 094.7, 094.81, 094.82, 094.83, 094.84, 094.85, 094.86, 094.87, 094.89, 094.9, 095.0, 095.1, 095.2, 095.3, 095.4, 095.5, 095.6, 095.7, 095.8, 095.9, 096.0, 097.0, 097.1, 097.9

Laboratory tests

None

Drug Abuse:

ICD-9 codes

304.00, 304.01, 304.02, 304.03, 304.20, 304.21, 304.22, 304.23, 304.40, 304.41, 304.42, 304.43, 304.60, 304.61, 304.62, 304.63, 304.70, 304.71, 304.72, 304.73, 304.90, 304.91, 304.92, 304.93, 305.50, 305.51, 305.52, 305.53, 305.60, 305.61, 305.62, 305.63, 305.70, 305.71, 305.72, 305.73, 305.90, 305.91, 305.92, 305.93

Laboratory tests

None

HIV Infection

ICD-9 codes

042., 042.1, 042.2, 042.9, 043.0, 043.1, 043.2, 043.3, 043.9, 044.9, 079.53, V08

Laboratory tests

Positive HIV antibody test or viral load

Homelessness

ICD-9 codes

V60.0

Laboratory tests

None

Rights and permissions

Reprints and permissions

About this article

Cite this article

Goetz, M.B., Hoang, T., Bowman, C. et al. A System-wide Intervention to Improve HIV Testing in the Veterans Health Administration. J GEN INTERN MED 23, 1200–1207 (2008). https://doi.org/10.1007/s11606-008-0637-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-008-0637-6

KEY WORDS

Search

Navigation