BACKGROUND/RATIONALE:
The VA is the largest single provider of HIV care in the United States. The late 1990's have seen a revolution in the quality standards for this disease with the onset of Highly Active Antiretroviral Therapy (HAART) and other developments.

OBJECTIVE(S):
The objective in this project is to develop a method for assessing quality in two important areas of HIV care - antiretroviral medications and opportunistic infection screening and prophylaxis - and explore the determinants of high quality care in order to suggest quality improvement strategies.

METHODS:
The analysis has four parts. First, we described the level of adherence to the indicators in VA HIV patients nationwide and compared VA HIV patients to national benchmarks. Second, we analyzed facility and patient level predictors of adherence to indicators of quality care and compared them with the predictors in the non VA population using staged logistic regressions. Third, we validated certain indicators (e.g., HAART therapy) against clinical outcomes like hospitalization and immune status. We have also modeled the clinical "price" that the VA pays for suboptimal clinical outcomes as a result of current performance levels. Fourth, we compared the performance of the facilities after one year of an intensive targeted indicator-specific feedback group versus those who received aggregate data only.

FINDINGS/RESULTS:
CR+GBQI facilities improved the proportion of patients with optimal overall care while either modality alone did not (OR=2.65, 95%CI 1.16-6.00). The pattern of improvement of component quality indicators varied. CR+GBQI facilities improved relative to controls on three (hepatitis A, toxoplasmosis screening, immune monitoring) as did CR alone (hepatitis A, toxoplasmosis and lipid screening). GBQI alone improved two endpoints (PCP prophylaxis and immune monitoring) but declined on one (hepatitis B screening).

IMPACT:
Within the VA, the results of this analysis will enable us to make concrete suggestions to focus VA quality improvement efforts at the patient, facility, and delivery system level. Outside the VA, predictors of quality within a system where access is more uniformly distributed provoke great interest. We will disseminate the results both though internal VA educational channels and peer reviewed journals.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Anaya HD, Yano EM, Asch SM. Early adoption of human immunodeficiency virus quality improvement in Veterans Affairs medical centers: use of organizational surveys to measure readiness to change and adapt interventions to local priorities. American journal of medical quality : the official journal of the American College of Medical Quality. 2004 Jul 1; 19(4):137-44. [view]
2. Kanwal F, Gralnek IM, Hays RD, Dulai GS, Spiegel BM, Bozzette S, Asch S. Impact of chronic viral hepatitis on health-related quality of life in HIV: results from a nationally representative sample. The American journal of gastroenterology. 2005 Sep 1; 100(9):1984-94. [view]
3. Korthuis PT, Asch SM, Anaya HD, Morgenstern H, Goetz MB, Yano EM, Rubenstein LV, Lee ML, Bozzette SA. Lipid screening in HIV-infected veterans. Journal of acquired immune deficiency syndromes. 2004 Mar 1; 35(3):253-60. [view]
4. Korthuis PT, Anaya HD, Bozzette SA, Brinkerhoff CV, Mancewicz M, Wang M, Asch SM. Quality of HIV care within the Veterans Affairs Health System: A comparison using outcomes from the HIV Cost and Services Utilization Study (HCSUS). Journal of clinical outcomes management : JCOM. 2004 Dec 1; 11(12):765-774. [view]

Center Products

1. Asch SM. Improving HIV screening and testing rates in the VA. 2005 Sep 1. [view]

Conference Presentations

1. Anaya HD, Asch SM, Fremont AM, Bozzette SA. Assessment of HIV Quality Improvement Interventions within the Veterans Administration. Paper presented at: AcademyHealth Annual Research Meeting; 2003 Jun 1; Nashville, TN. [view]
2. Anaya H, Asch SM, Bowman C, Freemont A, Bozzette SA. Results of a National Comparative HIV Quality-Improvement Initiative Within the VA Healthcare System. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC. [view]
3. Anaya H, Asch SM, Bowman C, Freemont A, Bozzette SA. Results of a National Comparative HIV Quality-Improvement Initiative Within the VA Healthcare System. Paper presented at: VA HSR&D National Meeting; 2004 Mar 10; Washington, DC. [view]
4. Anaya HD, Asch SM, Fremont AM, Bozzette SA. Results of a National Comparative HIV Quality-Improvement Initiative Within the VA Healthcare System. Paper presented at: Scientific Basis of Health Services International Annual Conference; 2003 Sep 1; Washington, DC. [view]
5. Bowman C, Anaya H, Asch S, Patterson E, Fremont A, Joyce G. Using Formative Evaluation to Translate Quality Improvement in HIV Care. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC. [view]
6. Asch SM. Who is at greatest risk for receiving poor quality of care? Paper presented at: RWJ Foundation Disparities Annual Conference; 2005 Mar 1; Washington, DC. [view]

DRA: Health Systems
DRE: Treatment - Observational
Keywords: Cost, HIV/AIDS, Translation
MeSH Terms: none