Multimodal Intervention Increases HIV Testing in VA Primary Care
The CDC recommends that providers routinely offer HIV testing to patients under the age of 65, but barriers exist (i.e., stigma, time constraints). Investigators with VA/HSR&D's HIV/Hepatitis Quality Enhancement Research Initiative (QUERI) previously developed, implemented, and evaluated a multimodal program to promote HIV testing, which more than doubled testing among at-risk Veterans. These results prompted the current study that scaled up this intervention in a large number of diverse VA facilities providing primary care to nearly 200,000 Veterans previously untested for HIV between 6/09 and 9/11. Investigators examined the effectiveness of promoting routine as well as risk-based HIV testing, and the effect of providing different levels of organizational support at study sites comprising three study arms: 1) Central (intervention with ongoing support from Project Management Team), 2) Local (no ongoing support after intervention implementation), and 3) Control (no intervention). Intervention components included: real-time electronic clinical reminder, quarterly audit-feedback system, removal of organizational barriers to testing, and a provider activation program (i.e., social marketing, patient/provider educational materials). Frequency of HIV testing in the six months prior to the intervention was then compared to the six months following the intervention.
- The use of clinical reminders, provider feedback, education, and social marketing in this HIV-testing intervention significantly increased the frequency at which HIV testing was offered and performed within the VA healthcare system. Implementation of this intervention increased the rate of risk-based HIV testing two- to three-fold, and increased routine testing three- to four-fold.
- The adjusted rate of risk-based testing increased by 0.4%, 6%, and 10% in the Control, Local, and Central arms, respectively. Similarly, the adjusted rate of routine testing of all patients, regardless of risk status, increased by 0.5%, 5%, and 9% in the Control, Local, and Central arms, respectively.
- At the end of the 6-month interventions, the proportion of all Veterans who were documented to have ever had an HIV test increased from 10% to 12% in the Control arm, from 13% to 25% in the Local arm, and from 10% to 28% in the Central arm.
- Authors note that the larger increases in both routine and risk-based testing among the Central arm vs. the Local arm suggest that centralization of resources is a more successful implementation strategy within VA's integrated system setting.
- Risk-based and routine HIV testing increased in all facility-, provider-, and patient-level groups.
- Investigators could not ascertain which component of the multimodal approach was most effective at increasing HIV testing rates.
- Modifications of this primary care-oriented intervention would be necessary to accommodate work flow patterns in other settings, i.e., substance abuse clinics and emergency departments.
AUTHOR/FUNDING INFORMATION: This study was funded through HIV/Hepatitis-QUERI (SDP 08-002). All authors are part of HIV/Hepatitis-QUERI.
Goetz M, Hoang T, Knapp H, Burgess J, Fletcher M, Gifford A, Asch S, and the HIV/Hepatitis-QUERI Center. Central Implementation Strategies Outperform Local Ones in Improving HIV Testing in Veterans Healthcare Administration Facilities. Journal of General Internal Medicine April 19, 2013;e-pub ahead of print.
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