Use of Clinical informatics in a Study to Improve HIV Testing

1. 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

2. 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

3. HIV testing in the VA Background

4. 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%

5. Testing for HIV is Cost Effective CDC recommends routine offer of HIV testing if prevalence of undiagnosed infection is > 0.1% 140,000 120,000 100,000 QALY without consideration of HIV transmission ($/QALY) 80,000 Incremental Cost Effectiveness 60,000 Testing in VA is cost effective even at very low HIV prevalence 40,000 20,000 QALY with consideration of HIV transmission $50,000/QALY 0 0 0.2 0.4 0.6 0.8 1 0.1 Prevalence (%) NEJM. 2005; 352:570. NEJM. 2005:352: 586

6. 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

7. Undiagnosed HIV Infection in VA Outpatients vs Age: 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

8. Benefits of Highly Active Antiretroviral Therapy (HAART) Intervention Survival gain Cancer chemotherapy 10 months Coronary artery by-pass 20 months HAART-HIV 180 months

9. 9 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

10. Promoting Better HIV Testing Interventions to Promote HIV Testing

11. 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

12. 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

13. Electronic prompt for identification and testing of patients at-risk for HIV infection 13

14. 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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16. Promoting Better HIV Testing The VISN 22 Project

17. 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

18. 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

19. 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

20. 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

21. 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

22. Results of VISN 22 Implementation

23. 80% HIV testing HIV evaluation without testing 70% 60% 50% Reminder Resolution (%) 40% 30% 20% 10% 0% -1 1 2 -1 1 2 -1 1 -1 1 2 -1 1 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

24. VISN22: Pre- vs Post-InterventionCumulative HIV Testing Rate Program implementation yields ~2-fold increase in cumulative HIV testing rates Intervention Year Control Site A Site B Site C Site D Site E

25. Age Income Ethnicity Marital status Homeless HCV Risk Fx HCV Infection HBV Infection Prior STD Illicit Drug Use 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.

26. Provider testing exp. Patient Load Prevalence ofat-risk pts. 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.

27. Sustainability of VISN 22 Implementation

28. 80% HIV testing HIV evaluation without testing 70% 60% 50% Reminder Resolution (%) 40% 30% 20% 10% 0% -1 1 2 -1 1 2 -1 1 -1 1 2 -1 1 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.

29. Adjusted HIV Testing Rates Time series shows attenuation of sustainability Goetz MB et al. Submitted for publication.

30. 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.

31. Adjusted HIV Test & Refusal Rates Overtime, fewer patients refuse offers of HIV testing Goetz MB et al. Submitted for publication.

32. Quarterly Costs of Expanded HIV TestingModel Based on Results in GLA and SD 8% 13% 8% 13% 8% 13% Baseline Quarter 1 Quarter 2 Quarter 3 Assumes 20,000 at risk patients, with 36% previously screened

33. 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

34. 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

35. Current Work Extension to VISNs 3 & 16

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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