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Devlin SA, Johnson AK, Stanford KA, Haider S, Ridgway JP. "There hasn't been a push to identify patients in the emergency department"-Staff perspectives on automated identification of candidates for pre-exposure prophylaxis (PrEP): A qualitative study. PLoS One 2024; 19:e0300540. [PMID: 38483939 PMCID: PMC10939190 DOI: 10.1371/journal.pone.0300540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
Automated algorithms for identifying potential pre-exposure prophylaxis (PrEP) candidates are effective among men, yet often fail to detect cisgender women (hereafter referred to as "women") who would most benefit from PrEP. The emergency department (ED) is an opportune setting for implementing automated identification of PrEP candidates, but there are logistical and practical challenges at the individual, provider, and system level. In this study, we aimed to understand existing processes for identifying PrEP candidates and to explore determinants for incorporating automated identification of PrEP candidates within the ED, with specific considerations for ciswomen, through a focus group and individual interviews with ED staff. From May to July 2021, we conducted semi-structured qualitative interviews with 4 physicians and a focus group with 4 patient advocates working in a high-volume ED in Chicago. Transcripts were coded using Dedoose software and analyzed for common themes. In our exploratory study, we found three major themes: 1) Limited PrEP knowledge among ED staff, particularly regarding its use in women; 2) The ED does not have a standardized process for assessing HIV risk; and 3) Perspectives on and barriers/facilitators to utilizing an automated algorithm for identifying ideal PrEP candidates. Overall, ED staff had minimal understanding of the need for PrEP among women. However, participants recognized the utility of an electronic medical record (EMR)-based automated algorithm to identify PrEP candidates in the ED. Facilitators to an automated algorithm included organizational support/staff buy-in, patient trust, and dedicated support staff for follow-up/referral to PrEP care. Barriers reported by participants included time constraints, hesitancy among providers to prescribe PrEP due to follow-up concerns, and potential biases or oversight resulting from missing or inaccurate information within the EMR. Further research is needed to determine the feasibility and acceptability of an EMR-based predictive HIV risk algorithm within the ED setting.
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Affiliation(s)
- Samantha A. Devlin
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, Illinois, United States of America
| | - Amy K. Johnson
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, United States of America
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Kimberly A. Stanford
- Department of Medicine, Section of Emergency Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Sadia Haider
- Department of Medicine, Section of Obstetrics and Gynecology, Rush University, Chicago, Illinois, United States of America
| | - Jessica P. Ridgway
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, Illinois, United States of America
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Wang R, Fruhauf TF, Sao SS, Gingher EL, Martin SJ, Coleman JS. Clinic-based interventions to increase preexposure prophylaxis awareness and uptake among United States patients attending an obstetrics and gynecology clinic in Baltimore, Maryland. Am J Obstet Gynecol 2023; 229:423.e1-423.e8. [PMID: 37531988 DOI: 10.1016/j.ajog.2023.07.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Cisgender women account for 1 of every 5 new US HIV diagnoses, with most cases (85%) attributed to heterosexual contact. HIV preexposure prophylaxis is an effective prevention strategy; however, preexposure prophylaxis awareness and prescriptions among women are low. OBJECTIVE This study aimed to increase preexposure prophylaxis counseling and uptake among cisgender women attending obstetrics and gynecology clinics. STUDY DESIGN The study included 3 obstetrics and gynecology clinics within a single health system in a high HIV prevalence region. There were 3 phases: baseline (the 3-month period before the clinical trial that included provider education and training of a registered nurse about preexposure prophylaxis), clinical trial (the 3-month period during which eligible patients were randomized to an active control or preexposure prophylaxis registered nurse intervention), and maintenance (the 3-month period after the trial ended). Electronic medical record clinical decision support tools were available to both arms during the clinical trial, which included best practice alerts, order sets, progress note templates, and written and video preexposure prophylaxis educational materials for patients. In the intervention arm, a preexposure prophylaxis nurse contacted and counseled patients and was equipped to prescribe preexposure prophylaxis. Moreover, this study evaluated the phases through the "reach, effectiveness, adoption, implementation, and maintenance" framework. The primary outcome of the study was effectiveness (eg, percentage of eligible patients with documented HIV prevention counseling in the electronic medical record or preexposure prophylaxis prescriptions). The secondary outcomes included reach (eg, percentage of best practice alerts that providers acted on or the percentage of eligible patients who spoke with the preexposure prophylaxis registered nurse), adoption (eg, percentage of eligible patients with a best practice alert that triggered or the percentage of eligible patients the preexposure prophylaxis registered nurse attempted to contact), and maintenance (eg, percentage of patients with documented HIV prevention counseling or preexposure prophylaxis prescriptions during the maintenance phase). RESULTS There were 904 unique patients in all phases with a mean age of 28.8±7.7 years, and 416 patients (46%) were pregnant; moreover, 436 patients were randomized in the clinical trial phase. Concerning reach and adoption, best practice alerts were triggered for 100% of eligible encounters; however, the providers acted on 52% of them. The preexposure prophylaxis nurse attempted to contact every patient and successfully spoke with 81.2% of them in the preexposure prophylaxis registered nurse arm. Concerning effectiveness, there were significantly more patients counseled about preexposure prophylaxis in the preexposure prophylaxis registered nurse group than in the active control group (66.5% vs 12.3%, respectively; P<.001), although preexposure prophylaxis prescriptions were equivalent (P=1.0). Among the subgroup of patients who were counseled about preexposure prophylaxis, 18.5% of patients in the active control arm and 3.4% in the preexposure prophylaxis registered nurse arm were prescribed preexposure prophylaxis (P=.02). Concerning maintenance, clinical decision support tools alone resulted in preexposure prophylaxis counseling of 1.0% of patients during the maintenance phase vs 0.6% of patients during the baseline phase and 11.2% of patients during the clinical trial phase (P<.001). Preexposure prophylaxis prescriptions were not statistically different among the 3 phases (P=.096). CONCLUSION A preexposure prophylaxis nurse effectively increased HIV prevention discussions but did not lead to more preexposure prophylaxis prescriptions than the preexposure prophylaxis-focused clinical decision support tools used by providers. The decrease in preexposure prophylaxis counseling after the trial phase suggests that persistent interventions are needed to maintain effects.
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Affiliation(s)
- Runzhi Wang
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Timothee F Fruhauf
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Saumya S Sao
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Erin L Gingher
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephen J Martin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jenell S Coleman
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Kimball AA, Zhu W, Yu L, Tanner MR, Iqbal K, Dominguez KL, Shankar A, Drezner K, Musgrove K, Mayes E, Robinson WT, Schumacher C, Delaney KP, Hoover KW. Benefits of Frequent HIV Testing in the THRIVE Demonstration Project: United States, 2015-2020. Am J Public Health 2023; 113:1019-1027. [PMID: 37410983 PMCID: PMC10413751 DOI: 10.2105/ajph.2023.307341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 07/08/2023]
Abstract
Objectives. To describe HIV testing among clients in the Targeted Highly Effective Interventions to Reverse the HIV Epidemic (THRIVE) demonstration project and evaluate testing frequency. Methods. We identified factors associated with an average testing frequency of 180 days or less compared with more than 180 days using adjusted Poisson regression models. We performed the Kaplan-Meier survival analysis to compare time to diagnosis by testing frequency. Results. Among 5710 clients with 2 or more tests and no preexposure prophylaxis (PrEP) prescription, 42.4% were tested frequently. Black/African American clients were 21% less likely and Hispanic/Latino clients were 18% less likely to be tested frequently than were White clients. Among 71 Black/African American and Hispanic/Latino cisgender men who have sex with men and transgender women with HIV diagnoses, those with frequent testing had a median time to diagnosis of 137 days, with a diagnostic testing yield of 1.5% compared with those tested less frequently, with 559 days and 0.8% yield. Conclusions. HIV testing at least every 6 months resulted in earlier HIV diagnosis and was efficient. Persons in communities with high rates of HIV who are not on PrEP can benefit from frequent testing, and collaborative community approaches may help reduce disparities. (Am J Public Health. 2023;113(9):1019-1027. https://doi.org/10.2105/AJPH.2023.307341).
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Affiliation(s)
- Anne A Kimball
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Weiming Zhu
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Lei Yu
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Mary R Tanner
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kashif Iqbal
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kenneth L Dominguez
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aparna Shankar
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kate Drezner
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Karen Musgrove
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Eric Mayes
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - William T Robinson
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Christina Schumacher
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Kevin P Delaney
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
| | - Karen W Hoover
- Anne A. Kimball, Weiming Zhu, Mary R. Tanner, Kashif Iqbal, Kenneth L. Dominguez, Kevin P. Delaney, and Karen W. Hoover are with the Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Lei Yu is with the DLH Corporation, Atlanta. Aparna Shankar is with the New York City Department of Health and Mental Hygiene, New York, NY. Kate Drezner is with the District of Columbia Department of Health, Washington, DC. Karen Musgrove is with Birmingham AIDS Outreach, Birmingham, AL. Eric Mayes is with the Virginia Department of Health, Richmond. William T. Robinson is with the Louisiana Office of Public Health and Louisiana State University Health Sciences Center, New Orleans. Christina Schumacher is with the Center for Child and Community Health Research, Johns Hopkins School of Medicine, Baltimore, MD
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Spensley CB, Plegue M, Seda R, Harper DM. Annual HIV screening rates for HIV-negative men who have sex with men in primary care. PLoS One 2022; 17:e0266747. [PMID: 35834582 PMCID: PMC9282649 DOI: 10.1371/journal.pone.0266747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 03/27/2022] [Indexed: 11/27/2022] Open
Abstract
Background Men who have sex with men (MSM) account for most new HIV diagnoses in the US. Annual HIV testing is recommended for sexually active MSM if HIV status is negative or unknown. Our primary study aim was to determine annual HIV screening rates in primary care across multiple years for HIV-negative MSM to estimate compliance with guidelines. A secondary exploratory endpoint was to document rates for non-MSM in primary care. Methods We conducted a three-year retrospective cohort study, analyzing data from electronic medical records of HIV-negative men aged 18 to 45 years in primary care at a large academic health system using inferential and logistic regression modeling. Results Of 17,841 men, 730 (4.1%) indicated that they had a male partner during the study period. MSM were screened at higher rates annually than non-MSM (about 38% vs. 9%, p<0.001). Younger patients (p-value<0.001) and patients with an internal medicine primary care provider (p-value<0.001) were more likely to have an HIV test ordered in both groups. For all categories of race and self-reported illegal drug use, MSM patients had higher odds of HIV test orders than non-MSM patients. Race and drug use did not have a significant effect on HIV orders in the MSM group. Among non-MSM, Black patients had higher odds of being tested than both White and Asian patients regardless of drug use. Conclusions While MSM are screened for HIV at higher rates than non-MSM, overall screening rates remain lower than desired, particularly for older patients and patients with a family medicine or pediatric PCP. Targeted interventions to improve HIV screening rates for MSM in primary care are discussed.
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Affiliation(s)
- Courtney B. Spensley
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Melissa Plegue
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States of America
| | - Robinson Seda
- Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Diane M. Harper
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States of America
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America
- Department of Women’s and Gender Studies, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
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Abstract
OBJECTIVE To understand the impact of clinical decision support systems (CDSSs) on improving HIV testing and diagnosis. DESIGN An original global systematic review (PROSPERO Number: CRD42020175576) of peer-reviewed articles reporting on electronic CDSSs that generate triggers encouraging healthcare providers to perform an HIV test. METHODS Medline, Embase, Cochrane CENTRAL and CINAHL EBSCOhost were searched up to 17 November 2020 and reference lists of included articles were checked. Qualitative and quantitative syntheses (using meta-analyses) of identified studies were performed. RESULTS The search identified 1424 records. Twenty-two articles met inclusion criteria (19 of 22 non-HIV endemic settings); 18 clinical and four laboratory-driven reminders. Reminders promoted 'universal' HIV testing for all patients without a known HIV infection and no recent documented HIV test, or 'targeted' HIV testing in patients with clinical risk-factors or specific diagnostic tests. CDSSs increased HIV testing in hospital and nonhospital setting, with the pooled risk-ratio amongst studies reporting comparable outcome measures in hospital settings (n = 3) of 2.57 [95% confidence interval (CI) 1.53-4.33, random-effect model] and in nonhospital settings (n = 4) of 2.13 (95% CI 1.78-4.14, random effect model). Results of the clinical impact of CDSSs on HIV diagnosis were mixed. CONCLUSION CDSSs improve HIV testing and may, potentially, improve diagnosis. The data support the broader study of CDSSs in low- and high prevalent HIV settings to determine their precise impact on UNAIDS goals to reach universal HIV testing and treatment coverage.
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Nguyen VT, Jatta A, Mayer R, Meier JL. Evaluation of Undiagnosed HIV Estimates Computed from the CD4 Depletion Model in a Rural, Medium-low HIV Prevalence State. AIDS Behav 2022; 26:613-622. [PMID: 34355286 DOI: 10.1007/s10461-021-03419-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2021] [Indexed: 11/25/2022]
Abstract
The CD4 depletion model estimates diagnosis delays by approximating infection date from CD4 T-cell count at diagnosis, and back-calculation can compute the proportion of undiagnosed PLWHA. The model assumes the immigration of PLWHA to the U.S. is negligible and counts as a transmission event, which may be impractical outside high prevalence states. Duration of U.S. residency among foreign-born PLWHA and diagnosis delays were compared. The impact on estimates of undiagnosed PLWHA was tested through simulation with different proportions of foreign-born people assumed to have acquired HIV abroad. In 67% of foreign-born people, the mean (SD) years of delay (9.9 (6.3)) exceeded the duration of U.S. residency (2.0 (1.9)). Additionally, inaccuracies in the estimates for proportions of undiagnosed PLWHA were pronounced when foreign-born people who acquired HIV abroad comprised 30% of diagnoses. The CD4 model inadvertently misclassified some diagnoses as in-state transmission events. Consequently, simulated results demonstrated inaccuracies and unstable calculations.
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Affiliation(s)
- V T Nguyen
- College of Public Health, University of Iowa, Iowa City, IA, USA.
- VA Connecticut Health Care System, West Haven, CT, USA.
- Yale University, Epidemiology & Public Health, PO Box 208034, New Haven, CT, 06520-8034, USA.
| | - A Jatta
- Iowa Department of Public Health, Bureau of HIV, STD, and Hepatitis, Des Moines, IA, USA
| | - R Mayer
- Iowa Department of Public Health, Bureau of HIV, STD, and Hepatitis, Des Moines, IA, USA
| | - J L Meier
- College of Public Health, University of Iowa, Iowa City, IA, USA
- College of Medicine, University of Iowa, Iowa City, IA, USA
- Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
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7
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Willis VC, Thomas Craig KJ, Jabbarpour Y, Scheufele EL, Arriaga YE, Ajinkya M, Rhee KB, Bazemore A. Digital Health Interventions to Enhance Prevention in Primary Care: Scoping Review. JMIR Med Inform 2022; 10:e33518. [PMID: 35060909 PMCID: PMC8817213 DOI: 10.2196/33518] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/19/2021] [Accepted: 12/04/2021] [Indexed: 12/20/2022] Open
Abstract
Background Disease prevention is a central aspect of primary care practice and is comprised of primary (eg, vaccinations), secondary (eg, screenings), tertiary (eg, chronic condition monitoring), and quaternary (eg, prevention of overmedicalization) levels. Despite rapid digital transformation of primary care practices, digital health interventions (DHIs) in preventive care have yet to be systematically evaluated. Objective This review aimed to identify and describe the scope and use of current DHIs for preventive care in primary care settings. Methods A scoping review to identify literature published from 2014 to 2020 was conducted across multiple databases using keywords and Medical Subject Headings terms covering primary care professionals, prevention and care management, and digital health. A subgroup analysis identified relevant studies conducted in US primary care settings, excluding DHIs that use the electronic health record (EHR) as a retrospective data capture tool. Technology descriptions, outcomes (eg, health care performance and implementation science), and study quality as per Oxford levels of evidence were abstracted. Results The search yielded 5274 citations, of which 1060 full-text articles were identified. Following a subgroup analysis, 241 articles met the inclusion criteria. Studies primarily examined DHIs among health information technologies, including EHRs (166/241, 68.9%), clinical decision support (88/241, 36.5%), telehealth (88/241, 36.5%), and multiple technologies (154/241, 63.9%). DHIs were predominantly used for tertiary prevention (131/241, 54.4%). Of the core primary care functions, comprehensiveness was addressed most frequently (213/241, 88.4%). DHI users were providers (205/241, 85.1%), patients (111/241, 46.1%), or multiple types (89/241, 36.9%). Reported outcomes were primarily clinical (179/241, 70.1%), and statistically significant improvements were common (192/241, 79.7%). Results were summarized across the following 5 topics for the most novel/distinct DHIs: population-centered, patient-centered, care access expansion, panel-centered (dashboarding), and application-driven DHIs. The quality of the included studies was moderate to low. Conclusions Preventive DHIs in primary care settings demonstrated meaningful improvements in both clinical and nonclinical outcomes, and across user types; however, adoption and implementation in the US were limited primarily to EHR platforms, and users were mainly clinicians receiving alerts regarding care management for their patients. Evaluations of negative results, effects on health disparities, and many other gaps remain to be explored.
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Affiliation(s)
- Van C Willis
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Kelly Jean Thomas Craig
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Yalda Jabbarpour
- Policy Studies in Family Medicine and Primary Care, The Robert Graham Center, American Academy of Family Physicians, Washington, DC, United States
| | - Elisabeth L Scheufele
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Yull E Arriaga
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Monica Ajinkya
- Policy Studies in Family Medicine and Primary Care, The Robert Graham Center, American Academy of Family Physicians, Washington, DC, United States
| | - Kyu B Rhee
- Center for Artificial Intelligence, Research, and Evaluation, IBM Watson Health, Cambridge, MA, United States
| | - Andrew Bazemore
- The American Board of Family Medicine, Lexington, KY, United States
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Chan CT, Vo M, Carlson J, Lee T, Chang M, Hart-Cooper G. Pediatric Provider Utilization of a Clinical Decision Support Alert and Association with HIV Pre-exposure Prophylaxis Prescription Rates. Appl Clin Inform 2022; 13:30-36. [PMID: 35021253 PMCID: PMC8754687 DOI: 10.1055/s-0041-1740484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES An electronic clinical decision support (CDS) alert can provide real-time provider support to offer pre-exposure prophylaxis (PrEP) to youth at risk for human immunodeficiency virus (HIV). The purpose of this study was to evaluate provider utilization of a PrEP CDS alert in a large academic-community pediatric network and assess the association of the alert with PrEP prescribing rates. METHODS HIV test orders were altered for patients 13 years and older to include a hard-stop prompt asking if the patient would benefit from PrEP. If providers answered "Yes" or "Not Sure," the CDS alert launched with options to open a standardized order set, refer to an internal PrEP specialist, and/or receive an education module. We analyzed provider utilization using a frequency analysis. The rate of new PrEP prescriptions for 1 year after CDS alert implementation was compared with the year prior using Fisher's exact test. RESULTS Of the 56 providers exposed to the CDS alert, 70% (n = 39) responded "Not sure" to the alert prompt asking if their patient would benefit from PrEP, and 54% (n = 30) chose at least one clinical support tool. The PrEP prescribing rate increased from 2.3 prescriptions per 10,000 patients to 6.6 prescriptions per 10,000 patients in the year post-intervention (p = 0.02). CONCLUSION Our findings suggest a knowledge gap among pediatric providers in identifying patients who would benefit from PrEP. A hard-stop prompt within an HIV test order that offers CDS and provider education might be an effective tool to increase PrEP prescribing among pediatric providers.
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Affiliation(s)
- Carrie T. Chan
- Center for Adolescent Health, Lucile Packard Children's Hospital, Palo Alto, California, United States,Department of Family Health Care Nursing, University of California San Francisco, San Francisco, California, United States,Address for correspondence Carrie Chan, MSN, MPH, CPNP Stanford Children's Health750 Welch Road Suite 212, Palo Alto, CA 94304United States
| | - Megen Vo
- Department of Pediatrics—Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California, United States
| | - Jennifer Carlson
- Department of Pediatrics—Adolescent Medicine, Stanford University School of Medicine, Palo Alto, California, United States
| | - Tzielan Lee
- Department of Pediatrics — Rheumatology, Stanford University School of Medicine, Palo Alto, California, United States
| | - Marcello Chang
- Stanford University School of Medicine, Stanford, California, United States
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9
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Universal HIV Screening in Ambulatory Care Settings. J Nurse Pract 2022. [DOI: 10.1016/j.nurpra.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Rowlinson E, Mawandia S, Ledikwe J, Bakae O, Tau L, Grande M, Seckel L, Mogomotsi GP, Mmatli E, Ngombo M, Norman T, Golden MR. HIV testing criteria to reduce testing volume and increase positivity in Botswana. AIDS 2021; 35:2007-2015. [PMID: 34138770 PMCID: PMC8416793 DOI: 10.1097/qad.0000000000002997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We used data from a routine HIV testing program to develop risk scores to identify patients with undiagnosed HIV infection while reducing the number of total tests performed. DESIGN Multivariate logistic regression. METHODS We included demographic factors from HIV testing data collected in 134 Botswana Ministry of Health & Wellness facilities during two periods (1 October 2018- 19 August 2019 and 1 December 2019 to 30 March 2020). In period 2, the program collected additional demographic and risk factors. We randomly split each period into prediction/validation datasets and used multivariate logistic regression to identify factors associated with positivity; factors with adjusted odds ratios at least 1.5 were included in the risk score with weights equal to their coefficient. We applied a range of risk score cutoffs to validation datasets to determine tests averted, test positivity, positives missed, and costs averted. RESULTS In period 1, three factors were significantly associated with HIV positivity (coefficients range 0.44-0.87). In period 2, 12 such factors were identified (coefficients range 0.44-1.37). In period 1, application of risk score cutoff at least 1.0 would result in 50% fewer tests performed and capture 61% of positives. In period 2, a cutoff at least 1.0 would result in 13% fewer tests and capture 96% of positives; a cutoff at least 2.0 would result in 40% fewer tests and capture 83% of positives. Costs averted ranged from 12.1 to 52.3%. CONCLUSION Botswana's testing program could decrease testing volume but may delay diagnosis of some positive patients. Whether this trade-off is worthwhile depends on operational considerations, impact of testing volume on program costs, and implications of delayed diagnoses.
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Affiliation(s)
| | - Shreshth Mawandia
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH)
| | - Jenny Ledikwe
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health (I-TECH)
| | - Odirile Bakae
- International Training and Education Center for Health (I-TECH)
| | - Lenna Tau
- International Training and Education Center for Health (I-TECH)
| | - Matias Grande
- International Training and Education Center for Health (I-TECH)
| | - Laura Seckel
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Esther Mmatli
- Botswana Ministry of Health and Wellness, HIV Testing Services Unit, Gaborone, Botswana
| | - Modise Ngombo
- Botswana Ministry of Health and Wellness, HIV Testing Services Unit, Gaborone, Botswana
| | - Tebogo Norman
- Botswana Ministry of Health and Wellness, HIV Testing Services Unit, Gaborone, Botswana
| | - Matthew R Golden
- Center for AIDS and STD and Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
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11
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Bogers SJ, Schim van der Loeff MF, van Dijk N, Groen K, Groot Bruinderink ML, de Bree GJ, Reiss P, Geerlings SE, van Bergen JEAM. Rationale, design and initial results of an educational intervention to improve provider-initiated HIV testing in primary care. Fam Pract 2021; 38:441-447. [PMID: 33367646 PMCID: PMC8317217 DOI: 10.1093/fampra/cmaa139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVES In the Netherlands, general practitioners (GPs) perform two-thirds of sexually transmitted infection (STI) consultations and diagnose one-third of HIV infections. GPs are, therefore, a key group to target to improve provider-initiated HIV testing. We describe the design and implementation of an educational intervention to improve HIV testing by Amsterdam GPs and explore trends in GPs' testing behaviour. METHODS Interactive sessions on HIV and STI using graphical audit and feedback started in 2015. Participating GPs developed improvement plans that were evaluated in follow-up sessions. Laboratory data on STI testing by Amsterdam GPs from 2011 to 2017 were collected for graphical audit and feedback and effect evaluation. The primary outcome was the HIV testing rate: number of HIV tests per 10 000 person-years (PY). Secondary endpoints were chlamydia and gonorrhoea testing rates and HIV positivity ratios. RESULTS Since 2015, 41% of GPs participated. HIV testing rate declined from 2011 to 2014 (from 175 to 116 per 10 000 PY), more in women than men (176 to 101 versus 173 to 132), and stabilized from 2015 to 2017. The HIV positivity ratio declined from 0.8% in 2011 to 0.5% in 2017. From 2011 to 2017, chlamydia and gonorrhoea testing rates declined in women (from 618 to 477 per 10 000 PY) but remained stable in men (from 270 to 278). CONCLUSIONS The stabilization of the downward trend in HIV testing coincided with this educational intervention. Follow-up data are needed to formally assess the intervention's impact on GP testing behaviour whilst considering contextual factors and secular trends.
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Affiliation(s)
- Saskia J Bogers
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten F Schim van der Loeff
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands
| | - Nynke van Dijk
- Department of General Practice, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karlijn Groen
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Marije L Groot Bruinderink
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Godelieve J de Bree
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Peter Reiss
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands.,Department of Global Health, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,HIV Monitoring Foundation, Amsterdam, the Netherlands
| | - Suzanne E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan E A M van Bergen
- Department of General Practice, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,STI AIDS Netherlands, Amsterdam, the Netherlands
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12
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Machine Learning and Clinical Informatics for Improving HIV Care Continuum Outcomes. Curr HIV/AIDS Rep 2021; 18:229-236. [PMID: 33661445 DOI: 10.1007/s11904-021-00552-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE OF REVIEW This manuscript reviews the use of electronic medical record (EMR) data for HIV care and research along the HIV care continuum with a specific focus on machine learning methods and clinical informatics interventions. RECENT FINDINGS EMR-based clinical decision support tools and electronic alerts have been effectively utilized to improve HIV care continuum outcomes. Accurate EMR-based machine learning models have been developed to predict HIV diagnosis, retention in care, and viral suppression. Natural language processing (NLP) of clinical notes and data sharing between healthcare systems and public health agencies can enhance models for identifying people living with HIV who are undiagnosed or in need of relinkage to care. Challenges related to using these technologies include inconsistent EMR documentation, alert fatigue, and the potential for bias. Clinical informatics and machine learning models are promising tools for improving HIV care continuum outcomes. Future research should focus on methods for combining EMR data with additional data sources (e.g., social media, geospatial data) and studying how to effectively implement predictive models for HIV care into clinical practice.
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13
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Jackman KMP, Murray S, Hightow-Weidman L, Trent ME, Wirtz AL, Baral SD, Jennings JM. Digital technology to address HIV and other sexually transmitted infection disparities: Intentions to disclose online personal health records to sex partners among students at a historically Black college. PLoS One 2020; 15:e0237648. [PMID: 32822360 PMCID: PMC7442257 DOI: 10.1371/journal.pone.0237648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 07/30/2020] [Indexed: 12/26/2022] Open
Abstract
Patient portals are creating new opportunities for youth to disclose high-fidelity sexually transmitted infection (STI) laboratory test result histories to sex partners. Among an online survey sample, we describe latent constructs and other variables associated with perceived behavioral intentions to disclose STI test history using patient portals. Participants were co-ed students aged 18 to 25 years (N = 354) attending a southern United States Historically Black College and University in 2015. Three reliable latent constructs were identified by conducting psychometric analyses on 27 survey items. Latent constructs represent, a) STI test disclosure valuation beliefs, b) communication practices, and c) performance expectancy beliefs for disclosing with patient portals. Multivariable logistic regression was used to estimate the relationship of latent constructs to perceived behavioral intentions to disclose STI test history using patient portals. Approximately 14% (48/354) reported patient portal use prior to study and 59% (208/354) endorsed behavioral intentions to use patient portals to disclose STI test history. The latent construct reflecting performance expectancies of patient portals to improve communication and accuracy of disclosed test information was associated with behavioral intentions to disclose STI test histories using patient portals [adjusted odds ratio (AOR) = 1.15; 95% CI = 1.08 to 1.22; p<0.001]. Latent constructs representing communication valuation beliefs and practices were not associated with intentions. Self-reporting prior STI diagnosis was also associated with intentions to disclose using patient portals (AOR = 2.84; 95% CI = 1.15 to 6.96; p = 0.02). Point of care messages focused on improvements to validating test results, communication, and empowerment, may be an effective strategy to support the adoption of patient portals for STI prevention among populations of college-aged Black youth.
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Affiliation(s)
- Kevon-Mark P. Jackman
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail: ,
| | - Sarah Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lisa Hightow-Weidman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Maria E. Trent
- Department of Pediatrics, Adolescent Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Andrea L. Wirtz
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Stefan D. Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jacky M. Jennings
- Department of Pediatrics, Center for Child and Community Health Research (CCHR), Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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14
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Tapp H, Ludden T, Shade L, Thomas J, Mohanan S, Leonard M. Electronic medical record alert activation increase hepatitis C and HIV screening rates in primary care practices within a large healthcare system. Prev Med Rep 2020; 17:101036. [PMID: 31970042 PMCID: PMC6965743 DOI: 10.1016/j.pmedr.2019.101036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 12/03/2019] [Accepted: 12/27/2019] [Indexed: 01/10/2023] Open
Abstract
The electronic medical record alert improved screening for HCV and HIV. 91% of HCV and 100% of HIV positive patients were linked into care. Low post-intervention screening rates suggest additional interventions are required.
Societal and economic burdens of hepatitis C virus (HCV) and human immunodeficiency virus (HIV) continue to grow. The Centers for Disease Control and Prevention recommends a one-time HCV screen for individuals in the Baby Boomer population (those born between 1945 and 1965) and a one-time HIV screen for all individuals between ages 13–64 years regardless of risk factors, with more frequent screening for both conditions based on individual risk factors. This study took place at Atrium Health, a healthcare system with approximately 12 million patient encounters per year. The aims of this study were to assess the impact of the HCV and HIV electronic medical record (EMR) alerts recently implemented on screening rates and linkage to care. Data were collected from 12 primary care practices. Implementation of EMR alerts increased HCV and HIV screening from 1,934 of 59,632 (3.2%) to 13,726 of 60,422 (22.7%) and 6,950 of 112,813 (6.2%) to 12,379 of 109,173 (11.3%) respectively. The HCV screening resulted in an increase of patients with antibody positive results having a subsequent RNA test from 68% (122/179) to 98% (430/442). 74 of 81 (91%) of HCV and 15 of 15 (100%) of HIV positive patients were linked into care. The addition of an EMR alert was associated with improved screening for HCV and HIV in primary care practices. Screening all patients decreases testing stigma since there is a lowered risk of disease transmission for those who test positive. However, post-intervention screening rates indicate further opportunities exist for additional interventions to increase screening rates.
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Affiliation(s)
- Hazel Tapp
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Thomas Ludden
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Lindsay Shade
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Jeremy Thomas
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Sveta Mohanan
- Department of Family Medicine, Atrium Health, 2001 Vail Avenue, Suite 400B, Charlotte, NC 28207, United States
| | - Michael Leonard
- Department of Infectious Diseases, Atrium Health, 4539 Hedgemore Drive, Suite 100, Charlotte, NC 28209, United States
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15
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Christensen K, Berkley-Patton J, Shah B, Aduloju-Ajijola N, Bauer A, Bowe Thompson C, Lister S. HIV Risk and Sociodemographic Factors Associated with Physician-Advised HIV Testing: What Factors Are Overlooked in African American Populations? J Racial Ethn Health Disparities 2019; 7:121-128. [PMID: 31654339 DOI: 10.1007/s40615-019-00641-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/12/2019] [Accepted: 09/20/2019] [Indexed: 11/24/2022]
Abstract
HIV is diagnosed at eight times the rate in African Americans (AAs) compared to whites. One-third of AAs have never been tested for HIV. Studies indicate low rates of HIV testing in healthcare settings, so understanding missed opportunities for HIV testing can inform prevention efforts in these settings. Our study examined predictors of self-reported physician-advised HIV testing using baseline survey data (N = 1500) from Taking It to the Pews (TIPS), a church-basedHIV/STD testing and education intervention. One-third (33%) of participants reported that their physician ever suggested an HIV test. Results indicated that participants who identified as homosexual/bisexual, received Medicaid or were uninsured, and/or had previously diagnosed STDs were more likely to report physician-advised HIV testing. AA churches provide a unique opportunity to increase the reach of HIV testing and may be well-positioned to equip their church and community members with information on HIV risk and strategies to advocate for physician-advised routine HIV testing in medical settings.
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Affiliation(s)
- Kelsey Christensen
- Department of Psychology, University of Missouri-Kansas City, Kansas City, MO, USA. .,Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.
| | - Jannette Berkley-Patton
- Department of Psychology, University of Missouri-Kansas City, Kansas City, MO, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Binoy Shah
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Natasha Aduloju-Ajijola
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Alexandria Bauer
- Department of Psychology, University of Missouri-Kansas City, Kansas City, MO, USA.,Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Carole Bowe Thompson
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Sheila Lister
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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16
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Gebrezgi MT, Mauck DE, Sheehan DM, Fennie KP, Cyrus E, Degarege A, Trepka MJ. Acceptance of Opt-Out HIV Screening in Outpatient Settings in the United States: A Systematic Review and Meta-Analysis. Public Health Rep 2019; 134:484-492. [PMID: 31365316 DOI: 10.1177/0033354919860510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES In the United States, about 15% of persons living with HIV infection do not know they are infected. Opt-out HIV screening aims to normalize HIV testing by performing an HIV test during routine medical care unless the patient declines. The primary objective of this systematic review and meta-analysis was to assess the acceptance of opt-out HIV screening in outpatient settings in the United States. METHODS We searched in PubMed and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for studies published from January 1, 2006, through December 31, 2018, of opt-out HIV screening in outpatient settings. We collected data from selected studies and calculated for each study (1) the percentage of persons who were offered HIV testing, (2) the percentage of persons who accepted the test, and (3) the percentage of new HIV diagnoses among persons tested. We also collected information on the reasons given by patients for opting out. The meta-analysis used a random-effects model to estimate the average percentages of HIV testing offered, HIV testing accepted, and new HIV diagnoses. RESULTS We initially identified 6986 studies; the final analysis comprised 14 studies. Among the 8 studies that reported the size of the study population eligible for HIV screening, 71.4% (95% confidence interval [CI], 53.9%-89.0%) of the population was offered an HIV test on an opt-out basis. The test was accepted by 58.7% (95% CI, 47.2%-70.2%) of persons offered the test. Among 9 studies that reported data on new HIV diagnoses, 0.18% (95% CI, 0.08%-0.26%) of the persons tested had a new HIV diagnosis. Patients' most frequently cited reasons for refusal of HIV screening were that they perceived a low risk of having HIV or had previously been tested. CONCLUSIONS The rates of offering and accepting an HIV test on an opt-out basis could be improved by addressing health system and patient-related factors. Setting a working target for these rates would be useful for measuring the success of opt-out HIV screening programs.
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Affiliation(s)
- Merhawi T Gebrezgi
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Daniel E Mauck
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Diana M Sheehan
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA.,2 Center for Research on US Latino HIV/AIDS and Drug Abuse (CRUSADA), Florida International University, Miami, FL, USA.,3 Research Centers in Minority Institutions (RCMI), Florida International University, Miami, FL, USA
| | - Kristopher P Fennie
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Elena Cyrus
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Abraham Degarege
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA
| | - Mary Jo Trepka
- 1 Department of Epidemiology, Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA.,3 Research Centers in Minority Institutions (RCMI), Florida International University, Miami, FL, USA
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17
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Kesten JM, Davies CF, Gompels M, Crofts M, Billing A, May MT, Horwood J. Qualitative evaluation of a pilot educational intervention to increase primary care HIV-testing. BMC FAMILY PRACTICE 2019; 20:74. [PMID: 31151414 PMCID: PMC6544931 DOI: 10.1186/s12875-019-0962-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 05/15/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND UK guidelines recommend a 'routine offer of HIV testing' in primary care where HIV diagnosed prevalence exceeds 2 in 1000. However, current primary care HIV testing rates are low. Efforts to increase primary care HIV testing are needed. To examine how an educational intervention to increase HIV testing in general practice was experienced by healthcare professionals (HCPs) and to understand the perceived impacts on HIV testing. METHOD Qualitative interviews with general practitioners (GPs) and nurses 3-months after receiving an educational intervention developed from an adapted version of the Medical Foundation for HIV and Sexual Health (MEDFASH) HIV Testing In Practice (TIPs) online educational tool which included training on HIV associated clinical indicator conditions, why, who, and how to test. The intervention was delivered in 19 high-HIV prevalence general practices in Bristol. 27 semi-structured interviews were conducted across 13 practices with 16 GPs, 10 nurses and the sexual health clinician who delivered the intervention. Transcripts were analysed thematically informed by Normalisation Process Theory. RESULTS HCPs welcomed the opportunity to update their HIV knowledge through a tailored, interactive session. Post-training, HCPs reported increased awareness of HIV indicator conditions, confidence to offer HIV tests and consideration of HIV tests. Continued testing barriers include perceived lack of opportunity. CONCLUSIONS This qualitative study found that HIV education is perceived as valuable in relation to perceived awareness, confidence, and consideration of HIV testing. However, repetition and support from other strategies are needed to encourage HCPs to offer HIV tests. Future interventions should consider using behaviour change theory to develop a complex intervention that addresses not only HCP capability to offer an HIV test, but also issues of opportunity and motivation.
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Affiliation(s)
- Joanna M. Kesten
- National Institute for Health Research (NIHR) Health Protection Research Unit in Evaluation of Interventions, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
- NIHR Collaborations for Leadership in Applied Health Research and Care West (CLAHRC West), University Hospitals Bristol, NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Charlotte F. Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Mark Gompels
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, BS10 5NB UK
| | - Megan Crofts
- Genitourinary medicine, Unity Sexual Health, Bristol Sexual Health Services, Tower Hill, Bristol, BS2 0JD UK
| | - Annette Billing
- Bristol, North Somerset and South Gloucestershire CCG, South Plaza, Marlborough Street, Bristol, BS1 3NX UK
| | - Margaret T. May
- National Institute for Health Research (NIHR) Health Protection Research Unit in Evaluation of Interventions, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Jeremy Horwood
- NIHR Collaborations for Leadership in Applied Health Research and Care West (CLAHRC West), University Hospitals Bristol, NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
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18
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Cayuelas Redondo L, Ruíz M, Kostov B, Sequeira E, Noguera P, Herrero MA, Menacho I, Barba O, Clusa T, Rifa B, González de la Fuente EM, González Redondo E, García F, Sisó Almirall A, León A. Indicator condition-guided HIV testing with an electronic prompt in primary healthcare: a before and after evaluation of an intervention. Sex Transm Infect 2019; 95:238-243. [PMID: 30679391 DOI: 10.1136/sextrans-2018-053792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Indicator condition (IC)-guided HIV testing is a strategy for the diagnosis of patients with HIV. The aim of this study was to assess the impact on the proportion of HIV tests requested after the introduction of an electronic prompt instructing primary healthcare (PHC) physicians to request an HIV test when diagnosing predefined IC. METHODS A prospective interventional study was conducted in 2015 in three PHC centres in Barcelona to assess the number of HIV test requests made during the implementation of an electronic prompt. Patients aged 18-65 years without HIV infection and with a new diagnosis of predefined IC were included. The results were compared with preprompt (2013) and postprompt data (2016). RESULTS During the prompt period, 832 patients presented an IC (median age 41.6 years [IQR 30-54], 48.2% female). HIV tests were requested in 296 individuals (35, 6%) and blood tests made in 238. Four HIV infections were diagnosed (positivity rate 1.7%, 95% CI 0.5% to 4.4%). The number of HIV tests requested based on IC increased from 12.6% in 2013 to 35.6% in 2015 (p<0.001) and fell to 17.9% after removal of the prompt in 2016 (p<0.001). Younger patient age (OR 0.97, 95% CI 0.96 to 0.98), birth outside Spain (OR 1.53, 95% CI 1.06 to 2.21) and younger physician age (OR 0.97, 95% CI 0.96 to 0.99) were independent predictive factors for an HIV test request during the prompt period. The electronic prompt (OR 3.36, 95% CI 2.70 to 4.18) was the factor most closely associated with HIV test requests. It was estimated that 10 (95% CI 3.0 to 26.2) additional new cases would have been diagnosed if an HIV test had been performed in all patients presenting an IC. CONCLUSIONS A significant increase in HIV test requests was observed during the implementation of the electronic prompt. The results suggest that this strategy could be useful in increasing IC-guided HIV testing in PHC centres.
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Affiliation(s)
- Laia Cayuelas Redondo
- Centro de Atención Primaria Casanova, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Marina Ruíz
- Centro de Atención Primaria Casanova, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Belchin Kostov
- Primary Healthcare Transversal Research Group, IDIBAPS, Barcelona, Spain
| | - Ethel Sequeira
- Centro de Atención Primaria Casanova, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Pablo Noguera
- Centro de Atención Primaria Casanova, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Maria Alba Herrero
- Centro de Atención Primaria Casanova, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Ignacio Menacho
- Centro de Atención Primaria Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Olga Barba
- Centro de Atención Primaria Comte Borrell, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Thaïs Clusa
- Centro de Atención Primaria Raval Sud, Institut Català de la Salut, Barcelona, Spain
| | - Benet Rifa
- Public Health Agency of Catalonia, Generalitat of Catalonia, Barcelona, Spain
| | | | - Eva González Redondo
- Hospital Clínico y Provincial de Barcelona, Unidad de Enfermedades Infecciosas, Barcelona, Spain
| | - Felipe García
- Hospital Clínico y Provincial de Barcelona, Unidad de Enfermedades Infecciosas, Barcelona, Spain
| | - Antoni Sisó Almirall
- Primary Healthcare Transversal Research Group, IDIBAPS, Barcelona, Spain.,Centro de Atención Primaria Les Corts, Consorci d'Atenció Primària de Salut Barcelona Esquerra (CAPSBE), Barcelona, Spain
| | - Agathe León
- Hospital Clínico y Provincial de Barcelona, Unidad de Enfermedades Infecciosas, Barcelona, Spain
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Davies CF, Kesten JM, Gompels M, Horwood J, Crofts M, Billing A, Chick C, May MT. Evaluation of an educational intervention to increase HIV-testing in high HIV prevalence general practices: a pilot feasibility stepped-wedged randomised controlled trial. BMC FAMILY PRACTICE 2018; 19:195. [PMID: 30545301 PMCID: PMC6292019 DOI: 10.1186/s12875-018-0880-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/22/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND HIV-infected patients often present to primary care several times with HIV-indicator conditions before diagnosis but the opportunity to test by healthcare professionals (HCPs) is frequently missed. Current HIV testing rates in primary care are low and educational interventions to facilitate HCPs to increase testing and awareness of HIV are needed. METHOD We implemented a pilot feasibility stepped-wedged randomised controlled trial of an educational intervention in high HIV prevalence practices in Bristol. The training delivered to HCPs including General Practitioners (GP) aimed to increase HIV testing and included why, who, and how to test. The intervention was adapted from the Medical Foundation for HIV and Sexual Health HIV Testing in Practice (MEDFASH) educational tool. Questionnaires assessed HCP feedback and perceived impacts of the intervention. HIV testing rates were compared between control and intervention practices using 12 monthly laboratory totals. RESULTS 169 HCPs (from 19 practices) received the educational intervention. 127 (75%) questionnaires were completed. Delivery of the intervention was received positively and was perceived as valuable for increasing awareness, confidence and consideration of testing, with HCPs gaining more awareness of HIV testing guidelines. The main pre-training HIV testing barrier reported by GPs was the patient not considering themselves at risk, whilst for nurses it was a concern about embarrassing or offending the patient. Most HCPs reported the intervention addressed these barriers. The HIV testing rate increased more in the control than in the intervention practices: mean difference 2.6 (95% CI 0.5,4.7) compared with 1.9 (- 0.5,4.3) per 1000 patients, respectively. The number of HIV tests across all practices increased from 1154 in the first 6 months to 1299 in the second 6 months, an annual increase in testing rate of 2.0 (0.7,3.4) from 16.3 to 18.3 per 1000 patients. CONCLUSION There was a small increase in HIV testing rates over the study period, but this could not be attributed to the educational intervention. More effective and sustainable programmes tailored to each practice context are needed to change testing culture and HCP behaviour. Repeated training, supported by additional measures, such as testing prompts, may be needed to influence primary care HIV testing.
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Affiliation(s)
- Charlotte F Davies
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Joanna M Kesten
- Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK.,National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol, NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, England.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Mark Gompels
- Department of Immunology, Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - Jeremy Horwood
- National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), University Hospitals Bristol, NHS Foundation Trust, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, England
| | - Megan Crofts
- Genitourinary medicine, Unity Sexual Health, Bristol Sexual Health Services, Tower Hill, Bristol, BS2 0JD, UK.
| | - Annette Billing
- NHS Bristol, North Somerset and South Gloucestershire CCG, South Plaza, Marlborough Street, Bristol, BS1 3NX, UK.
| | - Charlotte Chick
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Margaret T May
- Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
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20
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North F, Tulledge-Scheitel SM, Matulis JC, Pecina JL, Franqueira AM, Johnson SS, Chaudhry R. Population health challenges in primary care: What are the unfinished tasks and who should do them? SAGE Open Med 2018; 6:2050312118800209. [PMID: 30245819 PMCID: PMC6144580 DOI: 10.1177/2050312118800209] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 08/21/2018] [Indexed: 12/27/2022] Open
Abstract
Background There are numerous recommendations from expert sources that help guide primary care providers in cancer screening, infectious disease screening, metabolic screening, monitoring of drug levels, and chronic disease management. Little is known about the potential effort needed for a healthcare system to address these recommendations, or the patient effort needed to complete the recommendations. Methods For 73 recommended population healthcare items, we examined each of 28,742 patients in a primary care internal medicine practice to determine whether they were up-to-date on recommended screening, immunizations, counseling, and chronic disease management goals. We used a rule-based software tool that queries the medical record for diagnoses, dates, laboratory values, pathology reports, and other information used in creating the individualized recommendations. We counted the number of uncompleted recommendations by age groups and examined the healthcare staff needed to address the recommendations and the potential patient effort needed to complete the recommendations. Results For the 28,742 patients, there were 127,273 uncompleted recommendations identified for population health management (mean recommendations per patient 4.36, standard deviation of 2.65, range of 0-17 recommendations per patient). The age group with the most incomplete recommendations was age of 50-65 years with 5.5 recommendations per patient. The 18-35 years age group had the fewest incomplete recommendations with 2.6 per patient. Across all age groups, initiation of these recommendations required high-level input (physician, nurse practitioner, or physician's assistant) in 28%. To completely adhere to recommended services, a 1000-patient cross-section cohort would require a total of 464 procedures and 1956 lab tests. Conclusion Providers and patients face a daunting number of tasks necessary to meet guideline-generated recommendations. We will need new approaches to address the burgeoning numbers of uncompleted recommendations.
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Affiliation(s)
- Frederick North
- Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - John C Matulis
- Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Rajeev Chaudhry
- Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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21
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Ridgway JP, Almirol EA, Bender A, Richardson A, Schmitt J, Friedman E, Lancki N, Leroux I, Pieroni N, Dehlin J, Schneider JA. Which Patients in the Emergency Department Should Receive Preexposure Prophylaxis? Implementation of a Predictive Analytics Approach. AIDS Patient Care STDS 2018; 32:202-207. [PMID: 29672136 DOI: 10.1089/apc.2018.0011] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Emergency Departments (EDs) have the potential to play a crucial role in HIV prevention by identifying and linking high-risk HIV-negative clients to preexposure prophylaxis (PrEP) care, but it is difficult to perform HIV risk assessment for all ED patients. We aimed to develop and implement an electronic risk score to identify ED patients who are potential candidates for PrEP. Using electronic medical record (EMR) data, we used logistic regression to model the outcome of PrEP eligibility. We converted the model into an electronic risk score and incorporated it into the EMR. The risk score is automatically calculated at triage. For patients whose risk score is above a given threshold, an automated electronic alert is sent to an HIV prevention counselor who performs real time HIV prevention counseling, risk assessment, and PrEP linkage as appropriate. The electronic risk score includes the following EMR variables: age, gender, gender of sexual partner, chief complaint, and positive test for sexually transmitted infection in the prior 6 months. A risk score ≥21 has specificity of 80.6% and sensitivity of 50%. In the first 5.5 months of implementation, the alert fired for 180 patients, 34.4% (62/180) of whom were women. Of the 51 patients who completed risk assessment, 68.6% (35/51) were interested in PrEP, 17.6% (9/51) scheduled a PrEP appointment, and 7.8% (4/51) successfully initiated PrEP. The measured number of successful PrEP initiations is likely an underestimate, as it does include patients who initiated PrEP with outside providers or referred acquaintances for PrEP care.
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Affiliation(s)
- Jessica P. Ridgway
- Department of Medicine, University of Chicago, Chicago, Illinois
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - Ellen A. Almirol
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - Alvie Bender
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Andrew Richardson
- Department of Medicine, University of Chicago, Chicago, Illinois
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - Jessica Schmitt
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Eleanor Friedman
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - Nicola Lancki
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - Ivan Leroux
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - Nina Pieroni
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jessica Dehlin
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
| | - John A. Schneider
- Department of Medicine, University of Chicago, Chicago, Illinois
- Chicago Center for HIV Elimination, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
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