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Vallée A, Sveltlane D, Trichereau J, Neveu S, Fourn E, Majerholc C, Lesprit P, Mazaux L, Henintsoa SH, Matejczuk G, Vasse M, Zucman D. Electronic medical record alert increases HIV screening rates: the Foch hospital pilot POP-up project. BMC Health Serv Res 2022; 22:784. [PMID: 35710554 PMCID: PMC9202097 DOI: 10.1186/s12913-022-08176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 06/13/2022] [Indexed: 12/05/2022] Open
Abstract
Background Despite significant national human immunodeficiency virus (HIV) screening activity, there are persistent delays in screening, and many missed diagnostic opportunities. To facilitate targeted screening, an electronic medical record (EMR) alert reminder was applied in the Foch hospital. Screening rates after implementation were reported. Methods A prospective cohort analysis was performed in Foch Hospital between 24 April 2018 and 4 October 2019 among hospitalized patients born in high HIV prevalence countries and/or having social vulnerability criteria (universal health coverage). From the admissions software, when specific low health coverage was provided and/or high-prevalence country of birth was registered, an electronic alert (EMR alert) appeared on the ward where the patient was hospitalized. The EMR alert database was examined for HIV screening and activity responses from each service of the Hospital. Results Eight thousand one hundred eighty-one alerts were recovered during the period for 1448 patients. 27 services used the EMR alert. Most of the alerts were directly closed (74.4%), 14.5% of the alerts were closed due to doctors declaring that they did not have time to respond. 297 (3.6%) of the 8181 alerts resulted in a prescription of HIV serology corresponding for 20.5% of the patients. Conclusion EMR alert can help to increase the rate of HIV screening in hospital care practice. Through this EMR alert system, HIV screening can be implemented as a common practice like any other medical alternative. Future research should examine the factors influencing physicians’ attitudes to this alert system to improve the HIV screening rate.
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Affiliation(s)
- Alexandre Vallée
- Department of Epidemiology - Data - Biostatistics, Delegation of Clinical Research and Innovation, Foch Hospital, Suresnes, France.
| | - Dimi Sveltlane
- Department of Internal Medicine, Réseau Ville Hôpital Val de Seine, Foch Hospital, Suresnes, France
| | - Julie Trichereau
- Department of Epidemiology - Data - Biostatistics, Delegation of Clinical Research and Innovation, Foch Hospital, Suresnes, France
| | - Stéphane Neveu
- Département d'Informatique, Hôpital Foch, Suresnes, France
| | - Erwan Fourn
- Department of Internal Medicine, Réseau Ville Hôpital Val de Seine, Foch Hospital, Suresnes, France
| | - Catherine Majerholc
- Department of Internal Medicine, Réseau Ville Hôpital Val de Seine, Foch Hospital, Suresnes, France
| | - Philippe Lesprit
- Department of Hygiene and Infectious Disease, Foch Hospital, Suresnes, France
| | - Laurence Mazaux
- Service de Biologie Clinique, Hôpital Foch, Suresnes, France
| | - Seheno Harijaona Henintsoa
- Department of Epidemiology - Data - Biostatistics, Delegation of Clinical Research and Innovation, Foch Hospital, Suresnes, France
| | | | - Marc Vasse
- Service de Biologie Clinique, Hôpital Foch, Suresnes, France
| | - David Zucman
- Department of Internal Medicine, Réseau Ville Hôpital Val de Seine, Foch Hospital, Suresnes, France
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Puttkammer N, Simoni JM, Sandifer T, Chéry JM, Dervis W, Balan JG, Dubé JG, Calixte G, Robin E, François K, Casey C, Wilson I, Honoré JG. An EMR-Based Alert with Brief Provider-Led ART Adherence Counseling: Promising Results of the InfoPlus Adherence Pilot Study Among Haitian Adults with HIV Initiating ART. AIDS Behav 2020; 24:3320-3336. [PMID: 32715409 DOI: 10.1007/s10461-020-02945-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6 months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of ≥ 90% for "proportion of days covered" (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI 0.92-1.45, p = 0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC ≥ 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC ≥ 90% with the intervention was 4.00 (95% CI 1.91-8.38, p < 0.001), representing a highly favorable association between the intervention and the trajectory of PDC outcomes. Qualitative data affirmed acceptability of the intervention, although providers reported some challenges consistently implementing it. Future research is needed to demonstrate efficacy and explore optimal implementation strategies.
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Underutilization of HIV Testing Among Men with Incarceration Histories. AIDS Behav 2019; 23:883-892. [PMID: 30661215 DOI: 10.1007/s10461-018-02381-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Annual HIV testing is recommended for individuals at high risk of infection, specifically incarcerated populations. Incarcerated men carry a higher lifetime risk of acquiring HIV than the general population, yet little is known about their HIV testing behaviors. We collected Audio Computer Assisted Self Interview data for 819 men entering a state prison in North Carolina. We assessed correlates of previous HIV testing, including stigmatizing attitudes and beliefs, and explored two outcomes: (1) ever HIV tested before current incarceration, and (2) recency of last HIV test. Eighty percent had been HIV tested before; of those, 36% reported testing within the last year. Being African American, having education beyond high school, prior incarceration, and higher HIV knowledge increased odds of ever having tested. Results of this study highlight the need to expand HIV testing and education specific to incarcerated populations. Additionally, efforts should be made to monitor and encourage repeat screening.
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Abstract
BACKGROUND AND METHOD We examined specimens from 111 HIV-infected participants virally suppressed on ART for a minimum of 5 years who had donated serial peripheral blood mononuclear cell (PBMC) specimens to the University of Washington/Fred Hutch Center for AIDS Research (CFAR) Specimen Repository. We determined the HIV proviral copy number per million PBMCs, corrected for CD4 cell count, in 477 specimens collected after a minimum of 5 years of follow-up and up to 15.5 years of clinical viral suppression. Generalized estimating equation regression was used to examine the association between the reservoir size and time, age at study entry, antiretroviral regimen, and risk factors for HIV acquisition. RESULTS AND CONCLUSION We found that the inter-participant baseline HIV DNA level varied widely between 0.01 and 4.8 pol-copies per microgram genomic DNA and per CD4 cell number/micoliter; the HIV DNA level declined with time (half-life was estimated at 12 years, 95% confidence interval of 6.2-240 years); the HIV DNA level was lower for those who achieved viral suppression at a younger age; and the HIV DNA level was not affected by the specific antiretroviral regimen used to achieve and maintain suppression.
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Eaton EF, Joe W, Kilgore ML, Muzny CA. Reverse syphilis screening algorithm fails to demonstrate cost effectiveness in persons living with HIV. Int J STD AIDS 2017; 29:563-567. [PMID: 29173098 DOI: 10.1177/0956462417743409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although the reverse syphilis screening algorithm is more efficient than the traditional algorithm, it may lead to exorbitant costs for health systems serving persons living with HIV needing annual syphilis screening. Alternatively, the traditional screening algorithm is cost saving in many scenarios.
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Affiliation(s)
- Ellen F Eaton
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Winston Joe
- 2 School of Medicine, 9967 University of Alabama School of Medicine , University of Alabama at Birmingham, Birmingham, AL, USA
| | - Meredith L Kilgore
- 3 School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christina A Muzny
- 1 Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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Jung Y, Song KH, Choe PG, Park WB, Bang JH, Kim ES, Kim HB, Park SW, Kim NJ, Oh MD. Incidence of disseminated Mycobacterium avium-complex infection in HIV patients receiving antiretroviral therapy with use of Mycobacterium avium-complex prophylaxis. Int J STD AIDS 2017; 28:1426-1432. [PMID: 28592210 DOI: 10.1177/0956462417713432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The incidence of disseminated Mycobacterium avium complex (MAC) infection in HIV patients has fallen markedly since the introduction of effective antiretroviral therapy (ART). However, current guidelines still recommend primary prophylaxis. We conducted a retrospective cohort study in a university-affiliated hospital from January 1998 to January 2014. During that period, HIV patients who had at least one CD4 cell count below 50 cells/mm3 and had been treated with ART were enrolled. We compared incidence of disseminated MAC infection in the 12 months after the first CD4 cell count below 50 cells/mm3 between prophylaxis and nonprophylaxis groups. A total of 157 patients were enrolled and the total observation period was 144 patient-years (PY). Thirty-three patients (21%) received primary MAC prophylaxis. The initial CD4 cell count of the prophylaxis group was lower than that of the nonprophylaxis group ( P = 0.024), but the proportion of patients who reached a CD4 cell count >100 cells/mm3 ( P = 0.234) and were virologically suppressed ( P = 0.513) 12 months after ART commencement was not different in the prophylaxis and nonprophylaxis groups. The incidence of MAC did not differ significantly between the groups (3.4/100 PY versus 0.8/100 PY, P = 0.368). Routine MAC prophylaxis may be not required in the era of effective ART.
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Affiliation(s)
- Younghee Jung
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,2 Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Kyoung-Ho Song
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Pyoeng Gyun Choe
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Wan Beom Park
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Hwan Bang
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eu Suk Kim
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Bin Kim
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Won Park
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Joong Kim
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Myoung-Don Oh
- 1 Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Wolf E, Herbeck JT, Van Rompaey S, Kitahata M, Thomas K, Pepper G, Frenkel L. Short Communication: Phylogenetic Evidence of HIV-1 Transmission Between Adult and Adolescent Men Who Have Sex with Men. AIDS Res Hum Retroviruses 2017; 33:318-322. [PMID: 27762596 DOI: 10.1089/aid.2016.0061] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
HIV-1 incidence among youth, especially men who have sex with men (MSM), is increasing in the United States. We aimed to better understand the patterns of adolescent HIV-1 acquisition, to help guide future prevention interventions. We conducted a study combining epidemiologic and HIV-1 pol sequence data from a retrospective cohort of HIV-infected adults and adolescents in Seattle, WA between 2000 and 2013. Adolescents were defined as 13-24 years of age at the time of first HIV-1 care. Maximum-likelihood phylogenetic trees were reconstructed to identify putative viral transmission clusters of two or more individuals, followed by multivariable regression tests of associations between clustering and demographic and clinical parameters. The dataset included 3,102 sequences from 1,953 individuals; 72 putative transmission clusters were identified, representing 168 individuals (8.6%). MSM and MSM/intravenous drug use (IDU) were positively associated with clustering, with aOR 3.18 (95% CI: 1.34-7.55) and 2.59 (95% CI: 1.04-6.49), respectively. African American race was negatively associated with clustering (aOR 0.54 95% CI: 0.32-0.91). Twenty-five clusters contained one adolescent and five clusters contained two adolescents. Other individuals who clustered with adolescents were predominantly male (95%), white (85%), and either MSM (66%) or MSM/IDU (16%), with a greater mean age (34 years vs. 22 years; p < .01). In this Seattle cohort, HIV-1 transmission linkages were identified between white male adolescents and older MSM adults. Interventions aimed at age-discrepant pairs may reduce HIV-1 infections in adolescent males.
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Affiliation(s)
- Elizabeth Wolf
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
| | - Joshua T. Herbeck
- Department of Global Health, University of Washington, Seattle, Washington
| | | | - Mari Kitahata
- Center for AIDS Research, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
| | - Katherine Thomas
- Department of Global Health, University of Washington, Seattle, Washington
| | - Gregory Pepper
- Department of Medicine, University of Washington, Seattle, Washington
| | - Lisa Frenkel
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Laboratory Medicine, University of Washington, Seattle, Washington
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Drozd DR, Graham SM, Crane HM, Delaney JA, Kitahata MM, Liles WC. Short Communication: Effect of Antiretroviral Therapy on Circulating Damage-Associated Molecular Pattern Molecules and CD4 Immune Reconstitution in HIV-Infected Individuals. AIDS Res Hum Retroviruses 2016; 32:876-8. [PMID: 27170267 DOI: 10.1089/aid.2016.0059] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We examined levels of the damage-associated molecular pattern molecules, HMGB1 and S100A9, in individuals for whom stored samples were available before and after antiretroviral therapy (ART) initiation, to determine their association with CD4 reconstitution. Mean HMGB1 levels (1.95 ng/ml vs. 3.02 ng/ml) and the proportion of individuals with detectable S100A9 (19.6% vs. 43.1%) significantly increased after ART. Detectable post-ART S100A9 was independently associated with impaired immune reconstitution.
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Affiliation(s)
- Daniel R. Drozd
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Susan M. Graham
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Heidi M. Crane
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | | | - Mari M. Kitahata
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
| | - Wayne Conrad Liles
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
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Williams EC, Achtmeyer CE, Thomas RM, Grossbard JR, Lapham GT, Chavez LJ, Ludman EJ, Berger D, Bradley KA. Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study. J Gen Intern Med 2015; 30:1125-32. [PMID: 25731916 PMCID: PMC4510245 DOI: 10.1007/s11606-015-3248-z] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 01/28/2015] [Accepted: 02/05/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics. OBJECTIVE We aimed to understand factors that might contribute to low sensitivity of alcohol screening. DESIGN This was an observational, qualitative study. PARTICIPANTS Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S. APPROACH Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes. KEY RESULTS We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort. CONCLUSIONS This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.
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Affiliation(s)
- Emily C Williams
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA,
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10
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White BL, Walsh J, Rayasam S, Pathman DE, Adimora AA, Golin CE. What Makes Me Screen for HIV? Perceived Barriers and Facilitators to Conducting Recommended Routine HIV Testing among Primary Care Physicians in the Southeastern United States. J Int Assoc Provid AIDS Care 2014; 14:127-35. [PMID: 24643412 DOI: 10.1177/2325957414524025] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The Centers for Disease Control and Prevention have recommended routinely testing patients (aged 13-64) for HIV since 2006. However, many physicians do not routinely test. From January 2011 to March 2012, we conducted 18 in-depth individual interviews and explored primary care physicians' perceptions of barriers and facilitators to implementing routine HIV testing in North Carolina. Physicians' comments were categorized thematically and fell into 5 groups: policy, community, practice, physician, and patient. Lack of universal reimbursement was identified as the major policy barrier. Participants believed endorsement from the United States Preventive Services Tasks Force would facilitate adoption of routine HIV testing policies. Physicians reported HIV/AIDS stigma, socially conservative communities, lack of confidentiality, and rural geography as community barriers. Physicians believed public HIV testing campaigns would legitimize testing and decrease stigma in communities. Physicians cited time constraints and competing clinical priorities as physician barriers that could be overcome by delegating testing to nursing staff. HIV test refusal, low HIV risk perception, and stigma emerged as patient barriers. Physicians recommended adoption of routine HIV testing for all patients to facilitate and destigmatize testing. Physicians continue to experience a variety of barriers when implementing routine HIV testing in primary care settings. Our findings support multilevel approaches to enhance physician routine HIV testing in primary care settings.
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Affiliation(s)
- Becky L White
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Joan Walsh
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Swati Rayasam
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC, USA
| | - Donald E Pathman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adaora A Adimora
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Carol E Golin
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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Petroll AE, Phelps JK, Fletcher KE. Implementation of an electronic medical record does not change delivery of preventive care for HIV-positive patients. Int J Med Inform 2014; 83:273-7. [PMID: 24440204 DOI: 10.1016/j.ijmedinf.2013.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 12/10/2013] [Accepted: 12/16/2013] [Indexed: 01/12/2023]
Abstract
PURPOSE This study sought to determine the impact that an electronic medical record (EMR) had on the provision of preventive health measures - including obtaining serologies for viral hepatitis and administering vaccinations to non-immune patients - to HIV patients at a hospital-based clinic. METHODS Using a pre-post study design, we compared rates of preventive health delivery to HIV patients at an outpatient clinic during the use of a paper medical record (PMR) and after implementation of an EMR. Retrospective chart reviews were conducted at two time points: 12-16 months prior to and 24 months following EMR implementation. The records of 160 active patients were randomly selected for review during both time periods. RESULTS There was no difference between the PMR and EMR samples with regard to the proportion of patients who had hepatitis A (83% in PMR group; 77% in EMR) and hepatitis C (94% in both groups) serologies measured or the proportion of eligible patients who were given hepatitis vaccinations. Slightly fewer patients had a serology for hepatitis B measured in the EMR sample. CONCLUSIONS As EMR implementation expands, it is important to evaluate the effects that EMRs have on patient outcomes, including preventive health provision. Our study showed that after implementation of an EMR, the provision of most preventive care measures did not improve. This finding is in agreement with many published studies. Some studies have found positive effects from EMRs that may be attributable to specific aspects of EMRs. Further study of the effect of specific EMR attributes on health care outcomes is needed.
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Affiliation(s)
- Andrew E Petroll
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, USA; Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Jenise K Phelps
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Kathlyn E Fletcher
- Department of Medicine, Division of General Internal Medicine, College of Wisconsin, Milwaukee, WI, USA; Department of Medicine, Clement J Zablocki VA Medical Center, Milwaukee, WI, USA
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Durability of first ART regimen and risk factors for modification, interruption or death in HIV-positive patients starting ART in Europe and North America 2002-2009. AIDS 2013; 27:803-13. [PMID: 23719350 DOI: 10.1097/qad.0b013e32835cb997] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To estimate the incidence of and risk factors for modifications to first antiretroviral therapy (ART) regimen, treatment interruption and death. METHODS A total of 21 801 patients from 18 cohorts in Europe and North America starting ART on regimens including at least two nucleoside reverse transcriptase inhibitors and boosted protease inhibitor or non-nucleoside reverse transcriptase inhibitor during 2002-2009 were included. Incidence of modifications (change of drug class, substitution/addition within class, or switch to nonstandard regimen), interruption or death and associations with patient characteristics were estimated using competing-risks methods. RESULTS During median 28 months follow-up, 8786 (40.3%) patients modified first ART, 2346 (10.8%) interrupted and 427 (2.0%) died before changing regimen. Three-year cumulative percentages of modification, interruption and death were 47, 12 and 2%, respectively. After adjustment, rates of interruption were highest for IDUs and lowest for MSM, and higher for patients starting ART with CD4 cell count above 350 cells/μl than other patients. Compared to efavirenz, patients on lopinavir and other protease inhibitors had higher rates of modification and interruption, on atazanavir had lower rates of class change, and on nevirapine higher rates of interruption. Those on tenofovir/emtricitabine backbone had lowest rates of substitutions and switches to nonstandard regimen, and on abacavir/lamivudine lowest rates of interruption. Rates of substitution and switches to nonstandard regimen were lower in 2006-2009. CONCLUSION Rates of modification and interruption were high, particularly in the first year of ART. Decreased rates of substitutions or switches to nonstandard regimen in recent years may be linked to greater use of well tolerated once-daily drugs.
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Pasricha A, Deinstadt RTM, Moher D, Killoran A, Rourke SB, Kendall CE. Chronic Care Model Decision Support and Clinical Information Systems interventions for people living with HIV: a systematic review. J Gen Intern Med 2013; 28:127-35. [PMID: 22790615 PMCID: PMC3539016 DOI: 10.1007/s11606-012-2145-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 05/09/2012] [Accepted: 06/08/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Chronic Care Model is an effective framework for improving chronic disease management. There is scarce literature describing this model for people living with HIV. Decision Support (DS) and Clinical Information Systems (CIS) are two components of this model that aim to improve care by changing health care provider behavior. OBJECTIVE Our aim was to assess the effectiveness of DS and CIS interventions for individuals with HIV, through a systematic literature review. DESIGN We performed systematic electronic searches from 1996 to February 2011 of the medical (E.g. Medline, EMBASE, CINAHL) and grey literature. Effectiveness was measured by the frequency of statistically significant outcome improvement. Data and key equity indicator extraction and synthesis was completed. PARTICIPANTS AND INTERVENTIONS We included comparative studies of people living with HIV that examined the impact of DS or CIS interventions on outcomes. MAIN MEASURES The following measures were assessed: outcome (immunological/virological, medical, psychosocial, economic measures) and health care process/performance measures. KEY RESULTS Records were screened for relevance (n = 10,169), full-text copies of relevant studies were obtained (n = 123), and 16 studies were included in the review. Overall, 5/9 (55.6%) and 17/41 (41.5%) process measures and 5/12 (41.7%) and 3/9 (33.3%) outcome measures for DS and CIS interventions, respectively, were statistically significantly improved. DS-explicit mention of implementation of guidelines and CIS-reminders showed the most frequent improvement in outcomes. DS-only interventions were more effective than CIS-only interventions in improving both process and outcome measures. Clinical, statistical and methodological heterogeneity among studies precluded meta-analysis. Primary studies were methodologically weak and often included multifaceted interventions that made assessment of effectiveness challenging. CONCLUSIONS Overall, DS and CIS interventions may modestly improve care for people living with HIV, having a greater impact on process measures compared to outcome measures. These interventions should be considered as part of strategies to improve HIV care through changing provider performance.
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Arditi C, Rège-Walther M, Wyatt JC, Durieux P, Burnand B. Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2012; 12:CD001175. [PMID: 23235578 DOI: 10.1002/14651858.cd001175.pub3] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time. OBJECTIVES To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition). SEARCH METHODS For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. SELECTION CRITERIA We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care. DATA COLLECTION AND ANALYSIS Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome. MAIN RESULTS In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements. AUTHORS' CONCLUSIONS There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.
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Affiliation(s)
- Chantal Arditi
- Institute of Social and Preventive Medicine, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland.
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May MT, Hogg RS, Justice AC, Shepherd BE, Costagliola D, Ledergerber B, Thiébaut R, Gill MJ, Kirk O, van Sighem A, Saag MS, Navarro G, Sobrino-Vegas P, Lampe F, Ingle S, Guest JL, Crane HM, D'Arminio Monforte A, Vehreschild JJ, Sterne JAC. Heterogeneity in outcomes of treated HIV-positive patients in Europe and North America: relation with patient and cohort characteristics. Int J Epidemiol 2012; 41:1807-20. [PMID: 23148105 DOI: 10.1093/ije/dys164] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND HIV cohort collaborations, which pool data from diverse patient cohorts, have provided key insights into outcomes of antiretroviral therapy (ART). However, the extent of, and reasons for, between-cohort heterogeneity in rates of AIDS and mortality are unclear. METHODS We obtained data on adult HIV-positive patients who started ART from 1998 without a previous AIDS diagnosis from 17 cohorts in North America and Europe. Patients were followed up from 1 month to 2 years after starting ART. We examined between-cohort heterogeneity in crude and adjusted (age, sex, HIV transmission risk, year, CD4 count and HIV-1 RNA at start of ART) rates of AIDS and mortality using random-effects meta-analysis and meta-regression. RESULTS During 61 520 person-years, 754/38 706 (1.9%) patients died and 1890 (4.9%) progressed to AIDS. Between-cohort variance in mortality rates was reduced from 0.84 to 0.24 (0.73 to 0.28 for AIDS rates) after adjustment for patient characteristics. Adjusted mortality rates were inversely associated with cohorts' estimated completeness of death ascertainment [excellent: 96-100%, good: 90-95%, average: 75-89%; mortality rate ratio 0.66 (95% confidence interval 0.46-0.94) per category]. Mortality rate ratios comparing Europe with North America were 0.42 (0.31-0.57) before and 0.47 (0.30-0.73) after adjusting for completeness of ascertainment. CONCLUSIONS Heterogeneity between settings in outcomes of HIV treatment has implications for collaborative analyses, policy and clinical care. Estimated mortality rates may require adjustment for completeness of ascertainment. Higher mortality rate in North American, compared with European, cohorts was not fully explained by completeness of ascertainment and may be because of the inclusion of more socially marginalized patients with higher mortality risk.
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Affiliation(s)
- Margaret T May
- School of Social and Community Medicine, University of Bristol, Bristol, UK.
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Fathauer L, Meek J. Initial implementation and evaluation of a Hepatitis C treatment clinical decision support system (CDSS): a nurse practitioner-driven quality improvement initiative. Appl Clin Inform 2012; 3:337-48. [PMID: 23646082 DOI: 10.4338/aci-2012-04-ra-0012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 09/01/2012] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Clinician compliance with clinical guidelines in the treatment of patients with Hepatitis C (HCV) has been reported to be as low as 18.5%. Treatment is complex and patient compliance is often inconsistent thus, active clinician surveillance and support is essential to successful outcomes. A clinical decision support system (CDSS) embedded within an electronic health record can provide reminders, summarize key data, and facilitate coordination of care. To date, the literature is bereft of information describing the implementation and evaluation of a CDSS to support HCV treatment. OBJECTIVE The purpose of this case report is to describe the design, implementation, and initial evaluation of an HCV-specific CDSS while piloting data collection metrics and methods to be used in a larger study across multiple practices. METHODS The case report describes the design and implementation processes with preliminary reporting on impact of the CDSS on quality indicator completion by comparing the pre-CDSS group to the post-CDSS group. RESULTS The CDSS was successfully designed and implemented using an iterative, collaborative process. Pilot testing of the clinical outcomes of the CDSS revealed high rates of quality indicator completion in both the pre- and post-CDSS; although the post-CDSS group received a higher frequency of reminders (4.25 per patient) than the pre-CDSS group (.25 per patient). CONCLUSIONS This case report documents the processes used to successfully design and implement an HCV CDSS. While the small sample size precludes generalizability of findings, results did positively demonstrate the feasibility of comparing quality indicator completion rates pre-CDSS and post-CDSS. It is recommended that future studies include a larger sample size across multiple providers with expanded outcomes measures related to patient outcomes, staff satisfaction with the CDSS, and time studies to evaluate efficiency and cost effectiveness of the CDSS.
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Affiliation(s)
- L Fathauer
- Southeastern Indiana Gastroenterology, 2630 22nd St., Columbus, IN 47203, USA.
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Petersen TS, Andersen SE, Gerstoft J, Thorsteinsson K, Larsen CS, Pedersen G, Pedersen C, Obel N. Adherence to national guidelines for initiation of antiretroviral regimens in HIV patients: a Danish nationwide study. Br J Clin Pharmacol 2011; 72:116-24. [PMID: 21306418 DOI: 10.1111/j.1365-2125.2011.03935.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AIM To determine the adherence to the national guidelines for start of highly active antiretroviral treatment (HAART) in HIV infected patients. METHODS We used a Danish nationwide cohort of HIV infected patients to calculate the fraction of patients who in the period 1997-2006 started HAART according to the guidelines from The Danish Society of Infectious Diseases. We used Kaplan-Meier tables to estimate time from fulfilling the criteria for start of HAART to initiation of the treatment. Cox regression and logistic regression was used to identify risk factors for delayed initiation of treatment and chance of being included in clinical trials. RESULTS The study included 3223 patients, 74% of whom initiated HAART in the study period. Ninety-four% fulfilled the criteria for start of HAART, with minor differences over calendar periods. Ninety-four% initiated a recommended regimen or were included in a clinical trial. Intravenous drug use predicted initiation of a non-recommended regimen and delay in start of HAART, while non-Caucasians were less likely to be included in clinical trials. CONCLUSIONS In a Western world setting, the adherence to national guidelines for start of HAART can be high. We suggest that simplicity of the guidelines, centralization of treatment and involvement of local clinicians in the development of guidelines are of major importance for high adherence to treatment guidelines.
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Affiliation(s)
- Tonny S Petersen
- Department of Clinical Pharmacology, Copenhagen University Hospital, Bispebjerg Hospital, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.
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Achenbach CJ, Harrington RD, Dhanireddy S, Crane HM, Casper C, Kitahata MM. Paradoxical immune reconstitution inflammatory syndrome in HIV-infected patients treated with combination antiretroviral therapy after AIDS-defining opportunistic infection. Clin Infect Dis 2011; 54:424-33. [PMID: 22095568 DOI: 10.1093/cid/cir802] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The incidence of immune reconstitution inflammatory syndrome (IRIS) when antiretroviral therapy (ART) is initiated after an AIDS-defining opportunistic infection (OI) is uncertain and understudied for the most common OIs. METHODS We examined patients in the University of Washington Human Immunodeficiency Virus Cohort initiating potent ART subsequent to an AIDS-defining OI. IRIS was determined through retrospective medical record review and adjudication using a standardized data collection process and clinical case definition. We compared demographic and clinical characteristics, and immunologic changes in patients with and without IRIS. RESULTS Among 196 patients with 260 OIs, 21 (11%; 95% confidence interval, 7%-16%) developed paradoxical IRIS in the first year on ART. The 3 most common OIs among study patients were Pneumocystis pneumonia (PCP, 28%), Candida esophagitis (23%), and Kaposi sarcoma (KS, 16%). Cumulative 1-year incidence of IRIS was 29% (12/41) for KS, 16% (4/25) for tuberculosis, 14% (1/7) for Cryptococcus, 10% (1/10) for Mycobacterium avium complex, and 4% (3/72) for PCP. Morbidity and mortality were highest in those with visceral KS-IRIS compared with other types of IRIS (100% [6/6] vs 7% [1/15], P < .01). Patients with mucocutaneous KS and tuberculosis-IRIS experienced greater median increase in CD4(+) cell count during the first 6 months of ART compared with those without IRIS (+158 vs +53 cells/μL, P = .04, mucocutaneous KS; +261 vs +113, P = .04, tuberculosis). CONCLUSIONS Cumulative incidence and features of IRIS varied depending on the OI. IRIS occurred in >10% of patients with KS, tuberculosis, or Cryptococcus. Visceral KS-IRIS led to considerable morbidity and mortality.
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Affiliation(s)
- Chad J Achenbach
- Department of Medicine, Feinberg School of Medicine, Division of Infectious Diseases and Center for Global Health, Northwestern University, Chicago, Illinois 60611, USA.
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Yoon JC, Crane PK, Ciechanowski PS, Harrington RD, Kitahata MM, Crane HM. Somatic symptoms and the association between hepatitis C infection and depression in HIV-infected patients. AIDS Care 2011; 23:1208-18. [PMID: 21562994 PMCID: PMC3534977 DOI: 10.1080/09540121.2011.555739] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Studies of depression and hepatitis C virus (HCV) infection in HIV-infected patients have been contradictory and often not addressed key differences between HCV-infected and uninfected individuals including substance use. This cross-sectional observational study from the University of Washington HIV cohort examined associations between HCV, symptoms, and depression in HIV-infected patients in routine clinical care. Patients completed instruments measuring depression, symptoms, and substance use. We generated depression severity scores and used linear regression to examine the relationship with HCV accounting for demographic and clinical characteristics. We conducted sensitivity analyses in which we removed depression somatic symptom items (e.g., fatigue) from depression scores, and sensitivity analyses in which we also adjusted for nondepression somatic symptom items to examine the role of somatic and nonsomatic symptoms in the association between depression and HCV. Of 764 HIV-infected patients, 160 (21%) were HCV-infected. In adjusted analysis, HCV-infected patients had worse depression severity (p =0.01) even after adjusting for differences in substance use. HCV remained associated with depression severity in secondary analyses that omitted the depression somatic patient health questionnaire-9 (PHQ-9) items (p=0.01). However, when nondepression somatic symptoms were included as covariates in multivariate analyses, HCV was no longer associated with depression (p=0.09).
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Affiliation(s)
- Jeanie C Yoon
- Department of Medicine, University of Washington, Seattle, USA
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Yang X, Kadane JB, Crane HM, Kitahata MM. Whether to Retest the Lipids of HIV-Infected Patients: How Much Does Fasting Bias Matter? DECISION ANALYSIS 2011. [DOI: 10.1287/deca.1110.0203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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21
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Lawrence ST, Willig JH, Crane HM, Ye J, Aban I, Lober W, Nevin CR, Batey DS, Mugavero MJ, McCullumsmith C, Wright C, Kitahata M, Raper JL, Saag MS, Schumacher JE. Routine, self-administered, touch-screen, computer-based suicidal ideation assessment linked to automated response team notification in an HIV primary care setting. Clin Infect Dis 2010; 50:1165-73. [PMID: 20210646 DOI: 10.1086/651420] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) and AIDS continue to be associated with an underrecognized risk for suicidal ideation, attempted suicide, and completed suicide. Suicidal ideation represents an important predictor for subsequent attempted and completed suicide. We sought to implement routine screening of suicidal ideation and associated conditions using computerized patient-reported outcome (PRO) assessments. METHODS Two geographically distinct academic HIV primary care clinics enrolled patients who attended scheduled visits from December 2005 through February 2009. Touch-screen, computer-based PRO assessments were implemented into routine clinical care. Substance abuse, alcohol consumption, depression, and anxiety were assessed. The 9-item Patient Health Questionnaire assesses the frequency of suicidal ideation in the preceding 2 weeks. A response of "nearly every day" triggered an automated page to predetermined clinic personnel, who completed more detailed self-harm assessments. RESULTS Overall, 1216 patients (740 from the University of Alabama at Birmingham and 476 from the University of Washington) completed the initial PRO assessment during the study period. Patients were predominantly white (646 [53%]) and male (959 [79%]), with a mean age (+/- standard deviation) of 44 +/- 10 years. Among surveyed patients, 170 (14%) endorsed some level of suicidal ideation, whereas 33 (3%) admitted suicidal ideation nearly every day. In multivariable analysis, suicidal ideation risk was lower with advancing age (odds ratio [OR], 0.74 per 10 years; 95% confidence interval [CI], 0.58-0.96) and was increased with current substance abuse (OR, 1.88; 95% CI, 1.03-3.44) and more-severe depression (OR, 3.91 for moderate depression [95% CI, 2.12-7.22] and 25.55 for severe depression [95% CI, 12.73-51.30]). DISCUSSION Suicidal ideation was associated with current substance abuse and depression. The use of novel technologies to incorporate routine self-reported screening for suicidal ideation and other health domains allows for timely detection and intervention for this life-threatening condition.
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Affiliation(s)
- Sarah T Lawrence
- Department of Internal Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Damiani G, Pinnarelli L, Colosimo SC, Almiento R, Sicuro L, Galasso R, Sommella L, Ricciardi W. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. BMC Health Serv Res 2010; 10:2. [PMID: 20047686 PMCID: PMC2837004 DOI: 10.1186/1472-6963-10-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Accepted: 01/04/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines. METHODS Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care. RESULTS Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors. CONCLUSIONS From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.
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Affiliation(s)
- Gianfranco Damiani
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Luigi Pinnarelli
- San Filippo Neri-Hospital Trust-Rome, Italy, Piazza di Santa Maria della Pietà 5, 00135, Rome, Italy
| | - Simona C Colosimo
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Roberta Almiento
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Lorella Sicuro
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Rocco Galasso
- Oncological Referral Center of Basilicata (IRCCS CROB), Via Padre Pio 1, 85028, Rionero in Vulture, Potenza, Italy
| | - Lorenzo Sommella
- San Filippo Neri-Hospital Trust-Rome, Italy, Piazza di Santa Maria della Pietà 5, 00135, Rome, Italy
| | - Walter Ricciardi
- Department of Public Health-Università Cattolica Sacro Cuore-Rome, Largo Francesco Vito 1, 00168, Rome, Italy
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Kim HN, Harrington RD, Van Rompaey SE, Kitahata MM. Independent clinical predictors of impaired response to hepatitis B vaccination in HIV-infected persons. Int J STD AIDS 2008; 19:600-4. [PMID: 18725550 DOI: 10.1258/ijsa.2007.007197] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Protective response rates to hepatitis B (HB) vaccination have been reported as low as 18-62% in HIV-infected persons. The relative importance of various predictors for this poor response has not been fully characterized. In this retrospective cohort study, we examined the relationship between clinical characteristics and vaccine non-response (HB surface antibody <10 IU/L) among patients attending an urban HIV clinic. Among the 97 patients who met the inclusion criteria, 43 (44%) developed a protective antibody response. In multivariate analyses, age >40 years (odds ratio [OR] 3.03 [95% confidence interval [CI], 1.14-8.06]; P = 0.026) and alcohol abuse (OR 4.92 [95% CI, 1.72-20.89]; P = 0.007) were independent predictors of failure to develop vaccine response. In addition, CD4 nadir <200 (OR 7.24 [95% CI, 1.91-27.41]; P = 0.004), rather than CD4 current to vaccination, remained a strong independent risk factor. Patients with HIV viral suppression on highly active antiretroviral therapy had a significantly lower rate of vaccine failure (OR 0.31 [95% CI, 0.11-0.91]; P = 0.033), after adjusting for these other covariates. Our findings underscore the importance of confirming seroconversion after HB vaccination in HIV-infected patients and initiating vaccination early in the course of HIV infection.
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Affiliation(s)
- H Nina Kim
- Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
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Persistent Kaposi sarcoma in the era of highly active antiretroviral therapy: characterizing the predictors of clinical response. AIDS 2008; 22:937-45. [PMID: 18453853 DOI: 10.1097/qad.0b013e3282ff6275] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To evaluate the role of highly active antiretroviral therapy and chemotherapy on tumor response among persons with AIDS-related Kaposi sarcoma and identify factors associated with response in a clinic setting. DESIGN Retrospective cohort. METHODS One hundred and fourteen patients from two HIV clinics with a diagnosis of Kaposi sarcoma were identified via a clinical database. Records were reviewed to confirm Kaposi sarcoma diagnosis and abstract clinical and chemotherapy information. Demographics, laboratory values, and highly active antiretroviral therapy use were abstracted electronically. Cox's proportional hazards models identified predictors of Kaposi sarcoma improvement and resolution. RESULTS Thirty-six months following Kaposi sarcoma diagnosis, the rate of improvement among 64 patients with confirmed Kaposi sarcoma was 77% and that of complete resolution was 51%. In univariate analyses, recent chemotherapy was associated with Kaposi sarcoma improvement, and recent HIV viral load and highly active antiretroviral therapy were associated with both improvement and resolution. No measured baseline characteristics (tumor stage, diagnosis year, CD4 T-cell count, HIV viral load, or prior highly active antiretroviral therapy history) or recent CD4 T-cell counts predicted improvement or resolution. In multivariate analyses, recent chemotherapy (hazard ratio 5.5, 95% confidence interval: 2.7-11.2, P < 0.001) and highly active antiretroviral therapy (hazard ratio 4.1, 95% confidence interval: 1.4-12.6, P = 0.01) were predictors of improvement; only recent highly active antiretroviral therapy was associated with resolution (hazard ratio 6.2, 95% confidence interval: 1.5-26.4, P = 0.01). Response was not associated with type of highly active antiretroviral therapy regimen (non nucleoside reverse transcriptase inhibitor based, protease inhibitor based, or ritonavir-boosted protease inhibitor based). CONCLUSION Highly active antiretroviral therapy and chemotherapy are important in clinical Kaposi sarcoma response. Despite widespread availability of these therapies, Kaposi sarcoma continues to be a clinical problem; only half the patients achieved complete resolution of disease. New therapeutic approaches are needed.
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Lester WT, Zai AH, Chueh HC, Grant RW. Diabetes information technology: designing informatics systems to catalyze change in clinical care. J Diabetes Sci Technol 2008; 2:275-83. [PMID: 19885355 PMCID: PMC2771488 DOI: 10.1177/193229680800200218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current computerized reminder and decision support systems intended to improve diabetes care have had a limited effect on clinical outcomes. Increasing pressures on health care networks to meet standards of diabetes care have created an environment where information technology systems for diabetes management are often created under duress, appended to existing clinical systems, and poorly integrated into the existing workflow. After defining the components of diabetes disease management, the authors present an eight-step conceptual framework to guide the development of more effective diabetes information technology systems for translating clinical information into clinical action.
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Affiliation(s)
- William T Lester
- Laboratory of Computer Science, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Holodniy M, Hornberger J, Rapoport D, Robertus K, MaCurdy TE, Lopez J, Volberding P, Deyton L. Relationship Between Antiretroviral Prescribing Patterns and Treatment Guidelines in Treatment-Naive HIV-1-Infected US Veterans (1992-2004). J Acquir Immune Defic Syndr 2007; 44:20-9. [PMID: 17091020 DOI: 10.1097/01.qai.0000248354.63748.54] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze temporal patterns of antiretroviral (ARV) prescribing practices relative to nationally defined guidelines in treatment-naive patients with HIV-1 infection. DESIGN Retrospective cohort study. METHODS We evaluated ARV prescribing patterns among ARV treatment-naive veterans who were receiving care within the US Department of Veterans Affairs (VA) from 1992 through 2004 in comparison to evolving adult HIV-1 treatment guidelines. RESULTS A total of 15,934 patients initiated ARV treatment. Since 1999, >94% of patients initiated at least a 3-ARV medication combination, although the percentage of patients who initiated a guideline "preferred" or "alternative" regimen never rose to greater than 72% and was significantly associated with being black and with region of care. After 1999, 20% of patients started 4 or more active ARV agents in combination, which was significantly associated with lower baseline CD4 cell count, higher viral load, and receiving care in the western United States. The proportion of patients receiving guideline "not recommended" regimens (virologically undesirable or overlapping toxicities) was <1% after 1997. VA prescribing trends generally predated guideline recommendations by 6 to 12 months. CONCLUSIONS VA prescribing patterns for ARV initiation adhere to treatment guidelines that maximize safety. Guidelines designed to maximize efficacy were not followed as stringently. Evaluating clinical practice patterns against contemporary treatment guidelines can inform guideline development.
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Affiliation(s)
- Mark Holodniy
- AIDS Research Center, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94340, USA
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Altice FL, Mezger JA, Hodges J, Bruce RD, Marinovich A, Walton M, Springer SA, Friedland GH. Developing a directly administered antiretroviral therapy intervention for HIV-infected drug users: implications for program replication. Clin Infect Dis 2004; 38 Suppl 5:S376-87. [PMID: 15156426 DOI: 10.1086/421400] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Directly administered antiretroviral therapy (DAART) is one approach to improving adherence to among human immunodeficiency virus (HIV)-infected drug users. We evaluated the essential features of a community-based DAART intervention in a randomized, controlled trial of DAART versus self-administered therapy. Of the initial 72 subjects, 78% were racial minorities, and 32% were women. Social and medical comorbidities among subjects included homelessness (35% of subjects), lack of interpersonal support (86%), major depression (57%), and alcoholism (36%). At baseline, the median CD4+ cell count was 403 cells/mL and the median HIV-1 RNA load was 146,333 copies/mL (log10 5.31 copies/mL). During the prior 6 months, 33% of subjects had missed a medical appointment, and 47% had visited an emergency department. Although most subjects (67%) preferred to take their own medications, 76% would accept DAART if it were made compulsory. A methadone clinic was the DAART venue acceptable to the fewest subjects (36%), and a mobile syringe-exchange program was acceptable to the most subjects (83%). Adherence was higher for supervised than for unsupervised medication administration (P<.0001), a finding that supports use of daily supervision of once-daily regimens. Moreover, DAART should incorporate enhanced elements such as convenience, flexibility, confidentiality, cues and reminders, responsive pharmacy and medical services, and specialized training for staff.
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Affiliation(s)
- Frederick L Altice
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut 06510-2283, USA.
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Altice FL, Mezger JA, Hodges J, Bruce RD, Marinovich A, Walton M, Springer SA, Friedland GH. Developing a Directly Administered Antiretroviral Therapy Intervention for HIV-Infected Drug Users: Implications for Program Replication. Clin Infect Dis 2004. [DOI: 10.1086/421400 cid33205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Tedaldi EM, Baker RK, Moorman AC, Wood KC, Fuhrer J, McCabe RE, Holmberg SD. Hepatitis A and B vaccination practices for ambulatory patients infected with HIV. Clin Infect Dis 2004; 38:1478-84. [PMID: 15156488 DOI: 10.1086/420740] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Accepted: 01/21/2004] [Indexed: 12/12/2022] Open
Abstract
Few studies exist of adherence to guidelines for vaccination of persons infected with human immunodeficiency virus (HIV), especially in the era of highly active antiretroviral therapy (HAART). In a retrospective, cross-sectional analysis in the HIV Outpatient Study sites, 198 (32.4%) of 612 patients eligible for hepatitis B vaccine received at least 1 dose. In multivariate analysis, hepatitis B vaccination was associated with HIV risk category, education level, and number of visits to the HIV clinic per year. Among 716 patients eligible for hepatitis A vaccine, 167 (23.3%) received > or =1 dose. Response to hepatitis B vaccination was associated with higher nadir CD4+ cell counts (P=.008) and HIV RNA levels less than the level of detection (P=.04), although some response was documented at all CD4+ levels. Although there were low rates of complete hepatitis vaccination in this cohort of ambulatory patients, prompt efforts to vaccinate patients entering care, receipt of antiretroviral therapy, and practice reminder systems may enhance vaccination practices.
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Affiliation(s)
- Ellen M Tedaldi
- General Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA.
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Patterson ES, Nguyen AD, Halloran JP, Asch SM. Human factors barriers to the effective use of ten HIV clinical reminders. J Am Med Inform Assoc 2003; 11:50-9. [PMID: 14527974 PMCID: PMC305458 DOI: 10.1197/jamia.m1364] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Substantial variations in adherence to guidelines for human immunodeficiency virus (HIV) care have been documented. To evaluate their effectiveness in improving quality of care, ten computerized clinical reminders (CRs) were implemented at two pilot and eight study sites. The aim of this study was to identify human factors barriers to the use of these CRs. DESIGN Observational study was conducted of CRs in use at eight outpatient clinics for one day each and semistructured interviews were conducted with physicians, pharmacists, nurses, and case managers. MEASUREMENTS Detailed handwritten field notes of interpretations and actions using the CRs and responses to interview questions were used for measurement. RESULTS Barriers present at more than one site were (1) workload during patient visits (8 of 8 sites), (2) time to document when a CR was not clinically relevant (8 of 8 sites), (3) inapplicability of the CR due to context-specific reasons (9 of 26 patients), (4) limited training on how to use the CR software for rotating staff (5 of 8 sites) and permanent staff (3 of 8 sites), (5) perceived reduction of quality of provider-patient interaction (3 of 23 permanent staff), and (6) the decision to use paper forms to enable review of resident physician orders prior to order entry (2 of 8 sites). CONCLUSION Six human factors barriers to the use of HIV CRs were identified. Reducing these barriers has the potential to increase use of the CRs and thereby improve the quality of HIV care.
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Affiliation(s)
- Emily S Patterson
- VA Getting at Patient Safety Center, Cincinatti VAMC, The Ohio State University, Columbus, OH 43210, USA.
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