1
|
Leber W, Panovska-Griffiths J, Martin P, Morris S, Capelas Barbosa E, Estcourt C, Hutchinson J, Shahmanesh M, El-Shogri F, Boomla K, Delpech V, Creighton S, Anderson J, Figueroa J, Griffiths C. Evaluating the impact of post-trial implementation of RHIVA nurse-led HIV screening on HIV testing, diagnosis and earlier diagnosis in general practice in London, UK. EClinicalMedicine 2020; 19:100229. [PMID: 32140667 PMCID: PMC7046496 DOI: 10.1016/j.eclinm.2019.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 11/14/2019] [Accepted: 11/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND UK and European guidelines recommend HIV testing in general practice. We report on the implementation of the Rapid HIV Assessment trial (RHIVA2) promoting HIV screening in general practice into routine care. METHODS Interrupted time-series, difference-in-difference analysis and Pearson-correlation on three cohorts comprising 42 general practices in City & Hackney (London, UK); covering three periods: pre-trial (2009-2010), trial (2010-2012) and implementation (2012-2014). Cohorts comprised practices receiving: "trial intervention" only (n = 19), "implementation intervention" only (n = 13); and neither ("comparator") (n = 10). Primary outcomes were HIV testing and diagnosis rates per 1000 people and CD4 at diagnosis. FINDINGS Overall, 55,443 people were tested (including 38,326 among these cohorts), and 101 people were newly diagnosed HIV positive (including 65 among these cohorts) including 74 (73%) heterosexuals and 69 (68%) people of black African/Caribbean background; with mean CD4 count at diagnosis 357 (SD=237). Among implementation intervention practices, testing rate increased by 85% (from 1·798 (95%CI=(1·657,1·938) at baseline to 3·081 (95%CI=(2·865,3·306); p = 0·0000), diagnosis rate increased by 34% (from 0·0026 (95%CI=(0·0004,0·0037)) to 0·0035 (95%CI=(0·0007,0·0062); p = 0·736), and mean CD4 count at diagnosis increased by 55% (from 273 (SD=372) to 425 (SD=274) cells per μL; p = 0·433). Implementation intervention and trial intervention practices achieved similar testing rates (3·764 vs. 3·081; 6% difference; 95% CI=(-5%,18%); p = 0·358), diagnosis rates (0·0035 vs. 0·0081; -13% difference; 95%CI=(-77%,244%; p = 0·837), and mean CD4 count (425 (SD=274) vs. 351 (SD=257); 69% increase; 95% CI=(-61%,249%); p = 0·359). HIV testing was positively correlated with diagnosis (r = 0·114 (95% CI=[0·074,0·163])), and diagnosis with CD4 count at diagnosis (r = 0·011 (95% CI=[-0·177,0·218])). INTERPRETATION Implementation of the RHIVA programme promoting nurse-led HIV screening into routine practice in inner-city practices with high HIV prevalence increased HIV testing, and may be associated with increased and earlier diagnosis. HIV screening in primary care should be considered a key strategy to reduce undiagnosed infection particularly among high risk persons not attending sexual health services. FUNDING National Institute for Health Research ARC North Thames, and Barts and The London School of Medicine and Dentistry.
Collapse
Affiliation(s)
- Werner Leber
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London United Kingdom
- Corresponding authors.
| | - Jasmina Panovska-Griffiths
- Department of Applied Health Research, University College London, London, United Kingdom
- Institute for Global Health, University College London, London, United Kingdom
- Corresponding authors.
| | - Peter Martin
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, United Kingdom
- Institute of Public Health, University of Cambridge, Cambridge United Kingdom
| | - Estela Capelas Barbosa
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Claudia Estcourt
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom
- All East Sexual Health Services, Barts Health NHS Trust, London, United Kingdom
| | - Jane Hutchinson
- All East Sexual Health Services, Barts Health NHS Trust, London, United Kingdom
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, United Kingdom
| | - Farah El-Shogri
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London United Kingdom
| | - Kambiz Boomla
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London United Kingdom
| | - Valerie Delpech
- Department of HIV and STI, National Infection Service, Public Health England, London, United Kingdom
| | - Sarah Creighton
- Department of HIV and STI, National Infection Service, Public Health England, London, United Kingdom
| | - Jane Anderson
- Homerton Sexual Health Services, Homerton University Hospital NHS Foundation Trust, London, United Kingdom
| | - Jose Figueroa
- Specialised Commissioning Team, NHS England, London, United Kingdom
| | - Chris Griffiths
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London United Kingdom
| |
Collapse
|
2
|
Barbosa EC, Verhoef TI, Morris S, Solmi F, Johnson M, Sohal A, El-Shogri F, Dowrick S, Ronalds C, Griffiths C, Eldridge S, Lewis NV, Devine A, Spencer A, Feder G. Cost-effectiveness of a domestic violence and abuse training and support programme in primary care in the real world: updated modelling based on an MRC phase IV observational pragmatic implementation study. BMJ Open 2018; 8:e021256. [PMID: 30158224 PMCID: PMC6119435 DOI: 10.1136/bmjopen-2017-021256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 07/03/2018] [Accepted: 07/31/2018] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To evaluate the cost-effectiveness of the implementation of the Identification and Referral to Improve Safety (IRIS) programme using up-to-date real-world information on costs and effectiveness from routine clinical practice. A Markov model was constructed to estimate mean costs and quality-adjusted life-years (QALYs) of IRIS versus usual care per woman registered at a general practice from a societal and health service perspective with a 10-year time horizon. DESIGN AND SETTING Cost-utility analysis in UK general practices, including data from six sites which have been running IRIS for at least 2 years across England. PARTICIPANTS Based on the Markov model, which uses health states to represent possible outcomes of the intervention, we stipulated a hypothetical cohort of 10 000 women aged 16 years or older. INTERVENTIONS The IRIS trial was a randomised controlled trial that tested the effectiveness of a primary care training and support intervention to improve the response to women experiencing domestic violence and abuse, and found it to be cost-effective. As a result, the IRIS programme has been implemented across the UK, generating data on costs and effectiveness outside a trial context. RESULTS The IRIS programme saved £14 per woman aged 16 years or older registered in general practice (95% uncertainty interval -£151 to £37) and produced QALY gains of 0.001 per woman (95% uncertainty interval -0.005 to 0.006). The incremental net monetary benefit was positive both from a societal and National Health Service perspective (£42 and £22, respectively) and the IRIS programme was cost-effective in 61% of simulations using real-life data when the cost-effectiveness threshold was £20 000 per QALY gained as advised by National Institute for Health and Care Excellence. CONCLUSION The IRIS programme is likely to be cost-effective and cost-saving from a societal perspective in the UK and cost-effective from a health service perspective, although there is considerable uncertainty surrounding these results, reflected in the large uncertainty intervals.
Collapse
Affiliation(s)
| | | | - Steve Morris
- University College London, Department of Applied Health Research, London, UK
| | - Francesca Solmi
- Division of Psychiatry, University College London, London, UK
| | | | - Alex Sohal
- NIHR CLAHRC North Thames at Bart's Health NHS Trust, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Farah El-Shogri
- NIHR CLAHRC North Thames at Bart's Health NHS Trust, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Susanna Dowrick
- NIHR CLAHRC North Thames at Bart's Health NHS Trust, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Clare Ronalds
- Pankhurst Trust Incorporating, Manchester Women's Aid, Manchester, UK
| | - Chris Griffiths
- NIHR CLAHRC North Thames at Bart's Health NHS Trust, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Sandra Eldridge
- NIHR CLAHRC North Thames at Bart's Health NHS Trust, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Natalia V Lewis
- NIHR CLAHRC North Thames at Bart's Health NHS Trust, Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Angela Devine
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Anne Spencer
- University of Exeter Medical School, Exeter, Devon, UK
| | - Gene Feder
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| |
Collapse
|
3
|
Sohal AH, Feder G, Barbosa E, Beresford L, Dowrick A, El-Shogri F, Howell A, Lewis N, Johnson M, Nightingale C, Boomla K, Morris S, Eldridge S, Griffiths C. Improving the healthcare response to domestic violence and abuse in primary care: protocol for a mixed method evaluation of the implementation of a complex intervention. BMC Public Health 2018; 18:971. [PMID: 30075711 PMCID: PMC6091071 DOI: 10.1186/s12889-018-5865-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/19/2018] [Indexed: 11/28/2022] Open
Abstract
Background Domestic violence and abuse remains a major health concern. It is unknown whether the improved healthcare response to domestic violence and abuse demonstrated in a cluster randomised controlled trial of IRIS (Identification and Referral to Improve Safety), a complex intervention, including general practice based training, support and referral programme, can be achieved outside a trial setting. Aim: To evaluate the impact over four years of a system wide implementation of IRIS, sequentially into multiple areas, outside the setting of a trial. Methods An interrupted time series analysis of referrals received by domestic violence and abuse workers from 201 general practices, in five northeast London boroughs; alongside a mixed methods process evaluation and qualitative analysis. Segmented regression interrupted time series analysis to estimate impact of the IRIS intervention over a 53-month period. A secondary analysis compares the segmented regression analysis in each of the four implementation boroughs, with a fifth comparator borough. Discussion This is the first interrupted time series analysis of an intervention to improve the health care response to domestic violence. The findings will characterise the impact of IRIS implementation outside a trial setting and its suitability for national implementation in the United Kingdom. Electronic supplementary material The online version of this article (10.1186/s12889-018-5865-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Alex Hardip Sohal
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England.
| | - Gene Feder
- School of Social and Community Medicine, University of Bristol, Bristol, England
| | - Estela Barbosa
- Department of Applied Health Research, University College London, London, England
| | - Lee Beresford
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | - Anna Dowrick
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | - Farah El-Shogri
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | | | - Natalia Lewis
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | | | - Claire Nightingale
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | - Kambiz Boomla
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, England
| | - Sandra Eldridge
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| | - Chris Griffiths
- Queen Mary University of London, Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, London, England
| |
Collapse
|
4
|
Leber W, Beresford L, Nightingale C, Barbosa EC, Morris S, El-Shogri F, McMullen H, Boomla K, Delpech V, Brown A, Hutchinson J, Apea V, Symonds M, Gilliham S, Creighton S, Shahmanesh M, Fulop N, Estcourt C, Anderson J, Figueroa J, Griffiths C. Effectiveness and cost-effectiveness of implementing HIV testing in primary care in East London: protocol for an interrupted time series analysis. BMJ Open 2017; 7:e018163. [PMID: 29247095 PMCID: PMC5735409 DOI: 10.1136/bmjopen-2017-018163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION HIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets). METHODS AND ANALYSIS Service evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses. ETHICS AND DISSEMINATION The chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.
Collapse
Affiliation(s)
- Werner Leber
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Lee Beresford
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Claire Nightingale
- Population Health Research Institute, St George’s, University of London, London, UK
| | | | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Farah El-Shogri
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Heather McMullen
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Kambiz Boomla
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Valerie Delpech
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Alison Brown
- Department of HIV and STI, National Infection Service, Public Health England, London, UK
| | - Jane Hutchinson
- Barts Sexual Health Centre, Barts Health NHS Trust, London, UK
| | - Vanessa Apea
- Barts Sexual Health Centre, Barts Health NHS Trust, London, UK
| | - Merle Symonds
- Barts Sexual Health Centre, Barts Health NHS Trust, London, UK
| | | | - Sarah Creighton
- Centre for Sexual Health, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Maryam Shahmanesh
- Department of Applied Health Research, University College London, London, UK
| | - Naomi Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Claudia Estcourt
- Barts Sexual Health Centre, Barts Health NHS Trust, London, UK
- School of Health and Life Sciences, Glasgow Caledonian University, London, UK
| | - Jane Anderson
- Centre for Sexual Health, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Jose Figueroa
- Specialised Commissioning Team, NHS England, London, UK
| | - Chris Griffiths
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| |
Collapse
|