MAIN IMPLEMENTATION PROJECT:
Although studies have shown that real-time computerized clinical reminders (CR) modestly improve essential chronic disease care processes, no studies have compared the separate and combined effects of CR and group-based quality improvement (GBQI) collaboratives.
To evaluate CR, GBQI, and the interaction of the two in improving HIV quality (Step 4, Phase 2 per the QUERI framework).
Using a quasi-experimental design, 4091 patients in 16 VA facilities were stratified into four groups: CR, GBQI, CR+GBQI, and controls. CR facilities received software and technical assistance in implementing real time reminders. GBQI facilities participated in a year-long collaborative emphasizing rapid cycle quality improvement targets of their choice. Ten predefined clinical endpoints included the receipt of highly active antiretroviral (ARV) therapy, screening and prophylaxis for opportunistic infection, as well as monitoring of immune function and viral load. Optimal overall care was defined as receiving all care for which the patient was eligible. Interventional effects were estimated using clustered logistic regression, controlling for clinical and facility characteristics. Human subjects' protection approval was obtained.
Compared to controls, CR facilities improved the likelihood of hepatitis A, toxoplasma, and lipid screening. GBQI alone improved the likelihood of pneumocystis pneumonia prophylaxis, immune-monitoring on ARVs – but reduced the likelihood of hepatitis B screening. CR+GBQI facilities improved hepatitis A and toxoplasma screening, as well as immune-monitoring on ARV. CR+GBQI facilities improved the proportion of patients receiving optimal overall care (OR = 2.65; CI: 1.16–6.0), while either modality alone did not.
The effectiveness of CR and GBQI interventions varied by endpoint. The combination of the two interventions was effective in improving overall optimal care quality.
SUSTAINABILITY ANALYSIS SUPPLEMENT:
To ascertain whether the implemented interventions were sustained and became part of routine care, we measured the original outcomes for one additional year and evaluated continued intervention use at selected sites.
Interviews with key informants selected from the study sites revealed that some sites had ceased using the interventions, and some control sites had adopted them; analyzing odds of patients receiving guideline-based HIV care (HIVGBC) compared to controls no longer made sense. Thus, we evaluated sustained performance as follows: At the facility-rather than the arm-level, we examined raw rates of patients receiving HIVGBC at only those facilities in the intervention arms that had significant effects in the study year to determine whether they continued to show a significant increase in these rates in the following year, compared to their raw rate at baseline. We also conducted a qualitative component. Based on formative evaluation results assessing the use and usefulness of the reminders, we asked informants if identified barriers were subsequently removed and recommendations heeded. Also, we evaluated the extent to which staff members from the sites that participated in the collaboratives were still conducting rapid-cycle improvement methods to address local care quality problems; whether they still maintained the social networks established during the original study, and the degree to which they were used to disseminate subsequent quality improvement change ideas, and shared network contacts with – and taught the method to new staff.
For hepatitis A screening, we found that 4 out of the 5 sites that showed a significant increase in their raw rate at 12 months, also showed a significant increase in their raw rate at 24 months compared to baseline (p = .05). For the other four significant indicators of HIVGBC (hepatitis C and toxoplasma screening, CD4/viral load and lipids monitoring), all sites that showed significant increases in their raw performance rates at 12 months, showed a significant increase in their raw rates at 24 months compared to baseline.
Intervention effects were sustained for one year at nearly all the sites that showed significant increases in performance during the study period. Nearly all sites exposed to reminders were using at least some of the 10 available in the follow-up year. Collaborative methods were still being used, but only at the most activated of the original study sites.