Improving HIV Care Quality
Steven M. Asch MD MPH
VA Greater Los Angeles Healthcare System
Los Angeles, CA
Funding Period: August 2001 - December 2004

BACKGROUND/RATIONALE:
The VA is the largest single provider of HIV care in the United States. The late 1990's have seen a revolution in the quality standards for this disease with the onset of Highly Active Antiretroviral Therapy (HAART) and other developments.

OBJECTIVE(S):
The objective in this project is to develop a method for assessing quality in two important areas of HIV care - antiretroviral medications and opportunistic infection screening and prophylaxis - and explore the determinants of high quality care in order to suggest quality improvement strategies.

METHODS:
The analysis has four parts. First, we described the level of adherence to the indicators in VA HIV patients nationwide and compared VA HIV patients to national benchmarks. Second, we analyzed facility and patient level predictors of adherence to indicators of quality care and compared them with the predictors in the non VA population using staged logistic regressions. Third, we validated certain indicators (e.g., HAART therapy) against clinical outcomes like hospitalization and immune status. We have also modeled the clinical "price" that the VA pays for suboptimal clinical outcomes as a result of current performance levels. Fourth, we compared the performance of the facilities after one year of an intensive targeted indicator-specific feedback group versus those who received aggregate data only.

FINDINGS/RESULTS:
CR+GBQI facilities improved the proportion of patients with optimal overall care while either modality alone did not (OR=2.65, 95%CI 1.16-6.00). The pattern of improvement of component quality indicators varied. CR+GBQI facilities improved relative to controls on three (hepatitis A, toxoplasmosis screening, immune monitoring) as did CR alone (hepatitis A, toxoplasmosis and lipid screening). GBQI alone improved two endpoints (PCP prophylaxis and immune monitoring) but declined on one (hepatitis B screening).

IMPACT:
Within the VA, the results of this analysis will enable us to make concrete suggestions to focus VA quality improvement efforts at the patient, facility, and delivery system level. Outside the VA, predictors of quality within a system where access is more uniformly distributed provoke great interest. We will disseminate the results both though internal VA educational channels and peer reviewed journals.

PUBLICATIONS:

Journal Articles

1. Kanwal F, Gralnek IM, Hays RD, Dulai GS, Spiegel BM, Bozzette S, Asch S. Impact of chronic viral hepatitis on health-related quality of life in HIV: results from a nationally representative sample. American Journal of Gastroenterology. 2005; 100(9): 1984-94.
2. Korthuis PT, Anaya HD, Bozzette SA, Brinkerhoff CV, Mancewicz M, Wang M, Asch SM. Quality of HIV care withing the Veterans Affairs Health System: A comparison using outcomes from the HIV Cost and Services Utilization Study (HCSUS). Journal of Clinical Outcomes Management. 2004; 11(12): 765-774.
3. Anaya HD, Yano EM, Asch SM. Early adoption of human immunodeficiency virus quality improvement in Veterans Affairs medical centers: use of organizational surveys to measure readiness to change and adapt interventions to local priorities. American Journal of Medical Quality. 2004; 19(4): 137-44.
4. Korthuis PT, Asch SM, Anaya HD, Morgenstern H, Goetz MB, Yano EM, Rubenstein LV, Lee ML, Bozzette SA. Lipid screening in HIV-infected veterans. Journal of Acquired Immune Deficiency Syndromes. 2004; 35(3): 253-60.

DRA: Chronic Diseases, Health Services and Systems
DRE: Quality of Care, Treatment, Communication and Decision Making
Keywords: Cost, HIV/AIDS, Translation
MeSH Terms: none