A large hospital system in Cleveland implemented a simple and cost-effective strategy that rapidly and significantly increased the percentage of people receiving HIV testing for the first time.
Starting in July 2010, MetroHealth Medical Center and 11 affiliated community health centers added a prompt to their electronic medical record system. The prompt reminds providers to discuss and offer HIV testing to all untested patients aged 13-64 years, which the Centers for Disease Control and Prevention recommends for health care settings.
"About a week after the implementation went live, testing doubled, which was fabulous," Dr. Ann Avery said during a press telebriefing at the 2011 National HIV Prevention Conference sponsored by the Centers for Disease Control and Prevention. Dr. Avery holds dual positions as an infectious disease attending physician at MetroHealth and as medical director of the Cleveland Department of Public Health.
HIV testing nearly doubled in the 6 months after implementation at five of the outpatient health centers. Patient encounters led to 6,313 instances of HIV testing between July and December 2010, up from 3,851 instances in the first half of the year.
After the intervention, first-time testing among men increased from 2.9% to 6.1%, a significant difference. Researchers also found the proportion of patients never tested for HIV dropped from 58% to 54%.
"As of March 2011, testing has continued to increase on a significant basis among those getting first-time tested," Dr. Avery said.
"We see this as a cost-effective and fairly simple structural intervention that helped normalize testing for the providers and decreased barriers to getting individuals tested," Dr. Avery said. "We believe in settings where an electronic medical record system is in place [that] this may be a helpful structural intervention."
The study included a total of 524,074 outpatient clinic encounters and 49,046 hospital inpatient encounters between January 2008 and December 2010.
Dr. Avery and her associates were motivated by initial data that revealed only 4% of approximately 372,000 primary care encounters included HIV testing during 2008 and 2009 at MetroHealth’s primary care clinics and five outpatient sites. The low testing rate existed despite provider education efforts on CDC testing guidelines, she added.
The majority of men, 79%, had never been tested and therefore missed an opportunity for HIV screening between 1999 and their encounter in 2008 or 2009, Dr. Avery said. The women fared a little better, she added, with 50% of women of childbearing age tested, largely because of prenatal care screening.
"We have dramatically decreased missed opportunities for men of all ages and women, especially [those] 40 and older, although all women also benefited."
Dr. Avery and her associates used these findings to educate providers and to leverage the health system’s administrative power to add HIV to their list of preventive screening for health maintenance.
"We also updated our educational effort to focus on some of the [provider] barriers like communication and fear of talking," Dr. Avery said. MetroHealth offered a 1-hour, voluntary clinician education on improvement of communications skills and comfort level and knowledge related to HIV screening, relevant Ohio laws, and provision of test results.
Although patient and provider education can help to reduce barriers to HIV testing, this study indicates those efforts alone are insufficient, Dr. Avery said. An operational change added to education efforts may be required to increase routine HIV testing.
"These are impressive results," Dr. Jonathan Mermin, director of the CDC’s Division of HIV/AIDS Prevention, said at the press briefing "A relatively simple change ... has had a major impact on increasing uptake of routine HIV."
"I hope that the changes they were able to make in Cleveland will serve as an inspiration and model to other health care systems," he said.