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Missed Opportunities:
Improving Rates of HIV Screening and Linkage
among Primary Care Providers
Ann D. Bagchi, PhD, BSN, RN May 19, 2017
Missed Opportunities
2
BACKGROUND
Missed Opportunities
3
The Role of Primary Care
• Available tests are very accurate in detecting HIV
• Identifying those infected allows earlier initiation of antiretroviral therapy
• Testing is cost effective
• Risk-based screening is ineffective in identifying everyone
• Increasing routine screening can help to address HIV-related stigma
Rationale for routine screening (USPSTF)
Eradicating HIV requires participation of Primary Care Providers (PCPs)
• Since 2006, the Centers for Disease Control and Prevention (CDC) has recommended routine screening for everyone ages 13 to 64
• In 2013, the CDC recommendation was endorsed by the United States Preventive Services Task Force (USPSTF)
• Providers may not ask the right questions
• Patients do not think they are at risk
• Patients may not want to divulge risk behaviors to providers
Risk-based screening is ineffective
Missed Opportunities
PCPs are less likely to follow guidelines with a
public health benefit
168,000 people are living with HIV but
undiagnosed
4
Needs Assessment
Rates of routine testing are suboptimal
Evidence-based interventions are needed to overcome PCPs’
barriers to offering and implementing routine HIV testing
Approximately 6,800 may be undiagnosed
in New Jersey
PLHIV who are unaware of their
status are responsible for 30% of new transmissions
67% among HIV PCPs versus 38% among
non-HIV PCPs
HIV PCPs who are not credentialed as HIV
specialists have lower rates of routine HIV
testing than specialty providers
Focus on individual health concerns and
outcomes
Emphasize perceived individual risk factors
and behaviors for preventable conditions
Missed Opportunities
5
DOCTOR OF NURSING PRACTICE PROJECT
Missed Opportunities
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Objectives and Aims
• Identify PCPs’ barriers/facilitators to routine HIV testing
• Identify evidence-based approaches to improving guideline adherence
• Map testing barriers to evidence-based interventions
• Deliver interventions in a sample of PCPs
• Evaluate the effectiveness of interventions using a pre-/post-test design
Missed Opportunities
• PCPs (MDs / DOs / APNs / PAs)
• Provide health care services to consumers ages 13 to 64
• Family practice/Internal medicine/Pediatrics
7
Participants / Setting
• Qualtrics on-line survey (baseline and follow-up)
Participant background / practice characteristics
Frequency of HIV screening
Barriers to routine screening
• Interventions
Evidence-based / practice-specific
Delivered via customized PowerPoint presentation
• Expected outcomes
Increased frequency of offering routine HIV screening
Increased screening by visit type/patient characteristics
Approach
Missed Opportunities
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Intervention
• HIV prevalence/Care Continuum
• CDC/USPSTF recommendations
• Stigma/Ryan White
• Top 3 barriers identified from baseline survey
• Linked to TDF domains and evidence-based behavioral change techniques
• Copies of guidelines
• Referral sources/Ryan White providers
• Reporting forms/billing codes
• Patient/provider educational materials
• Interview: Dr. Yelena Karasina
Missed Opportunities
9
Missed Opportunities
10
Lack of Referral Sources
Primary care providers are increasingly providing care for people living with HIV in consultation with experts:
Contact Ryan White-funded sites for access to HIV specialists
(See Resources for list of sites in NJ)
For additional assistance identifying resources and referrals, contact:
848-932-4191 or
[email protected] 800-624-2377
Missed Opportunities
11
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HIV SpecialistsWorking in Primary
Care Settings
Non-HIV SpecialistsWorking in HIVPrimary Care
Non-HIV SpecialistsWorking in Non-HIV
Primary CareSettings
Reported Estimatefor Your Practice
78%
57%
38%
5%
Rates of Routine HIV Screening
Missed Opportunities
12
FINDINGS
Missed Opportunities
13
Education on HIV in the Last 3 years
8%
15%
15%
23%
23%
23%
39%
39%
46%
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
ONLINE WEBINAR
GRAND ROUNDS
JOURNAL ARTICLE
CONFERENCE PRESENTATION
TEXTBOOK
NONE
ACADEMIC COURSE
DISCUSSION WITH AN EXPERT/COLLEAGUE
CONTINUING EDUCATION COURSE
Missed Opportunities
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Barriers Identified
Patients do not want to be tested for HIV.
Difficulty screening adolescents when accompanied by a parent/guardian.
Financial costs to patients if testing is not covered by insurance.
It should be the patient’s responsibility to request an HIV test.
Lack of access to point-of-care testing (i.e., a rapid test) for HIV.
Suggesting HIV testing might damage the patient-provider relationship.
It is not the responsibility of primary care providers to conduct HIV screening.
Discomfort discussing HIV risk behaviors with patients.
Discomfort discussing a positive test result with a patient.
Uncertainty about the legal obligations for reporting a positive test result.
HIV screening should be limited to those with risk factors for infection.
Lack of referral sources if a patient tested positive for HIV.
Pre-test counseling significantly lengthens the time required to screen for HIV.
Inadequate training in how to discuss HIV with patients.
HIV screening is not relevant to the reason for the patient visit.
Risk of breaking patient confidentiality when billing for HIV screening.
Lack of standardized practice protocol for HIV screening.
Lack of awareness of the CDC recommendation.
Lack of support for HIV screening among practice administration.
Forgetting to screen for HIV.
Missed Opportunities
15
25
20
80
90
5 5
20
35
4
10
1
20
50 50
20
80
70
10 10
25
75
10
25
0 0 0 0
10
20
30
40
50
60
70
80
90
100
PCP01 PCP03 PCP06 PCP08 PCP09 PCP10 PCP12 PCP13 PCP14 PCP16 PCP17 PCP07 PCP15
Rep
ort
ed
% o
f P
ati
en
ts S
cre
en
ed
Primary Care Providers (Coded)
Pre (Mean = 28.1%)
Post (Mean = 34.1%)
Pre vs Post: % of Patients Screened
Missed Opportunities
16
Pre vs Post: % of Patients Screened by Encounter
Missed Opportunities
17
Pre vs Post: % of Patients Screened by Age Groups
Missed Opportunities
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Pre vs Post: % of Patients Screened by Patient Presentation
Missed Opportunities
19
Interview with Dr. Karasina
• Lack of awareness of HIV Testing Law
• Fear of damaging patient / provider relationship
• Perception regarding stigma among patients
• Incorporating HIV screening into the electronic medical record
• Identified 3 patients who were infected with HIV
Patients she would not have thought to screen
Would not have been identified otherwise
Patients referred to infectious disease specialist
Missed Opportunities
20
IMPLICATIONS
Missed Opportunities
21
Opportunities
Ryan White-funded providers can help PCPs improve prevention and care
• Provide access to rapid testing
• Serves as referral sites when patients test positive
• Act as expert consultants for PCPs willing to provide care for PLHIV
• Offer education to enhance competencies of PCPs
Policy initiatives could enhance screening rates
Increasing routine screening in primary care can help identify PLHIV
• Require continuing education credits on HIV screening for PCPs
• Adopt an HIV Testing Law in New Jersey
• Implement interventions to address HIV-related stigma
Missed Opportunities
22
Enhancing Linkages
Missed Opportunities
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Q & A
Missed Opportunities
24
Ann D. Bagchi, PhD, DNP-F, RN Instructor, School of Nursing
Rutgers University – Newark
366 Ackerson Hall
180 University Avenue
Newark, NJ 07102
(973) 353-1042
Contact Information
Missed Opportunities
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