Fostering Transformational Change in an Integrated System:

The Case of HIV Testing

Steven M. Asch MD MPH

VA GLAHS/UCLA/RAND

Examples of Broad Systemic Reforms for Quality

In the Early 1990s, a Prominent Health Care Provider Was at a

Crossroads

• Its failings were widely publicized in the news media and popular movies

• Studies showed serious access, quality and satisfaction problems

• Some argued that this health organization needed new management

But Within 10 Years, Its Quality Greatly Improved

• The organization’s quality of care was found “significantly better” than that of Medicare on 11 out of 12 measures (Jha 2003)

• It provided better care than commercial insurers to diabetes patients on 7 out of 7 measures (Kerr 2004)

The VA Implemented Important Reforms

• Expansion of primary care

• Researcher-administrator partnership

• Electronic medical records system

– Tracks patients

– Alerts clinicians of needed care

The VA Implemented Important Reforms

• Performance tracking of key indicators especially chronic and preventive care

• Managers held accountable

• Able to allocate resources across integrated system

• Big investment

VA National

Source Administrative data

Random sample

Sites 26 facilities 12 cities

Number of patients

597 992

Chronic conditions per patient

2.9 2.3

Age 62 59

Overall, VA Patients Were More Likely to Receive Recommended Care

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VANational Sample

Asch Annals Int Med 2004

National Sample Adjusted Overall Quality by Income

53 55 57

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<$15k $15-$50k >$50k

Overall

(52-54) (54-56) (56-58)

The VA Scored Higher Across the Spectrum of Health Care

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VA

NationalSample

Diagnosis Follow-UpScreening Treatment

The VA Outpaced the National Sample on Chronic and Preventive Care

0102030405060708090

100

Chronic Preventive Acute

VA

NationalSample

The VA Scored Higher on Care that It Measured

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VA-Targeted Performance Measures

Measures Unrelated to VA Targets

VA Also Scored Higher in Areas

Related to Measured Processes

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VA-Targeted Performance Measures

Measures Unrelated to VA Targets

Related Performance Measures

Performance Measurement Chain Reaction

Influenza Vaccination

Pneumonia Vaccination

Tetanus Vaccination

Checking Hearing

Targeted Process

Related Processes

Lessons from Integrated VA Model• Health information technology is important

and easier for integrated systems, but it’s not enough

• Performance measurement, QI, and accountability are also critical

• Integration of service delivery and financing allows for strategic resource allocation

• Organizational determinants of quality are just as important as individual determinants

HIV/Hepatitis QUERI

• VA as a QI laboratory• Teams HSR researchers and national QI

managers• Translation project to improve HIV testing

rates merged several streams of organizational change: – Systemic redesign– Clinical reminders– Provider activation

We Had to Make a Case to VA Managers

• HIV easier/cheaper to treat if HIV easier/cheaper to treat if detected early (~<$25,000/QALY)detected early (~<$25,000/QALY)

• VA has high prevalence of HIV VA has high prevalence of HIV (~2%)(~2%)

• VA performance falls short (~20%)VA performance falls short (~20%)

• Therefore we should improve Therefore we should improve screening and testing ratesscreening and testing rates

They Asked Us a Question

““You’ve given us a strong rationale for You’ve given us a strong rationale for long-term benefits of earlier long-term benefits of earlier identification, but what is the short identification, but what is the short term impact of increasing screening term impact of increasing screening and an acute influx of HIV patients on and an acute influx of HIV patients on the system?”the system?”

or

“Where is it coming out of my budget when?”

Business Case Modeling

• Data-driven models for making Data-driven models for making managerial or technical managerial or technical decisions decisions

• Valuable tool for program Valuable tool for program managers although underused managers although underused in public sectorin public sector

Excerpt of Modeling Process

Quarter on Quarter Increases in Overall

Costs

300000

350000

400000

450000

500000

550000

600000

1st Qtr 2ndQtr

3rd Qtr 4th Qtr

30 to 40%

30 to 50%

Increasing HIV screening rates from…

Barriers to HIV Testing

• Organizational

• Cumbersome written informed consent & pre-

test counseling

• Provider time constraints, especially post-test

• Provider behaviors

• Incomplete recognition of HIV risk factors

• Belief that only trained counselors can do

HIV counseling

System Redesign

• Streamlined counseling

• Telephonic notification of negative tests

• Removed restrictions on who could

order tests

• Audit-feedback: clinic level progress

reports

Provider Activation

• Leverage group dynamics

• Academic detailing

• Social marketing

• Opinion leaders

Implementation and Evaluation Plan

• Prospective, controlled quasi-experimental

implementation in southern CA and NV

• Primary endpoints

– Rate of evaluation for HIV

– Rate of HIV testing in at-risk patients

HIV Testing & Evaluation RatesOne Year Post Intervention

0%

20%

40%

60%

80%

100%

GLA GLA SD SD LV LV LB LB LL LL

HIV Testing HIV Evaluation without testingSite A Site B Site C Site D Site E

Primary care clinics

Conclusion

• Integrated systems have many of the elements for transformational change.

• Integrated systems can serve as a laboratory for more focused QI programs

• How these elements can be transferred to more distributed systemd remains an area for future research.