15,198 research outputs found

    Implementation of repeat HIV testing during pregnancy in Kenya: a qualitative study.

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    BackgroundRepeat HIV testing in late pregnancy has the potential to decrease rates of mother-to-child transmission of HIV by identifying mothers who seroconvert after having tested negative for HIV in early pregnancy. Despite being national policy in Kenya, the available data suggest that implementation rates are low.MethodsWe conducted 20 in-depth semi-structured interviews with healthcare providers and managers to explore barriers and enablers to implementation of repeat HIV testing guidelines for pregnant women. Participants were from the Nyanza region of Kenya and were purposively selected to provide variation in socio-demographics and job characteristics. Interview transcripts were coded and analyzed in Dedoose software using a thematic analysis approach. Four themes were identified a priori using Ferlie and Shortell's Framework for Change and additional themes were allowed to emerge from the data.ResultsParticipants identified barriers and enablers at the client, provider, facility, and health system levels. Key barriers at the client level from the perspective of providers included late initial presentation to antenatal care and low proportions of women completing the recommended four antenatal visits. Barriers to offering repeat HIV testing for providers included heavy workloads, time limitations, and failing to remember to check for retest eligibility. At the facility level, inconsistent volume of clients and lack of space required for confidential HIV retesting were cited as barriers. Finally, at the health system level, there were challenges relating to the HIV test kit supply chain and the design of nationally standardized antenatal patient registers. Enablers to improving the implementation of repeat HIV testing included client dissemination of the benefits of antenatal care through word-of-mouth, provider cooperation and task shifting, and it was suggested that use of an electronic health record system could provide automatic reminders for retest eligibility.ConclusionsThis study highlights some important barriers to improving HIV retesting rates among pregnant women who attend antenatal clinics in the Nyanza region of Kenya at the client, provider, facility, and health system levels. To successfully implement Kenya's national repeat HIV testing guidelines during pregnancy, it is essential that these barriers be addressed and enablers capitalized on through a multi-faceted intervention program

    Prioritising prevention strategies for patients in antiretroviral treatment programmes in resource-limited settings

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    Expanded access to antiretroviral therapy (ART) offers opportunities to strengthen HIV prevention in resource-limited settings. We invited 27 ART programmes from urban settings in Africa, Asia and South America to participate in a survey, with the aim to examine what preventive services had been integrated in ART programmes. Twenty-two programmes participated; eight (36%) from South Africa, two from Brazil, two from Zambia and one each from Argentina, India, Thailand, Botswana, Ivory Coast, Malawi, Morocco, Uganda and Zimbabwe and one occupational programme of a brewery company included five countries (Nigeria, Republic of Congo, Democratic Republic of Congo, Rwanda and Burundi). Twenty-one sites (96%) provided health education and social support, and 18 (82%) provided HIV testing and counselling. All sites encouraged disclosure of HIV infection to spouses and partners, but only 11 (50%) had a protocol for partner notification. Twenty-one sites (96%) supplied male condoms, seven (32%) female condoms and 20 (91%) provided prophylactic ART for the prevention of mother-to child transmission. Seven sites (33%) regularly screened for sexually transmitted infections (STI). Twelve sites (55%) were involved in activities aimed at women or adolescents, and 10 sites (46%) in activities aimed at serodiscordant couples. Stigma and discrimination, gender roles and funding constraints were perceived as the main obstacles to effective prevention in ART programmes. We conclude that preventive services in ART programmes in lower income countries focus on health education and the provision of social support and male condoms. Strategies that might be equally or more important in this setting, including partner notification, prompt diagnosis and treatment of STI and reduction of stigma in the community, have not been implemented widely

    Introduction of HIV Point-of-Care Testing in Adolescent Primary Care: A Quality Improvement Project

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    BACKGROUND: HIV, first identified in 1981, remains a persistent public health problem affecting 1.1 million Americans today. Detection is a critical first step to ending the HIV epidemic and the CDC recommends universal HIV screening for all patients 13-64 years of age regardless of risk factors. HIV screening rates are suboptimal especially in adolescent and young adult populations who face unique barriers to screening. The aim of this project was to improve HIV screening rates in adolescent and young adult patients at a large, urban FQHC. LOCAL PROBLEM: In the state of Rhode Island, 1 in 10 persons living with HIV are unaware of their HIV diagnosis with a disproportionate burden of undiagnosed disease falling on adolescents and young adults. At a large FQHC in Providence, R.I., screening rates for adolescents and young adults have been noted to be low. METHODS: A systematic review of the literature revealed six applicable interventions to improve HIV screening rates for the target population. HIV point-of-care testing was the focus of this quality improvement project as research demonstrated it improves screening rates and it aligned with existing clinical workflows. This project was guided by the Chronic Care Model to develop and implement a HIV point-of-care testing protocol in adolescent and young adult primary care. Rapid Plan-Do-Study-Act cycles and Lewin’s Change model steered this process change. INTERVENTION: An HIV point-of-care testing protocol was developed and implemented over a 12-week project focused on universal screening for patients 15-25 years of age. Staff received training and follow up survey regarding acceptance of the new protocol. Patient education on HIV screening and safe sex practices was standardized in this protocol. RESULTS: The introduction of a HIV point-of-care testing protocol resulted in a 16.3% increase in completed HIV screenings from baseline. The project was met with general support from staff with feasibility challenges noted. CONCLUSIONS: HIV point-of-care testing improves HIV screening rates in adolescent and young adult patients. Future quality improvement cycles should address the clinic time constraints and ways to cover the costs of testing to achieve sustainable outcomes

    Restoring Health to Health Reform: Integrating Medicine and Public Health to Advance the Population\u27s Wellbeing

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    The Patient Protection and Affordable Care Act is a major achievement in improving access to health care services. However, evidence indicates that the nation could achieve greater improvements in health outcomes, at a lower cost, by shifting its focus to public health. By focusing nearly exclusively on health care, policy makers have chronically starved public health of adequate and stable funding and political support. The lack of support for public health is exacerbated by the fact that health care and public health are generally conceptualized, organized, and funded as two separate systems. In order to maximize gains in health status and to spend scarce health resources most effectively, health care and public health should be treated as two interactive parts of a single, unified health system. The core purpose of health reform ought to be the improvement of the population’s health. We propose five criteria that would significantly advance this goal: prevention and wellness, human resources, a strong and sustainable health infrastructure, robust performance measurement, and reduction of health disparities. Although the Patient Protection and Affordable Care Act includes provisions addressing these criteria, population health is not a central focus of the reform. In order to guide health reform implementation and to inform future health reform efforts, we offer three major policy reforms: changing the environment to incentivize healthy behavioral choices, strengthening the public health infrastructure at the state and local levels, and developing a health-in-all policies strategy that would engage multiple agencies in improving health incomes. Adopting these reforms would facilitate integration and dramatically improve the population’s health, particularly when compared to the health gains likely to be realized from a continued focus on access to health care services

    HPN Winter 2011 Download Full PDF

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    Predictive modeling of housing instability and homelessness in the Veterans Health Administration

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    OBJECTIVE: To develop and test predictive models of housing instability and homelessness based on responses to a brief screening instrument administered throughout the Veterans Health Administration (VHA). DATA SOURCES/STUDY SETTING: Electronic medical record data from 5.8 million Veterans who responded to the VHA's Homelessness Screening Clinical Reminder (HSCR) between October 2012 and September 2015. STUDY DESIGN: We randomly selected 80% of Veterans in our sample to develop predictive models. We evaluated the performance of both logistic regression and random forests—a machine learning algorithm—using the remaining 20% of cases. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from two sources: VHA's Corporate Data Warehouse and National Homeless Registry. PRINCIPAL FINDINGS: Performance for all models was acceptable or better. Random forests models were more sensitive in predicting housing instability and homelessness than logistic regression, but less specific in predicting housing instability. Rates of positive screens for both outcomes were highest among Veterans in the top strata of model‐predicted risk. CONCLUSIONS: Predictive models based on medical record data can identify Veterans likely to report housing instability and homelessness, making the HSCR screening process more efficient and informing new engagement strategies. Our findings have implications for similar instruments in other health care systems.U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D), Grant/Award Number: IIR 13-334 (IIR 13-334 - U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSRD))Accepted manuscrip

    Implementing and evaluating a regional strategy to improve testing rates in VA patients at risk for HIV, utilizing the QUERI process as a guiding framework: QUERI Series

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    <p>Abstract</p> <p>Background</p> <p>We describe how we used the framework of the U.S. Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) to develop a program to improve rates of diagnostic testing for the Human Immunodeficiency Virus (HIV). This venture was prompted by the observation by the CDC that 25% of HIV-infected patients do not know their diagnosis – a point of substantial importance to the VA, which is the largest provider of HIV care in the United States.</p> <p>Methods</p> <p>Following the QUERI steps (or process), we evaluated: 1) whether undiagnosed HIV infection is a high-risk, high-volume clinical issue within the VA, 2) whether there are evidence-based recommendations for HIV testing, 3) whether there are gaps in the performance of VA HIV testing, and 4) the barriers and facilitators to improving current practice in the VA.</p> <p>Based on our findings, we developed and initiated a QUERI step 4/phase 1 pilot project using the precepts of the Chronic Care Model. Our improvement strategy relies upon electronic clinical reminders to provide <it>decision support</it>; audit/feedback as a <it>clinical information system</it>, and appropriate changes in <it>delivery system design</it>. These activities are complemented by academic detailing and social marketing interventions to achieve <it>provider activation</it>.</p> <p>Results</p> <p>Our preliminary formative evaluation indicates the need to ensure leadership and team buy-in, address facility-specific barriers, refine the reminder, and address factors that contribute to inter-clinic variances in HIV testing rates. Preliminary unadjusted data from the first seven months of our program show 3–5 fold increases in the proportion of at-risk patients who are offered HIV testing at the VA sites (stations) where the pilot project has been undertaken; no change was seen at control stations.</p> <p>Discussion</p> <p>This project demonstrates the early success of the application of the QUERI process to the development of a program to improve HIV testing rates. Preliminary unadjusted results show that the coordinated use of audit/feedback, provider activation, and organizational change can increase HIV testing rates for at-risk patients. We are refining our program prior to extending our work to a small-scale, multi-site evaluation (QUERI step 4/phase 2). We also plan to evaluate the durability/sustainability of the intervention effect, the costs of HIV testing, and the number of newly identified HIV-infected patients. Ultimately, we will evaluate this program in other geographically dispersed stations (QUERI step 4/phases 3 and 4).</p

    Improving Routine Human Immunodeficiency Virus Screening in a Primary Care Setting

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    According to the Centers for Disease Control and Prevention, in 2017, over 38,700 people receive an human immunodeficiency virus (HIV) diagnosis in the US. The United States Preventive Services Task Force (USPSTF) published recommendations in 2013 for routine HIV screening of patients ages 15 to 65 years old. Primary care providers who offer routine HIV screening can identify patients with a positive result and promptly connect them to care to decrease transmission of HIV. This process improvement project targeted health care providers and staff, using evidence-based interventions, 2013 USPSTF recommendations, and the Chronic Care Model, to improve HIV screening at a primary care site. Information sessions were held with health care providers and staff pre- and post-intervention. Participants were given a pre-survey (n=28) and post-survey (n=25) questionnaires, information on the electronic medical record screening reminder and educational materials about routine HIV screening. Monthly visits were made to the clinic by the primary investigator who conducted semi-structured interviews with participants. A retrospective chart review evaluated HIV screening data during the months of September, October, and November for 2017, (baseline year), compared to September - November 2018, intervention months. The pre- and post-intervention surveys were confidential and paired by the number assigned to each provider participant (n=6). The results were analyzed using descriptive statistics and paired t-tests to determine if perspectives on HIV screening changed from pre- to post-survey. There were no statistically significant findings from the survey questionnaire results, however, the mean Likert scores improved in the post-survey in most topics. Twenty-five percent of encounters during the 2017 baseline months and 2018 intervention months had an HIV test ordered. During the 2018 intervention year, September had a 3.5% increase and October had a 1.0% increase in percentage of tests ordered when compared to 2017; however, November 2018 had a 5.8% decrease from November 2017. This project piloted interventions to increase provider and clinic staff’s knowledge on routine HIV screening practices to help further reduce HIV transmissions among patients with an unknown serostatus. Further work is needed to identify ways to improve screening rates, such as clinic staff-initiated screening and rapid screening.Doctor of Nursing Practic

    The New York City Health and Hospitals Corporation: Transforming a Public Safety Net Delivery System to Achieve Higher Performance

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    Describes the results of the public benefit corporation's improvement initiatives -- a common clinical information system for continuity, coordination on chronic disease management, teamwork and continuous innovation, and access to appropriate care

    A Gap Analysis of Syphilis Screening During Pregnancy by Prenatal Care Clinicians

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    abstract: Congenital syphilis (CS) is increasing at an alarming rate in Arizona. The state health department has recommended increased screening to include the third trimester, but providers in individual counties are not following the recommendation. A literature search and appraisal showed increased screening reduces the incidence of CS and presented interventions to increase screening rates. Furthermore, the literature suggests provider education increases screening rates. However, before education could be completed an understanding of providers current knowledge, attitudes, and practice was needed. Using this information, a gap analysis that was completed in an Arizona county (“the County”) of syphilis screening during pregnancy by prenatal care clinicians will be presented guided by the Knowledge-Attitude-Practice (KAP) Model and the ACE Star Model of Knowledge Transformation
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