How Should We Organize Care for Patients With Human Immunodeficiency Virus and Comorbidities? A Multisite Qualitative Study of Human Immunodeficiency Virus Care in the United States Department of Veterans Affairs.

BACKGROUND: With human immunodeficiency virus (HIV) now managed as a chronic disease, health care has had to change and expand to include management of other critical comorbidities. We sought to understand how variation in the organization, structure and processes of HIV and comorbidity care, based on patient-centered medical home (PCMH) principles, was related to care quality for Veterans with HIV. RESEARCH DESIGN: Qualitative site visits were conducted at a purposive sample of 8 Department of Veterans Affairs Medical Centers, varying in care quality and outcomes for HIV and common comorbidities. Site visits entailed conduct of patient interviews (n=60); HIV care team interviews (n=60); direct observation of clinic processes and team interactions (n=22); and direct observations of patient-provider clinical encounters (n=45). Data were analyzed using a priori and emergent codes, construction of site syntheses and comparing sites with varying levels of quality. RESULTS: Sites highest and lowest in both HIV and comorbidity care quality demonstrated clear differences in provision of PCMH-principled care. The highest site provided greater team-based, comprehensive, patient-centered, and data-driven care and engaged in continuous improvement. Sites with higher HIV care quality attended more to psychosocial needs. Sites that had consistent processes for comorbidity care, whether in HIV or primary care clinics, had higher quality of comorbidity care. CONCLUSIONS: Provision of high-quality HIV care and high-quality co-morbidity care require different care structures and processes. Provision of both requires a focus on providing care aligned with PCMH principles, integrating psychosocial needs into care, and establishing explicit consistent approaches to comorbidity management.

Roadblocks to PrEP: What Medical Records Reveal About Access to HIV Pre-exposure Prophylaxis.

BACKGROUND: Pre-exposure prophylaxis (PrEP) has been shown to be efficacious in preventing HIV; however, its uptake remains modest. Given that there are fewer cost barriers to receiving PrEP within VHA than via commercial insurance, VHA represents an ideal setting in which to study other barriers that may impact patients seeking PrEP. OBJECTIVE: We sought to understand potential barriers to obtaining PrEP within the Veterans Health Administration (VHA) through examination of documentation in electronic medical records. DESIGN: Retrospective structured chart review, including chart abstractions of notes, referrals, and communications; content analysis of charts from a subsample of patients receiving PrEP in VHA. PARTICIPANTS: One hundred sixty-one patients prescribed PrEP at 90 sites varying in PrEP prescribing rates. APPROACH: We extracted descriptive information and conducted a qualitative analysis of all PrEP-relevant free-text notes including who initiated the PrEP conversation (patient vs. provider), time interval between request and prescription, reasons for denying PrEP, and patient responses to barriers. KEY RESULTS: Patients initiated 94% of PrEP conversations and 35% of patients experienced delays receiving PrEP ranging from six weeks to 16 months. Over 70% of cases evidenced barriers to access. Barriers included provider knowledge gaps about PrEP, provider knowledge gaps about VHA systems related to PrEP, confusion or disagreement over clinic purview for PrEP, and provider attitudes or stigma associated with patients seeking PrEP. CONCLUSIONS: Although PrEP is recommended for HIV prevention in high-risk persons, many PrEP-eligible individuals faced barriers to obtaining a prescription. Current practices place substantial responsibility on patients to request and advocate for this service, in contrast to many other preventive services. Understanding the prevalence and content of PrEP knowledge gaps and attitudinal barriers can inform organizational interventions to increase PrEP access and decrease HIV transmission.

Understanding the Context of High- and Low-Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): a Qualitative Study.

BACKGROUND: Inappropriate testosterone use and variations in testosterone prescribing patterns exist in the Veterans Health Administration (VHA) despite the presence of clinical guidelines. OBJECTIVE: We examined system and clinician factors that contribute to patterns of potentially inappropriate testosterone prescribing in VHA. DESIGN: Qualitative study using a positive deviance approach to understand practice variation in high- and low-testosterone prescribing sites. PARTICIPANTS: Twenty-two interview participants included primary care and specialty clinicians, key opinion leaders, and pharmacists at 3 high- and 3 low-testosterone prescribing sites. APPROACH: Semi-structured phone interviews were conducted, transcribed, and coded using a priori theoretical constructs and emergent themes. Case studies were developed for each site and a cross-case matrix was created to evaluate variation across high- and low-prescribing sites. KEY RESULTS: We identified four system-level domains related to variation in testosterone prescribing: organizational structures and processes specific to testosterone prescribing, availability of local guidance on testosterone prescribing, well-defined dissemination process for local testosterone polices, and engagement in best practices related to testosterone prescribing. Two clinician-level domains were also identified, specifically, structured initial testosterone prescribing process and specified follow-up testosterone prescribing process. High- and low-testosterone prescribing sites systematically varied in the four system-level domains, while the clinician-level domains looked similar across all sites. The third high-prescribing site was unusual in that it exhibited the four domains similar to the 3 low-prescribing sites at the time of our visit. This site had greatly reduced its prescribing of testosterone in the interim. CONCLUSIONS: Findings suggest that local organizational factors play an important role in influencing prescribing. Sites have the potential to transform their utilization patterns by providing access to specialty care expertise, an electronic health record-based system to facilitate guideline-concordant prescribing, well-defined dissemination processes for information, guidance from multiple sources, and clarity regarding best practices for prescribing.

Experiences with interferon-free hepatitis C therapies: addressing barriers to adherence and optimizing treatment outcomes.

BACKGROUND: Millions of Americans are living with hepatitis C, the leading cause of liver disease in the United States. Medication treatment can cure hepatitis C. We sought to understand factors that contribute to hepatitis C treatment completion from the perspectives of patients and providers. METHODS: We conducted semi-structured interviews at three Veterans Affairs Medical Centers. Patients were asked about their experiences with hepatitis C treatments and perspectives on care. Providers were asked about observations regarding patient responses to medications and perspectives about factors resulting in treatment completion. Transcripts were analyzed using a grounded thematic approach-an inductive analysis that lets themes emerge from the data. RESULTS: Contributors to treatment completion included Experience with Older Treatments, Hope for Improvement, Symptom Relief, Tailored Organized Routines, and Positive Patient-Provider Relationship. Corresponding barriers also emerged, including pill burden and skepticism about treatment effectiveness and safety. CONCLUSION: Despite the improved side-effect profile of newer HCV medications, multiple barriers to treatment completion remain. However, providers and patients were able to identify avenues for addressing such barriers.

Use of testosterone in men infected with human immunodeficiency virus in the veterans healthcare system.

Testosterone supplementation has been widely used in those infected with human immunodeficiency virus (HIV) for hypogonadism, and wasting. But with effective antiretroviral therapy and increasing recognition of atherosclerotic disease and adults infected with HIV, the risks of inappropriate testosterone use in HIV-infected patients are far better recognized than previously. Testosterone use has expanded among U.S. males, but few studies have examined prescribing in those infected with HIV. In a national cohort of males with at least one outpatient prescription in the Veterans Health Administration (VHA), we examined 9475 HIV-infected males, including 2484 who had received testosterone and a randomly selected 6991 who had not. For comparison, we identified 1,387,241 uninfected males (189,369 had received testosterone and a randomly selected 1,197,872 had not). We determined rates of new and prevalent testosterone use, and also examined the adequacy of the diagnostic evaluation that had preceded testosterone initiation among our HIV-infected and uninfected testosterone groups. Our main results were as follows. HIV-infected men had higher rates of initiation (0.8% vs. 0.4% in FY09; p < 0.001) and prevalence of testosterone use (2.2% vs. 0.8% in FY08; p < 0.001) compared to the uninfected men across the entire period. Trends of prescribing for both groups followed a similar pattern, rising from FY08, reaching a peak in FY13, and then dipping in FY 14. Only 1.1% of HIV-infected patients had a fully guideline-concordant workup before starting testosterone therapy, compared to 3.5% of uninfected patients (p < 0.001). In conclusion, testosterone use among HIV-infected patients in the VHA system rose to a peak in FY13 and has decreased somewhat since. Only a small minority of HIV-infected patients who receive testosterone therapy from VHA have undergone an appropriate workup before starting therapy, suggesting an opportunity for improvement.

Treatment experiences among LGBT veterans with discrimination-based trauma exposure: A pilot study.

Past research suggests that rates of trauma exposure and Posttraumatic Stress Disorder (PTSD) are elevated among lesbian, gay, bisexual, and transgender (LGBT) veterans compared to heterosexual and cisgender veterans. Given higher rates of trauma exposure and PTSD, and the culture associated with the Department of Defense's history of policies excluding LGBT people, it is important to understand if LGBT veterans are seeking PTSD treatment following discrimination-based traumatic events, where they seek care, and if they are satisfied with treatment. This study aimed to describe the experiences of discrimination-based trauma-exposed LGBT veterans' (n = 47) experiences with PTSD treatment, including location of treatment (Veterans Health Administration [VHA] versus non-VHA) and satisfaction with care. The majority of veterans had received a PTSD diagnosis from a health-care provider in their lifetimes (78.72%, n = 37), and over half reported currently experiencing PTSD symptoms. Approximately 47% of LGBT veterans with discrimination-based trauma histories preferred to seek PTSD treatment exclusively at VHA (46.81%) or with a combination of VHA and non-VHA services (38.30%). Veterans who received PTSD treatment exclusively from VHA reported higher satisfaction ratings (7.44 on 0-9 scale) than veterans who received PTSD treatment exclusively from outside VHA (5.25 on 0-9 scale). For veterans who sought PTSD treatment at both VHA and non-VHA facilities, there were no significant differences regarding satisfaction ratings for their PTSD treatment in the two settings. Results are discussed in terms of VHA's continued efforts to establish equitable, patient-centered health care for all veterans and the importance of non-VHA facilities to recognize veteran identities.

"Where's My Choice?" An Examination of Veteran and Provider Experiences With Hepatitis C Treatment Through the Veteran Affairs Choice Program.

BACKGROUND: The Department of Veterans Affairs (VA) is the country's largest provider for chronic hepatitis C virus (HCV) infection. The VA created the Choice Program, which allows eligible veterans to seek care from community providers, who are reimbursed by the VA. OBJECTIVES: This study aimed to examine perspectives and experiences with the VA Choice Program among veteran patients and their HCV providers. RESEARCH DESIGN: Qualitative study based on semistructured interviews with veteran patients and VA providers. Interview transcripts were analyzed using rapid assessment procedures based in grounded theory. SUBJECTS: A total of 38 veterans and 10 VA providers involved in HCV treatment across 3 VA medical centers were interviewed. MEASURES: Veterans and providers were asked open-ended questions about their experiences with HCV treatment in the VA and through the Choice Program, including barriers and facilitators to treatment access and completion. RESULTS: Four themes were identified: (1) there were difficulties in enrollment, ongoing support, and billing with third-party administrators; (2) veterans experienced a lack of choice in location of treatment; (3) fragmented care led to coordination challenges between VA and community providers; and (4) VA providers expressed reservations about sending veterans to community providers. CONCLUSIONS: The Choice Program has the potential to increase veteran access to HCV treatment, but veterans and VA providers have described substantial problems in the initial years of the program. Enhancing care coordination, incorporating shared decision-making, and establishing a wide network of community providers may be important areas for further development in designing community-based specialist services for needy veterans.

Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care.

BACKGROUND: Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States. METHOD: The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data. SIGNIFICANCE: Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities.

Poverty and mental health practice: within and beyond the 50-minute hour.

Despite the high and increasing prevalence of poverty in the United States, psychologists and allied professionals have done little to develop mental health interventions that are tailored to the specific sociocultural experiences of low-income families. In this article, we describe the sociocultural stressors that accompany the material deprivations of poverty, and the mental health difficulties to which they often give rise. Next, we outline the psychosocial and class-related issues surrounding low-income adults' access to and use of mental health services and suggest a conceptual framework to guide the modification of mental health practice to better accommodate poor peoples' complex needs. This framework describes opportunities for practice modification at three levels of intervention, beginning at the individual level of traditional individual psychotherapy and subsequently targeting increasingly broad contextual elements of poverty.

Medication Adherence in a Nationwide Cohort of Veterans Initiating Pre-exposure Prophylaxis (PrEP) to Prevent HIV Infection.

BACKGROUND: Current guidelines for pre-exposure prophylaxis (PrEP) to prevent HIV infection call for long-term, daily use of tenofovir disoproxil fumarate/emtricitabine (TDF/FTC). Little is known about long-term adherence with TDF/FTC prescribed for PrEP in routine clinical practice. SETTING: Veterans Health Administration (VHA) clinics. METHODS: We used VHA data to create a nationwide cohort of Veterans initiating PrEP between July 1, 2012, and June 30, 2016. We examined pharmacy refill data to estimate adherence based on the proportion of days covered (PDC) by TDF/FTC in the first year and used logistic regression to identify patient characteristics associated with high adherence (ie, PDC >0.8). We also quantified how often Veterans discontinued PrEP in the first year, based on a gap of 120 days or more in medication possession. RESULTS: Among 1086 individuals initiating PrEP, the median PDC for TDF/FTC in the first year was 0.74 (interquartile range 0.40-0.92). In multivariable analysis, high adherence was associated with older age (odds ratio 1.97; 1.41-2.74 for age 50-64 compared with <35), white compared with black race (odds ratio 2.12; 1.53-2.93), and male sex (odds ratio 3.39; 1.37-8.42). Forty-four percent discontinued PrEP in the first year. CONCLUSIONS: First-year adherence with TDF/FTC was overall high in a nationwide cohort of PrEP users. Differences in adherence by age, race, and sex suggest potential for disparities in PrEP effectiveness in routine clinical practice.

The moral discourse of HIV providers within their organizational context: An ethnographic case study.

OBJECTIVE: Providers make judgments to inform treatment planning, especially when adherence is crucial, as in HIV. We examined the extent these judgments may become intertwined with moral ones, extraneous to patient care, and how these in turn are situated within specific organizational contexts. METHODS: Our ethnographic case study included interviews and observations. Data were analyzed for linguistic markers indexing how providers conceptualized patients and clinic organizational structures and processes. RESULTS: We interviewed 30 providers, observed 43 clinical encounters, and recorded fieldnotes of 30 clinic observations, across 8 geographically-diverse HIV clinics. We found variation, and identified two distinct judgment paradigms: 1) Behavior as individual responsibility: patients were characterized as "good," "behaving," or "socio-paths," and "flakes." Clinical encounters focused on medication reconciliation; 2) Behaviors as socio-culturally embedded: patients were characterized as struggling with housing, work, or relationships. Encounters broadened to problem-solving within patients' life-contexts. In sites with individualized conceptualizations, providers worked independently with limited support services. Sites with socio-culturally embedded conceptualizations had multidisciplinary teams with resources to address patients' life challenges. CONCLUSIONS AND PRACTICE IMPLICATIONS: When self-management is viewed as an individual's responsibility, nonadherence may be seen as a moral failing. Multidisciplinary teams may foster perceptions of patients' behaviors as socially embedded.