Use of the PARIHS Framework for Retrospective and Prospective Implementation Evaluations.

BACKGROUND: The Promoting Action on Research Implementation in Health Services (PARIHS) framework has been used by implementation researchers to assess factors impacting implementation and to use that information to identify optimal interventions and implementation strategies. In this paper, two studies are presented demonstrating the utility of PARIHS as a tool for retrospective and prospective evaluation of implementation in the health care setting. STUDY DESIGN: Descriptive case study. METHODS: A qualitative consensus process was used to evaluate provider perceptions of PARIHS constructs of evidence, context, and facilitation and their subelements which were scored on a continuum of low to high. RESULTS: The first example demonstrates retrospective use of PARIHS which provided insight into the factors contributing to variations in implementation across sites in an ongoing program. Evidence was strong (high), whereas context noted some challenges in culture and measurement (mixed), and the presence of dedicated program facilitators was positive but dual roles limited their ability to fully support implementation (mixed). The second example demonstrates prospective use of PARIHS for evaluation which gathered information about intervention sites for the purposes of selecting implementation strategies responsive to site needs. Evidence supporting the intervention was limited (low), context noted that limited awareness of the intervention was a challenge (low), and that a strong internal facilitator supported implementation (high). LINKING EVIDENCE TO ACTION: The descriptive case study presented here underscores the value of a theory-guided approach to implementation and highlights that PARIHS can help implementers understand factors impacting implementation, identify areas for future intervention, and inform selection of strategies to support or enhance implementation efforts.

Implementing an HIV Rapid Testing-Linkage-to-Care Project Among Homeless Individuals in Los Angeles County: A Collaborative Effort Between Federal, County, and City Government.

Objectives. We developed and implemented an HIV rapid testing-linkage-to-care initiative between federal and local government. Methods. We used mixed methodology; HIV testing data were collected on-site, and qualitative data were collected via telephone. We used postintervention stakeholder and staff interviews to evaluate barriers and facilitators to this initiative. Results. We tested 817 individuals. We identified and confirmed 7 preliminary HIV positive individuals (0.86% seropositivity), 5 of whom were linked to care. Mean testing cost was $48.95 per client; cost per positive result was $5714. Conclusions. This initiative can be used as a template for other health departments and research teams focusing on homelessness and mitigation of the HIV/AIDS epidemic.

The potential for health-related uses of mobile phones and internet with homeless veterans: results from a multisite survey.

BACKGROUND: Addressing the health needs of homeless veterans is a priority in the United States, and, although information technologies can potentially improve access to and engagement in care, little is known about this population's use of information technologies or their willingness to use technologies to communicate with healthcare providers and systems. MATERIALS AND METHODS: This study fills this gap through a survey of homeless veterans' use of information technologies and their attitudes about using these technologies to assist with accessing needed healthcare services. RESULTS: Among the 106 homeless veterans surveyed, 89% had a mobile phone (one-third were smartphones), and 76% used the Internet. Among those with a mobile phone, 71% used text messaging. Nearly all respondents (93%) were interested in receiving mobile phone reminders (text message or phone call) about upcoming medical appointments, and a similar proportion (88%) wanted mobile phone outreach asking if they would like to schedule an appointment if they had not been seen by a health provider in over a year. In addition, respondents already used these technologies for information and communication related to health, housing, and jobs. CONCLUSIONS: These findings suggest new avenues for communication and health interventions for hard-to-reach homeless veterans.

HIV rapid testing in a Veterans Affairs hospital ED setting: a 5-year sustainability evaluation.

Routine HIV testing in primary care settings is now recommended in the United States. The US Department of Veterans Affairs (VA) has increased the number of patients tested for HIV, but overall HIV testing rates in VA remain low. A proven strategy for increasing such testing involves nurse-initiated HIV rapid testing (HIV RT). The purpose of this work was to use a mixed methodology approach to evaluate the 5-year sustainability of an intervention that implemented HIV RT in a VA emergency department setting in a large, urban VA medical center to reduce missed diagnostic and treatment opportunities in this vulnerable patient population. In-person semistructured interviews were conducted with providers and stakeholders. Interview notes were qualitatively coded for emerging themes. Quarterly testing rates were evaluated for a 5-year time span starting from the launch in July 2008. Findings indicate that HIV RT was sustained by the enthusiasm of 2 clinical champions who oversaw the registered nurses responsible for conducting the testing. The departure of the clinical champions was correlated with a substantial drop-off in testing. Findings also indicate potential strategies for improving sustainability including engaging senior leadership in the project, engaging line staff in the implementation planning from the start to increase ownership over the innovation, incorporating information into initial training explaining the importance of the innovation to quality patient care, providing ongoing training to maintain skills, and providing routine progress reports to staff to demonstrate the ongoing impact of their efforts.

A five-year self-sustainability analysis of nurse-administered HIV rapid testing in Veterans Affairs primary care.

In 2008, nurse-administered HIV oral rapid testing (RT) was introduced at the Veterans Affairs Primary Care Clinic in Downtown Los Angeles. Analysis at five years revealed variable yet increasing rates of HIV RT at that facility despite the fact that no post-launch support was provided by the implementation team. Qualitative interviews among stakeholders conducted at five years revealed the pre-existing implementation practices endemic to this clinic that facilitated this unprecedented success (e.g. history of positive quality improvement implementations, leadership support, clinician involvement at each step of the process to facilitate empowerment, ownership and feasible customisation of the implementation, cohesive communication among clinicians and leadership, training, efficient supply pathway, progressive performance feedback and ongoing encouragement).

Sustaining nurse-rapid HIV testing in the U.S. Department of Veterans Affairs: lessons learned from a comparative evaluation.

Routine HIV testing in primary care is now recommended in the United States. The U.S. Department of Veterans Affairs (VA) has increased the number of patients tested for HIV, but overall HIV testing rates remain low. A promising intervention for increasing HIV testing is nurse-initiated rapid testing (NRT). The purpose of this study was to build upon our previous research by implementing NRT in primary care clinics at two geographically distinct VA medical centers, and then conduct an evaluation to identify the barriers and facilitators to implementing and sustaining it. Semistructured telephone interviews were conducted with providers and stakeholders at two VA medical centers, one each on the East Coast and in the Southwest. Fieldnotes were developed following each interview and qualitatively coded for emerging themes. Findings indicate NRT was well integrated in both settings. NRT took little time to conduct, was well received by patients, and did not disrupt clinical scheduling. However, there were some sustainability challenges, including difficulties using the electronic medical record, and the challenges of new care practice structures. Implementing NRT is feasible in VA primary care settings. However, organizational challenges should be taken into account for subsequent efforts to implement NRT in VA primary care settings.

Implementation of nurse-initiated rapid HIV testing at high-prevalence primary care sites within the U.S. Veterans Affairs Health Care System.

Nurse-initiated HIV rapid testing (NRT) increases testing/receipt of results compared with traditional testing. We implemented NRT in primary care clinics at 2 Veterans Affairs hospitals.At site 1, 2364 tests were conducted; 5 HIV positives were identified. At site 2, 2522 tests were conducted; 9 HIV positives were identified. Success varied across demographic/clinical strata.

Budget impact analysis of HIV testing in the VA healthcare system.

OBJECTIVES: The long-term cost effectiveness of routine HIV testing is favorable relative to other medical interventions. Facility-specific costs of expanded HIV testing and care for newly identified patients, however, are less well defined. To aid in resource allocation decisions, we developed a spreadsheet-based budget-impact tool populated with estimates of facility-specific HIV testing and care costs incurred with an expanded testing program. METHODS: We modeled intervention effects on quarterly costs of antiretroviral therapy (ART), outpatient resource utilization, and staff expenditures in the Department of Veterans Affairs over a 2-year period of increasing HIV testing rates. We used HIV prevalence estimates, screening rates, counseling, positive tests, Veterans Affairs treatment, and published sources as inputs. We evaluated a single-facility cohort of 20,000 patients and at baseline assumed a serodiagnostic rate of 0.45%. RESULTS: Expanding testing from 2% to 15% annually identified 21 additional HIV-positive patients over 2 years at a cost of approximately $290,000, more than 60% of which was due to providing ART to newly diagnosed patients. While quarterly testing costs decreased longitudinally as fewer persons required testing, quarterly ART costs increased from $10,000 to more than $60,000 over 2 years as more infected patients were identified and started on ART. In sensitivity analyses, serodiagnostic and annual HIV testing rates had the greatest cost impact. CONCLUSIONS: Expanded HIV testing costs are greatest during initial implementation and predominantly due to ART for new patients. Cost determinations of expanded HIV testing provide an important tool for managers charged with allocating resources within integrated systems providing both HIV testing and care.

Implementation science in the real world: a streamlined model.

The process of quality improvement may involve enhancing or revising existing practices or the introduction of a novel element. Principles of Implementation Science provide key theories to guide these processes, however, such theories tend to be highly technical in nature and do not provide pragmatic nor streamlined approaches to real-world implementation. This paper presents a concisely comprehensive six step theory-based Implementation Science model that we have successfully used to launch more than two-dozen self-sustaining implementations. In addition, we provide an abbreviated case study in which we used our streamlined theoretical model to successfully guide the development and implementation of an HIV testing/linkage to care campaign in homeless shelter settings in Los Angeles County.

Implementation of routine rapid HIV testing within the U.S. Department of Veterans Affairs Healthcare System.

Current HIV testing methods can be ineffective; patients often do not return for results. HIV rapid testing (RT) provides accurate results in 20 min. Patients find nurse-initiated HIV rapid testing (NRT) more acceptable than current testing methods and increases receipt of test results. Translating research findings into sustainable practice poses widely recognized implementation challenges. To ascertain effectiveness of NRT implementation, formative and process evaluations were conducted within the U.S. Department of Veterans Affairs Healthcare System (VA). Nurses and physicians at 2 VA medical centers were trained to administer RT. A preimplementation formative evaluation was conducted at Site 1. Process evaluations of ongoing RT activities were conducted at Site 2. Interviews were conducted with key informants. Content and thematic analysis was conducted on the field notes. A variety of barriers and facilitators were discovered that impacted the implementation of NRT. Findings indicate concerns regarding training and incorporating NRT into workflow. Process interviews indicated that training concerns could be alleviated through various means. Finally, interviewees highlighted that other clinic settings might be a more preferred setting for NRT than primary care. Findings are currently being used for the implementation of additional NRT interventions, and can also guide NRT adoption in other facilities.

Interactive internet-based clinical education: an efficient and cost-savings approach to point-of-care test training.

BACKGROUND: We successfully created and implemented an effective HIV rapid testing training and certification curriculum using traditional in-person training at multiple sites within the U.S. Department of Veterans Affairs (VA) Healthcare System. OBJECTIVE: Considering the multitude of geographically remote facilities in the nationwide VA system, coupled with the expansion of HIV diagnostics, we developed an alternate training method that is affordable, efficient, and effective. METHODS: Using materials initially developed for in-person HIV rapid test in-services, we used a distance learning model to offer this training via live audiovisual online technology to educate clinicians at a remote outpatient primary care VA facility. RESULTS: Participants' evaluation metrics showed that this form of remote education is equivalent to in-person training; additionally, HIV testing rates increased considerably in the months following this intervention. Although there is a one-time setup cost associated with this remote training protocol, there is potential cost savings associated with the point-of-care nurse manager's time productivity by using the Internet in-service learning module for teaching HIV rapid testing. If additional in-service training modules are developed into Internet-based format, there is the potential for additional cost savings. Our cost analysis demonstrates that the remote in-service method provides a more affordable and efficient alternative compared with in-person training. CONCLUSIONS: The online in-service provided training that was equivalent to in-person sessions based on first-hand supervisor observation, participant satisfaction surveys, and follow-up results. This method saves time and money, requires fewer personnel, and affords access to expert trainers regardless of geographic location. Further, it is generalizable to training beyond HIV rapid testing. Based on these consistent implementation successes, we plan to expand use of online training to include remote VA satellite facilities spanning several states for a variety of diagnostic devices. Ultimately, Internet-based training has the potential to provide "big city" quality of care to patients at remote (rural) clinics.

Attributes of an independently self-sustaining implementation: nurse-administered HIV rapid testing in VA primary care.

BACKGROUND: Human immunodeficiency virus (HIV) oral rapid testing (RT) has the potential to facilitate the expansion of such diagnostics to front line providers, specifically clinical nursing staff. Training, policy requirements, and implementation methods used to launch such services have not been widely explored. OBJECTIVES: To evaluate the sustainability of a nurse-initiated HIV-RT intervention at 1 veterans affairs primary care clinic for 1 year. METHODS: Policies were implemented, enabling nurses to carry out HIV RTs. Willing RNs voluntarily enrolled in a 2-part in-service designed to teach pre- and posttest counseling techniques, administering, interpreting, and entering results in the patient's medical records. RESULTS: RNs administered a steady rate of HIV RTs (monthly mean = 25, SD = 3) along with an unexpected increase in HIV blood testing among other clinical staff, leading to a 70% (P < .0001) site-wide increase in HIV testing, with RNs accounting for one-third of these tests. CONCLUSION: In light of the researchers' 1-shot launch efforts, the steady rate of HIV RTs among RNs over the course of a year, combined with the concurrent progressive increase in HIV (blood) testing administered by MDs, PAs, and NPs stands as an anomaly in light of existing implementation science literature.

Cost-effectiveness of strategies to improve HIV testing and receipt of results: economic analysis of a randomized controlled trial.

BACKGROUND: The CDC recommends routine voluntary HIV testing of all patients 13-64 years of age. Despite this recommendation, HIV testing rates are low even among those at identifiable risk, and many patients do not return to receive their results. OBJECTIVE: To examine the costs and benefits of strategies to improve HIV testing and receipt of results. DESIGN: Cost-effectiveness analysis based on a Markov model. Acceptance of testing, return rates, and related costs were derived from a randomized trial of 251 patients; long-term costs and health outcomes were derived from the literature. SETTING/TARGET POPULATION: Primary-care patients with unknown HIV status. INTERVENTIONS: Comparison of three intervention models for HIV counseling and testing: Model A = traditional HIV counseling and testing; Model B = nurse-initiated routine screening with traditional HIV testing and counseling; Model C = nurse-initiated routine screening with rapid HIV testing and streamlined counseling. MAIN MEASURES: Life-years, quality-adjusted life-years (QALYs), costs and incremental cost-effectiveness. KEY RESULTS: Without consideration of the benefit from reduced HIV transmission, Model A resulted in per-patient lifetime discounted costs of $48,650 and benefits of 16.271 QALYs. Model B increased lifetime costs by $53 and benefits by 0.0013 QALYs (corresponding to 0.48 quality-adjusted life days). Model C cost $66 more than Model A with an increase of 0.0018 QALYs (0.66 quality-adjusted life days) and an incremental cost-effectiveness of $36,390/QALY. When we included the benefit from reduced HIV transmission, Model C cost $10,660/QALY relative to Model A. The cost-effectiveness of Model C was robust in sensitivity analyses. CONCLUSIONS: In a primary-care population, nurse-initiated routine screening with rapid HIV testing and streamlined counseling increased rates of testing and receipt of test results and was cost-effective compared with traditional HIV testing strategies.

Evaluation of the sustainability of an intervention to increase HIV testing.

BACKGROUND: Sustainability-the routinization and institutionalization of processes that improve the quality of healthcare-is difficult to achieve and not often studied. OBJECTIVE: To evaluate the sustainability of increased rates of HIV testing after implementation of a multi-component intervention in two Veterans Health Administration healthcare systems. DESIGN: Quasi-experimental implementation study in which the effect of transferring responsibility to conduct the provider education component of the intervention from research to operational staff was assessed. PATIENTS: Persons receiving healthcare between 2005 and 2006 (intervention year) and 2006 and 2007 (sustainability year). MEASUREMENTS: Monthly HIV testing rate, stratified by frequency of clinic visits. RESULTS: The monthly adjusted testing rate increased from 2% at baseline to 6% at the end intervention year and then declined reaching 4% at the end of the sustainability year. However, the stratified, visit-specific testing rate for persons newly exposed to the intervention (i.e., having their first through third visits during the study period) increased throughout the intervention and sustainability years. Increases in the proportion of visits by patients who remained untested despite multiple, prior exposures to the intervention accounted for the aggregate attenuation of testing during the sustainability year. Overall, the percentage of patients who received an HIV test in the sustainability year was 11.6%, in the intervention year 11.1%, and in the pre-intervention year 5.0% CONCLUSIONS: Provider education combined with informatics and organizational support had a sustainable effect on HIV testing rates. The effect was most pronounced during patients' early contacts with the healthcare system.

The impact of integrated HIV care on patient health outcomes.

BACKGROUND: Control of viral replication through combination antiretroviral therapy (cART) improves patient health outcomes. Yet many HIV-infected patients have comorbidities that pose social and clinical barriers to achieving viral suppression. Integration of subspecialty services into HIV primary care may overcome such barriers. OBJECTIVE: To evaluate effect of integrated HIV care (IHC) on suppression of HIV replication. RESEARCH DESIGN: A retrospective cohort study of HIV patients from 5 Veterans Affairs healthcare facilities 2000 to 2006. SUBJECTS: Patients with >3 months of follow-up, sufficient baseline HIV severity, on cART. MEASURES: We measured and ranked Integrated Care at the facilities. These rankings were applied to patient visits to form an index of IHC utilization. We evaluated effect of IHC utilization on likelihood of achieving viral suppression while on cART, controlling for demographic and clinical factors using survival analysis. RESULTS: : The 1018 HIV-infected patients eligible for analysis had substantial barriers to responding to cART: 93% had comorbidities with mean 3.2 comorbidities per patient (SD = 2.0); 52% achieved viral suppression in median 231 days (SD = 411.6). Patients visiting clinics that offered hepatitis, psychiatric, psychologic, and social services in addition to HIV primary care were 3.1 times more likely to achieve viral suppression than patients visiting clinics which offered only HIV primary care (hazard ratio = 3.1, P < 0.001). CONCLUSIONS: Patients who visited IHC clinics were more likely to achieve viral suppression while on cART. Future research should investigate which elements of Integrated Care are most associated with viral control and what role provider experience plays in this association.

Expanding HIV rapid testing via point-of-care paraprofessionals.

HIV counselling and testing has traditionally been performed by highly trained professionals in clinical settings. With HIV rapid testing, a reliable and easy to use diagnostic tool, paraprofessionals can be trained to administer on-site HIV testing in a variety of non-traditional settings, broadening the HIV detection rates. Our objective was to create a robust and sustainable paraprofessional training module to facilitate off-site HIV rapid testing in non-clinical settings. Trainees attended a series of training sessions involving HIV education, rapid test instructions and communication techniques. After these sessions, trainees competently carried out HIV rapid testing in homeless shelters throughout the Los Angeles county. Agencies motivated to expand HIV screening programmes may use trained paraprofessionals to administer a full range of services (recruitment, pretest counselling, test administration, interpretation of results, post-test counselling and documentation) through this training model and enabling more highly trained healthcare providers to focus efforts on patients identified as HIV-positive.

Improving HIV screening and receipt of results by nurse-initiated streamlined counseling and rapid testing.

BACKGROUND: HIV testing is cost-effective in unselected general medical populations, yet testing rates among those at risk remain low, even among those with regular primary care. HIV rapid testing is effective in many healthcare settings, but scant research has been done within primary care settings or within the US Department of Veteran's Affairs Healthcare System. OBJECTIVES: We evaluated three methods proven effective in other diseases/settings: nurse standing orders for testing, streamlined counseling, and HIV rapid testing. DESIGN: Randomized, controlled trial with three intervention models: model A (traditional counseling/testing); model B (nurse-initiated screening, traditional counseling/testing); model C (nurse-initiated screening, streamlined counseling/rapid testing). PARTICIPANTS: Two hundred fifty-one patients with primary/urgent care appointments in two VA clinics in the same city (one large urban hospital, one freestanding outpatient clinic in a high HIV prevalence area). MEASUREMENTS: Rates of HIV testing and receipt of results; sexual risk reduction; HIV knowledge improvement. RESULTS: Testing rates were 40.2% (model A), 84.5% (model B), and 89.3% (model C; p = <.01). Test result receipt rates were 14.6% (model A), 31.0% (model B), 79.8% (model C; all p = <.01). Sexual risk reduction and knowledge improvement did not differ significantly between counseling methods. CONCLUSIONS: Streamlined counseling with rapid testing significantly increased testing and receipt rates over current practice without changes in risk behavior or posttest knowledge. Increased testing and receipt of results could lead to earlier disease identification, increased treatment, and reduced morbidity/mortality. Policymakers should consider streamlined counseling/rapid testing when implementing routine HIV testing into primary/urgent care.

An HIV collaborative in the VHA: do advanced HIT and one-day sessions change the collaborative experience?

BACKGROUND: Many organizations participate in quality collaboratives, yet the return on investment of the associated time and costs is unclear. METHOD: Semistructured interviews, surveys, and direct observation were used to assess experiences, improvement activities, and costs associated with participation in a year-long modified Institute for Healthcare Improvement-style collaborative designed to improve HIV care within the Veterans Health Administration. All nine sites had access to automated patient registries and semi-automated clinical measure reports; five sites also received computerized clinical reminders. Three one-day learning sessions were conducted. RESULTS: Participants reported that burden was small and value high, although many suggested that more time for peer-to peer learning would have been helpful. Teams averaged five quality improvement activities per site and most reported improvements in HIV care processes. The average annual cost per site was dollars 28,000 but costs varied considerably by site. DISCUSSION: Shortened learning sessions and the incorporation of health information technology can reduce some of the costs and burdens associated with collaboratives, yet peer-to-peer interaction and local organizational factors remain important to ensuring perceived effectiveness of collaboratives.

Differences among sexually abused and nonabused youth living with HIV.

Risk behaviors were compared between sexually abused and nonabused youth living with HIV (YLH). Abused YLH were significantly more likely to have attempted suicide, to have been admitted into an alcohol and/or drug treatment program, and to have engaged in crack cocaine use than were nonabused YLH and had a greater number of sexual partners. A significantly higher proportion of abused YLH had been incarcerated in contrast to nonabused youth. There were also significantly greater conduct problems among abused YLH. Finally, abused YLH had significantly higher scores on positive action and social-support coping styles than nonabused youth. Consistent with previous research, abused youth are at higher risk for a variety of negative outcomes and are also similar in many respects to sexually abused youth who are not HIV-positive. The high frequencies of two positive styles of coping among abused YLH were also observed.