Organization and Management of Care for Military Veterans with ...

MILITARY MEDICINE, 170, 11:952, 2005

Organization and Management of Care for Military Veterans with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in Department of Veterans Affairs Medical Centers Guarantor: Elizabeth M. Yano, PhD Contributors: Elizabeth M. Yano, PhD*†; Steven M. Asch, MD*‡§¶; Barbara Phillips, PhD‡; Henry Anaya, PhD*‡; Candice Bowman, PhD‡; Sophia Chang, MD储**; Samuel Bozzette, MD PhD‡¶†† Objective: As the largest provider of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome health care services, the Department of Veterans Affairs (VA) has launched a national quality improvement program. As a first step, an assessment of how care for veterans with HIV/acquired immunodeficiency syndrome was organized was conducted. Methods: Structured surveys were administered to senior HIV clinicians in 118 VA facilities, about local approaches to structuring, staffing, and delivering HIV health services. Results: HIV care was chiefly delivered in special VA-based HIV clinics. HIV-related services were widely available on site, with non-VA referrals being more commonly needed to meet longterm care needs. Urban VA facilities had greater HIV caseloads, were more likely to have separate HIV clinics, and had greater access to HIV expertise, whereas rural practices focused on primary care-based models and tended to rely on off-site VA HIV experts. Conclusions: Understanding the organization and management of VA-based HIV services will help design systematic quality improvement efforts and meet the treatment needs of HIV-infected veterans.

Introduction U.S. Armed Forces has conducted routine testing for T hehuman immunodeficiency virus (HIV) antibodies among all

active duty personnel since 1985, in part because military service members serve as their own blood donors.1–5 Over the past 25 years, the HIV incidence among U.S. military personnel has been low and stable.6 The rate of HIV seroconversion among U.S. Army active duty personnel also remains low (e.g., 1,275 seroconverters among ⬎2 million active duty personnel).7 Although active duty personnel with newly acquired infection and/or HIV disease remain a relatively small population, the Department of *Center for the Study of Healthcare Provider Behavior, Veterans Affairs Greater Los Angeles Health Services Research and Development Center of Excellence, Veterans Affairs Greater Los Angeles Healthcare System, Sepulveda, CA 91343. †Department of Health Services, University of California, Los Angeles, School of Public Health, Los Angeles, CA 90095. ‡Veterans Affairs Quality Enhancement Research Initiative for HIV, Veterans Affairs San Diego Healthcare System, La Jolla, CA 92161. §University of California, Los Angeles, School of Medicine, Los Angeles, CA 90095. ¶RAND Health, Santa Monica, CA 90407. 储Veterans Affairs Center for Quality Management in Public Health, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA 94304. **Current address: California Healthcare Foundation, Oakland, CA 94607. ††University of California, San Diego, School of Medicine, La Jolla, CA 92093. Presented at the Academy for Health Services Research and Health Policy Meeting, June 12, 2001, Atlanta, GA. This manuscript was received for review in August 2004 and was accepted for publication in September 2004.

Military Medicine, Vol. 170, November 2005

Defense works to provide high-quality care for their beneficiaries, which can be a challenge because of distances to experienced providers.8 The Department of Veterans Affairs (VA) faces similar challenges but, in contrast, cares for ⬎20,000 patients with HIV infection, providing ⬎1 million outpatient clinic visits and 170,000 days of hospital care, making it the single largest provider of HIV care in the United States.9 Having treated ⬎45,000 veterans with HIV/acquired immunodeficiency syndrome (AIDS) since the disease was first recognized in 1981, some of the earliest interdisciplinary clinics for treating HIV disease were launched in VA settings.10 Today, after significant restructuring and eligibility reforms, the VA health care system has transitioned into a comprehensive, and virtually uncapped, health plan for eligible veterans, with special capitation rates for veterans with HIV/AIDS.11 Rapid changes in HIV treatment have made evaluating how HIV care is delivered increasingly important to health care managers within and outside the VA. Although providers work to keep pace with treatment advances, the dramatic changes in therapy that followed the introduction of highly active antiretroviral therapy (HAART) in late 1995 effectively transformed HIV infection from an acute illness to a chronic illness.12 At the same time, increased use of HAART and other complex drug regimens for treating opportunistic infections has served to significantly increase medication costs, decrease inpatient and home health expenditures, and lower annual mortality rates.13,14 Although the debate regarding the best approach to organizing HIV care has its roots in the earliest days of the epidemic, the shift to a chronic care model has had important ramifications for organizing, staffing, and managing HIV service delivery models.15,16 Furthermore, health care leaders are commonly constrained to allocate scarce resources across programs that deliver direct HIV-related services in specialty programs vs. those that focus on HIV prevention among the larger service population.17 At an average annual cost of $20,000 per patient with HIV, identifying the right balance between prevention and treatment is critical.18 The complexity and costs of caring for patients with HIV infection, combined with the VA’s significant HIV caseload, compelled VA health care leaders to select HIV/AIDS as one of their first eight conditions for national assessment and quality improvement (QI).19,20 The resulting consortium of VA-based HIV researchers and clinicians behind the Quality Enhancement Research Initiative for HIV/AIDS (QUERI-HIV) set out to systematically assess variations in HIV care, identify their determinants, and design and test interventions to improve screening, treatment, and ongoing management of HIV disease.21 However, systematic information about the structure, availability, and

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Care for Veterans with HIV/AIDS

management of HIV health care services throughout the VA health care system was lacking, limiting their ability to design interventions for improving care.22 Building on theoretical models of institutional change that dictate that provider organizational surveys serve as one of the first steps in planning systematic reforms,23–26 we conducted a national assessment of how care for patients with HIV/AIDS was organized in VA settings. In this article, we present the results of a national VA organizational survey that assessed how HIV care is organized (e.g., practice arrangements, clinic structures/staffing models, provider experience, and access to experts) and managed (e.g., service availability on site vs. off site, use of case managers, practice management, use of clinical guidelines, and QI). We further assess the organizational factors associated with variations in HIV practice structure (i.e., specialty vs. primary carebased HIV care delivery) and service availability, specifically examining geographic variations (region and urban/rural location) and the influence of academic affiliation.

Methods Subjects We identified a census of all VA medical centers (VAMCs) that delivered HIV care to one or more HIV-positive patients during fiscal year 1999 (October 1, 1998 to September 30, 1999), based on records mapped to both the VA Immunology Case Registry and the Outpatient Care file (see http://www.virec.research. med.va.gov/Reference/RUG/RUG-NPCD-OPC99.pdf) at the Austin Automation Center (N ⫽ 165).27–29 We then asked local VA HIV coordinators and chiefs of staff (i.e., medical directors) to identify the senior clinicians most knowledgeable about HIV care delivery at their respective VAMCs, to participate as key informants for the organizational assessment. Materials For the organizational assessment, we developed a provider organizational survey to be completed by each HIV clinician key informant. We adapted measures of clinic structure, staffing, provider experience, access to HIV experts, service availability, and use of HIV case managers from existing survey tools, including the HIV Costs and Services Utilization Study Provider Site Survey30 and the Under-Secretary’s 1997 Survey of VA HIV/AIDS Treatment and Prevention Programs (Facility Survey).31 The resulting Veterans Health Administration Survey of HIV/AIDS Programs and Practices (available on request) was refined by an interdisciplinary team of infectious disease and general internal medicine physicians and social scientists, reviewed by national HIV experts, and pilot-tested among local clinicians in large and small practices before being fielded nationally. Procedures The Veterans Health Administration Survey of HIV/AIDS Programs and Practices was administered to the senior HIV clinicians (or alternative physicians if the lead clinicians were not available) at a national VA provider conference (in 2000). If no physician attended, then we randomly selected another attending provider. Surveys were mailed to conference nonresponders, conference invitees who had not attended, and lead clinicians

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identified after the conference, with telephone and electronic mail follow-up. The survey protocol was approved by the institutional review board of the VA San Diego Healthcare System. All survey data were double-entered. Discrepant entries were manually reviewed and corrected through team review (E.M.Y. and S.M.A.). Univariate statistics were used to describe variations in organization and management of HIV care delivery. Bivariate analyses examining variations in practice features and service availability by geography (i.e., urban/rural location and geographic region) were analyzed using ␹2 statistics for differences in proportions.

Results Response Rates Of 165 VAMCs serving one or more patients with HIV/AIDS in fiscal year 1999, 27 facilities (16%) reported that they did not deliver direct HIV patient care and instead referred their patients with HIV/AIDS to another VA for HIV treatment (e.g., from a low-volume site to a high-volume site within an integrated health care system). These sites were excluded from further participation. Of the remaining 138 eligible VAMCs, we received completed surveys from 118 sites (86% response rate). Organization of HIV Care Delivery in VA Settings Organization of HIV care delivery was conceptualized as a function of each medical center’s practice arrangements for managing HIV disease, including their principal clinic structures and staffing models, provider experience with treating HIV disease, and access to HIV experts to aid in the management of patients with HIV/AIDS. Practice Arrangements for Management of HIV Disease

The majority of VAMCs managed their patients with HIV disease in a specialty clinic or program (e.g., infectious disease, oncology, or special HIV/AIDS program) (Table I). The next most common practice arrangement was care delivery by a primary care provider and a HIV expert (17.8% and 13.6% for substance abuse patients and all other patients, respectively). Few VAMCs managed their patients without some degree of joint management with a HIV expert, and fewer still referred them to community- or university-based programs outside VAMCs. Only one VAMC indicated that their facility had a dedicated inpatient HIV/AIDS unit or ward (0.8%) (data not shown). Practice Structure of Special HIV Outpatient Clinics

Overall, 85 VAMCs (72%) reported that at least some of their HIV patients were seen in special HIV clinics, with the balance (28%) indicating that they mainstreamed their HIV patients in undifferentiated primary care or specialty clinic sessions. Among VAMCs with dedicated HIV clinics, 59 (69%) were open up to 2 half-days per week; ⬍10% were open full time (i.e., all 10 half-days per week). Few facilities (7%) saw HIV patients on weekday evenings; none provided weekend clinic hours. Staffing models for dedicated HIV clinics varied. Approximately one-half (52%) relied on staff physicians, followed by multidisciplinary provider teams (e.g., physician, nurse practitioner, and fellow) and housestaff-run clinics with on-site physician attending supervision (each 13%). Relatively few HIV clinMilitary Medicine, Vol. 170, November 2005


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Care for Veterans with HIV/AIDS TABLE I PRACTICE ARRANGEMENTS FOR VETERANS WITH HIV/AIDS IN VAMCS (N ⫽ 118) Treated Mainly by Types of Patients with HIV

History of substance abuse All other patients

Referred to

Mental Health Primary Care Primary Care Physician Specialty Community-Based University-Based Other Provider Physician and HIV Expert Clinic Program Program Arrangement 0.8

2.5

17.8

69.5

0.8

0

5.9

—

3.4

13.6

78.0

0

0.8

1.7

Three respondents among the 118 VAMCs (2.5%) left each of these questions blank; therefore, rows sum to 97.5% instead of 100%.

ics (5%) were led by nurse practitioners or physician assistants. Another 17% of VAMCs described some other practice model (e.g., nurse practitioner on one half-day and a part-time physician on another half-day). HIV Physician Staffing and Experience

The number of HIV providers varied substantially across facilities, from 1 to 50 in a single practice (mean, 5.1 providers) (Table II). Attending physicians outnumbered physician trainees (fellows, residents, and interns) by ⬎3 to 1. Infectious disease was the most common physician specialty, followed closely by internal medicine. Most providers had considerable experience treating patients with HIV disease. On average, VA HIV providers had ⬎10 years of experience treating HIV patients (Table II). HIV providers had cared for an average of 120 patients with HIV disease during the past 5 years, with some caring for as many as 750 patients. On average, VAMCs with special HIV clinics had approximately one-half the number of physicians delivering HIV care as did those that mainstreamed HIV care (4.1 and 7.9 physicians, respectively) (Table II). Almost all physicians providing care in mainstream programs were attending physicians, as opposed to physician trainees. In contrast, approximately one-third of physicians in HIV clinics were trainees. Infectious disease was the

most common specialty in HIV clinics, whereas internal medicine was the most common specialty in mainstreamed programs. Although years of experience did not differ significantly, providers in HIV clinics had cared for, on average, twice the number of patients with HIV as those in mainstreamed programs (140 patients vs. 71 patients, p ⬍ 0.0001). Access to Experts in HIV Care

More than one-half of the facilities (53%) indicated that they had on-call access to HIV experts 24 hours per day, 7 days per week (data not shown). Types of on-site consultation included regular office hours (20%), on-site on-call experts (20%), and consultant availability by appointment (19%). Off-site VA consultants were used more often than off-site non-VA consultants (e.g., university-based experts) (14% and 5%, respectively) (more than one arrangement could be recorded). Management of HIV Care Delivery in VA Settings Management of HIV care delivery was viewed as a function of the availability and location of health care services (e.g., on site vs. off site), use of case managers in care coordination, use of multidisciplinary team conferences, and use of formal and informal management practices to improve care quality (e.g., presence of a HIV QI program, treatment adherence policies/pro-

TABLE II CHARACTERISTICS OF PRIMARY PROVIDERS OF HIV CARE IN VAMCS (N ⫽ 118) Mean ⫾ SD (Range) Characteristics of Primary Providers of HIV Care Total no. of physicians serving as primary HIV providers No. of physicians by training level Attending physicians Physician trainees (fellows, residents, and interns) No. of physicians by type of specialty Infectious diseases Internal medicine Psychiatry Family practice Oncology Ophthalmology Provider experience with HIV Years experience treating HIV No. of patients with HIV treated

VAMCs Serving Patients with HIV (N ⫽ 118)

Special HIV Clinic (n ⫽ 85)

Mainstreamed Care (n ⫽ 33)

5.1 ⫾ 6.0 (1–50)

4.1 ⫾ 4.0

7.9 ⫾ 8.9

3.7 ⫾ 5.5 (0–50) 1.1 ⫾ 1.9 (0–11)

2.6 ⫾ 2.2 1.4 ⫾ 2.2c

7.3 ⫾ 9.2b 0.6 ⫾ 1.2

2.6 ⫾ 2.6 (0–14) 2.0 ⫾ 4.2 (0–20) 0.4 ⫾ 2.9 (0–30) 0.1 ⫾ 0.5 (0–5) 0.02 ⫾ 0.13 (0–1) 0.02 ⫾ 0.13 (0–1)

3.1 ⫾ 2.7a 0.8 ⫾ 2.4 0.2 ⫾ 0.2 0.02 ⫾ 0.2 0.01 ⫾ 0.11 0.01 ⫾ 0.11

1.4 ⫾ 1.9 5.1 ⫾ 5.9a 1.2 ⫾ 5.3 0.3 ⫾ 0.2b 0.03 ⫾ 0.2 0.03 ⫾ 0.2

10.3 ⫾ 4.5 140 ⫾ 135a

9.2 ⫾ 4.4 71 ⫾ 117

10.2 ⫾ 4.8 (1–21) 121.4 ⫾ 133.8 (1–750)

a

Numbers of physicians are counted as full-time equivalent employees (FTEEs) and not unique individuals. a p ⬍ 0.0001. b p ⬍ 0.05. c p ⬍ 0.005.

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grams, use of HIV clinical practice guidelines, and guideline implementation methods in use). Availability and Location of HIV-Related Health Care Services

Patients commonly had on-site access to pharmacy services, mental health care, urgent care, substance abuse treatment, routine Pap smears, eye examinations, and infusions (Table III). Transportation to clinic visits and availability of domiciliary services were most likely to be unavailable (18% and 14%, respectively). Domiciliary care was the only service most often available only through off-site referral. Referral to a non-VA site was most common for long-term care services (31%), hospice care (27%), dental care (20%), and community housing referrals (18%). Use of HIV Case Managers

Nearly one-half (47%) of VAMCs used a HIV case manager to serve as a manager or care coordinator to help arrange and coordinate medical, mental health, and social services. At most sites (91%), case managers were made available to all HIVpositive patients, rather than being allocated only to symptomatic patients with AIDS. HIV case managers were usually registered nurses (69%) but were also social workers (33%) or nurse practitioners or physician assistants (24%). Some facilities had case managers from more than one discipline. Most VAMCs had at least one full-time VA case manager (49% had one, 14% two, and 5% more than two full-time case managers). Use of Multidisciplinary Team Conferences

Most VAMCs (60%) did not use multidisciplinary team conferences, apart from teaching rounds, to discuss the care of patients with HIV. Where arranged, team conferences were most commonly held at least weekly (46%) or monthly (22%). The remainder held multidisciplinary conferences several times per year or less often.

Formal and Informal Management Practices for Improving HIV Care Quality

Approximately one-quarter of VAMCs had either partially (14%) or fully (12%) implemented a QI program for HIV/AIDS. Another 23% planned or were considering QI for HIV/AIDS. Of the VAMCs that had begun HIV-related QI, 60% had initiated one or two QI teams during the past year to address health care issues in HIV disease. Despite the complexities of HIV treatment regimens, few VAMCs had any written HIV-related directives, policies, or programs in effect to address treatment adherence. The most common programs were interventions designed to improve patients’ adherence (e.g., education and/or behavioral strategies to influence patient behavior) (38%), followed by continuing medical education (CME) courses for HIV providers focused on issues related to treatment adherence (23%). Only 17% had reminder systems to prompt clinicians to ask how well patients adhered to antiretroviral therapy, whereas 14% reported local use of medical center directives or policies requiring clinicians to discuss adherence to antiretroviral therapy with patients. One of every five (20%) VAMCs serving HIV patients was also involved in one or more research projects on treatment adherence. We found that fewer than one-half of the VAMCs serving HIV patients had adopted HIV practice guidelines (55 VAMCs, or 47%). Among the facilities that had adopted some form of HIV guidelines, the aspects of care most frequently addressed included initial evaluation and screening, opportunistic infection prophylaxis, and use of antiretroviral therapy. To integrate the guidelines into care, most clinics relied on informal discussion or used the guidelines as general reference material. Only six (11%) of the 55 had explicitly incorporated them into the medical record (e.g., flow sheet on chart or computerized). Most VAMCs that had adopted HIV clinical practice guidelines relied on physician education programs or informal feedback to promote guideline compliance (Table IV). For example, guideline

TABLE III AVAILABILITY AND LOCATION OF HEALTH CARE SERVICES FOR VETERANS WITH HIV/AIDS IN VAMCs (N ⫽ 118) Availability and Location of Services (% of VAMCs) (n ⫽ 118) Service Location Health Care Services

Service Is Available

At This VA

At Another VA

At a Non-VA Site

Service Not Available

Do Not Know

Pharmacy Mental health services Urgent care Substance abuse treatment Eye examinations by ophthalmologists Infusions (e.g., antibiotics) Routine Pap smears Hospice care Long-term care Dental care Community housing referrals Respite care Domiciliary care Transportation to clinic visits

100 100 100 100 97 97 95 94 93 90 88 80 79 74

100 99 99 97 92 88 93 64 54 70 70 66 36 68

— 1 1 2 2 2 1 3 8 — — 3 25 1

— — — 2 3 7 1 27 31 20 18 11 18 5

— — — — 2 2 — 2 3 5 1 8 14 18

— — — — 1 1 4a 2 2a 5a 10a 11a 6a 8a

Some rows sum to ⬎100% because of rounding. a One respondent did not answer.


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Care for Veterans with HIV/AIDS TABLE IV

GUIDELINE IMPLEMENTATION METHODS USED TO PROMOTE AND MONITOR COMPLIANCE WITH HIV GUIDELINES IN VAMCs (N ⫽ 118)

HIV Guideline Implementation Methods for Promoting and Monitoring Compliance Methods used to promote compliance Feedback of comparative data to providers in the practice Informal feedback Performance incentives for guideline adherence Physician education programs Methods used to monitor compliance Physicians informally monitor each other’s practice patterns Occasional chart reviews Formal medical record audits by facility personnel Formal medical record audits by external personnel (e.g., Joint Commission on Accreditation of Healthcare Organizations) Concurrent computer-based monitoring (e.g., Computerized Patient Record System check boxes)

Percent among VAs Using HIV Guidelines a (n ⫽ 55) Yes

more likely to have 24-hour/7-day access to HIV expertise, whereas rural practices tended to rely on off-site VA experts in HIV care (p ⬍ 0.0001). Service availability did not vary, although rural VAMCs reported having no HIV case managers (p ⬍ 0.05). We found no other regional variations in HIV practice structure, service availability, or access to HIV expertise.

Do not Know

No

27.3

69.1

1.8

65.4 3.6

30.9 90.9

1.8 3.6

74.5

21.8

1.8

56.4

32.7

7.3

52.7 25.4

34.5 56.4

9.1 14.5

27.3

54.5

12.7

20.0

65.4

10.9

Discussion Given the rapid pace of change and complexity in delivering care to patients with HIV disease, the ways in which health care facilities organize themselves for providing high-quality HIV care is increasingly important.32 Structural differences in how HIV care is organized have been shown to increase the variance explained by patient factors alone by 2- to 4-fold,33 although not all studies have identified similar site-level effects on patient ratings of quality.34 In our study, we found significant structural variations in the organization of care for veterans with HIV/ AIDS, which illuminates important issues for designing interventions to optimize their quality of care.

Totals to ⬎100% because respondents indicated all of the various methods they used to promote or monitor guideline implementation.

a

implementation was most commonly discerned through informal physician monitoring of the practices of their peers or through occasional chart reviews. Few had taken advantage of other methods for changing provider behavior, such as comparative feedback or performance incentives. Some had conducted more formal chart audits at defined intervals; these were typically performed either internally (e.g., by facility personnel) or externally (e.g., by network personnel or Joint Commission on Accreditation of Healthcare Organizations consultants). Geographic Practice Variations in the Organization of HIV Care Delivery Urban VAMCs (82% of sample) had significantly higher HIV caseloads than did rural VAMCs (mean number of patients, 169 vs. 23; p ⬍ 0.0001) and were more likely to have adopted a dedicated HIV clinic model than primary care-based delivery for veterans with HIV (Table V). Urban practices were also much

Generalist and Specialist HIV Care Delivery in VAMCs We found that the majority of VAs have adopted dedicated HIV clinics for providing care for patients with HIV/AIDS, staffed chiefly by infectious disease specialists. However, not all VAs have the capacity or caseload to warrant or accommodate such specialization, and nearly 30% mainstream their HIV patients in primary care or substance use clinics. Interestingly, the years of experience treating HIV did not differ between generalist and specialist venues, although consolidating HIV care in specialty clinics resulted in caseloads twice as large. Patients with HIV seen in mainstreamed settings were more likely to be seen by attending physicians, whereas one-third of the physicians in HIV specialty programs were trainees. What all of this means for quality of care is not certain, since controversy exists regarding the optimal primary provider for patients with HIV disease.35–38 Current guidelines suggest that it is incumbent upon HIV providers to have significant experience in the management of HIV/AIDS and, when that is not possible, to obtain access to HIV expertise to appropriately use the complex medication regimens at the core of HIV disease management.39 The ensuing debate has focused on the appropriate medical “home” for patients with HIV, namely, specialist vs. generalist care.40 The literature is mixed in this regard. Early studies suggested that primary care providers inadequately diagnosed and treated patients with HIV.41–43 Patients with HIV seen at primary carebased models in the hospital or the community were less likely to undergo standardized initial HIV evaluations and received fewer HIV services, compared with HIV specialty care.44 How-

TABLE V GEOGRAPHIC VARIATIONS IN HIV PRACTICE STRUCTURE, ACCESS TO HIV EXPERTISE, AND USE OF HIV CASE MANAGERS (N ⫽ 118) Practice Variations

Large Urban (%)

Small City (%)

Semirural (%)

Rural (%)

p

Special HIV clinic 24-Hour/7-day access to HIV experts Use of off-site VA experts Use of HIV case managers

85 72 2 48

67 52 21 20

54 18 36 0

30 10 50 0

0.0012 ⬍0.0001 ⬍0.0001 0.033



ever, patients with HIV with a generalist physician as their “dominant provider” also experienced 18 to 23% lower odds of emergency department use than did AIDS specialty clinic patients.45 In a study comparing HIV care in a general medicine clinic vs. a HIV specialty/infectious disease clinic, general medicine clinic patients were as likely to receive Pneumocystis carinii pneumonia prophylaxis, Pneumovax, and HAART as were infectious disease clinic patients and even had higher tuberculosis screening rates. However, they also had more emergency department visits and hospital use and lower CD4⫹ cell counts.46 More recent research has shown that the quality of care associated with HIV treatment experience is not necessarily reliant on specialty training. Landon et al.47 found that knowledge of HIV care standards was more strongly associated with HIV caseload than with specialty training and that higher caseload physicians, whether generalist or specialist, likely obtained that knowledge through greater attendance at local and national HIV meetings, compared with nonexperts or lower caseload physicians. They subsequently found no differences in HAART use between expert generalists and specialists, and they noted that observed differences in HAART use stemmed from low-volume nonexpert physicians.48 Given the inconsistent use of HIV clinical practice guidelines in VA settings we found and the central role of HIV expertise in quality of care, the VA has already begun evaluating the relative benefits of different approaches to helping frontline providers deliver more guideline-concordant care. Specifically, QUERIHIV investigators have been comparing intensive QI support, HIV-specific computerized reminders, and audit-and-feedback on the processes and outcomes of care for veterans with HIV disease. Results are forthcoming. Providing Quality HIV Care for Veterans in Urban and Rural Areas Although the majority of veterans reside in urban centers, the VA health care system is also responsible for ensuring access to high-quality health care services in rural areas. Most rural VAs, however, have limited specialty access and tend to rely on primary care providers to deliver certain specialty services or refer their patients to distant VAs that have the needed services. For the most part, rural VAs have accomplished their mission with comparable chronic disease and prevention performance and higher patient satisfaction, compared with their urban counterparts.49 However, it is not known whether patients who are treated for HIV disease in rural VA settings enjoy similar benefits. Outside the VA, HIV patients residing in rural areas receive less HAART and P. carinii pneumonia prophylaxis treatment.50 Although urban/rural VA treatment rates have not yet been compared, we found that rural VAs had much lower HIV caseloads, had less access to needed HIV expertise, and, not surprisingly, tended to mainstream HIV care. There are currently few successful models of rural HIV/AIDS care.51 In the HIV Costs and Services Utilization Study, almost three-quarters of rural HIV patients received their HIV care in urban areas, with significant travel, increased delays, and significant inconvenience.52 Several programs have aimed to overcome distance-related barriers to care (e.g., infectious disease “traveling doctors” or shared care arrangements between networked urban and rural providers), but to unknown effect.53–55 Future research should determine the extent to which rural VAs’

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reliance on off-site VA experts is meeting their needs and whether increased migration of patients with HIV/AIDS to their hometowns requires development of new care models and case management mechanisms to ensure access to needed services and expertise.56 Variations in the Availability and Management of Services for Veterans with HIV/AIDS Among veterans with HIV/AIDS who used the VA, almost all of their HIV-related health care services were widely available on site. This level of service availability is a principal strength of their enrollment in the VA health care system as an integrated delivery model. Future research needs to address patients’ patterns of care to discern the extent to which they have timely access to needed services, the extent to which the available services meet their specific HIV care needs, and whether providers in these other departments have appropriate HIV-related training. Our study findings also point to the role and potential value of HIV case managers in coordinating care delivery among generalist and specialist providers and across hospital-based and community-based settings. We found that many VAs had integrated HIV case managers. Because provision of HIV case management services has been associated with fewer unmet needs among patients with HIV, as well as higher levels of use of HIV medications, it would be useful to determine whether VAMCs without them are using regular hospital case managers or are doing without. This is especially important in VA settings, in view of recent evidence suggesting that case management may have less benefit among substance abusers with HIV/AIDS.57–59 Given the preponderance of guideline-driven performance measurement underway in the VA, we were surprised that HIV guideline use was underway in fewer than one-half of the VAs delivering HIV care. Even in those VAs where HIV guidelines had been adopted, guideline implementation was principally informal and CME driven. Unfortunately, dissemination of innovations (including guidelines) is unlikely to be successful without structured interventions not only to foster their adoption among providers but also to actively integrate guideline features into a care delivery model.60 Previous research also demonstrated that CME is not an effective approach for changing provider behavior.61 The launch of the VA QUERI-HIV is designed to overcome these barriers, leading to systematic improvements in HIV care through implementation of evidence-based practices.62

Comment The costs and challenges of HIV medical care continue to accelerate as studies demonstrate the value of new treatments, with others laying the groundwork for the clinical management of HIV disease as a chronic condition (e.g., lipids management).63,64 Understanding the organization and environment for delivery of HIV health care services is therefore an important adjunct to efforts to systematically improve quality.65 To keep pace with these changes, medical centers and clinics must continually evaluate and enhance the structure and management of their practices, to facilitate the translation of new discoveries into clinical care routines. Military Medicine, Vol. 170, November 2005


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Acknowledgments We acknowledge the contributions of Lawrence Deyton, MD, MSPH (VA Central Office), Valerie McWhorter, MD, and Chris Unfred, MPH (VA San Diego Healthcare System), Alissa Simon, MA, MingMing Wang, MPH, and Ismelda Canelo (VA Sepulveda Ambulatory Care Center), and the QUERIHIV Executive Committee. This project was funded by the VA QUERI-HIV (Grant HIV 98-000) and the VA Greater Los Angeles Health Services Research and Development Center of Excellence (Grant HFP 94-028). Dr. Asch was also a VA Health Services Research and Development Research Career Development Awardee at the time of this project (Grant RCD 97-303).

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