New York City, NY
From 2018 to 2019, the Individualized Provider Feedback on HIV/HCV Testing intervention used tailored feedback to providers within two New York City emergency departments to increase HIV and hepatitis C virus (HCV) testing and case detection. The intervention was built upon existing evidence that HIV and HCV testing in urban emergency departments is cost effective, and offers a critical access point for people who need testing but lack access to routine care. Staff implementing this approach in 2018 relied on an already existing HIV/HCV team that linked patients to care. Additionally, a physician champion delivered tailored feedback to providers, which included comparisons across all emergency department providers regarding their performance in HIV/HCV testing. The two emergency departments participating in this intervention had existing linkage to care programs and opt-out HIV screening. HIV/HCV testing levels increased during the 30-week intervention period compared to the pre-intervention period.
Screening for HIV and HCV is the first step to accessing critical care. However, opportunities for early testing and diagnosis are often missed. Routine testing in a high-stress, busy environment, such as an emergency department, can be a challenge. Emergency department providers have said that higher-priority issues, a lack of resources, intricate consent processes, and time-consuming follow-up visits impede the HIV/HCV testing process and frequency. Because of this, HIV/HCV testing in emergency department settings is often overlooked, potentially delaying necessary treatment for people with HIV/HCV, and the allocation of resources to people who would benefit from HIV prevention services.
This approach used a feedback intervention theory (FIT)-informed HIV/HCV testing intervention that integrated multiple theories aimed at understanding how feedback interventions affect provider performance. FIT is comprised of three processes—meta-tasks, focal tasks, and task details—that focus on learning to improve performance. In this intervention, the three-pronged FIT model gave actionable, non-punitive, and timely feedback to providers to improve the frequency and quality of their provision of HIV/HCV testing.
A physician champion gave individualized feedback to all clinical staff, including physicians, residents, physician assistants, and nurse practitioners who worked in the emergency department, and could offer HIV/HCV testing. The physician champion sent all staff an email with both individual and peer HIV/HCV screening counts at the one- and six-month marks, overall screening rates for the prior month, and a screening goal for the following month. Physicians and physician assistants also received text messages every month with performance feedback that included provider-specific screening rates and comparative peer screening rates.
All positive test results were followed up by the existing HIV/HCV testing and response team. Care coordinators on the team were assigned to specific patients and then linked them to appropriate care, reducing time spent by emergency department staff on this task.
“There was an HIV/HCV testing and response team that took responsibility for following up on all positive test results and arranging for linkage to care, reducing the amount of emergency department time and resources dedicated to this often-difficult task.”
Individualized Provider Feedback on HIV/HCV Testing staff conducted an interrupted time series analysis on an observational cohort to evaluate the impact of the intervention on weekly HIV/HCV testing levels in two related emergency departments from 2018 to 2019. Throughout the intervention period, which was 30 weeks in total, there were 215,622 emergency department visits. Compared to the pre-intervention period, more patients were screened for HIV and HCV in the intervention period. During the post-intervention period, which included testing but not physician champion feedback, testing levels declined again but not to the pre-intervention levels.
| Category | Information |
|---|---|
| Evaluation data | Data were abstracted from the electronic health record for 30 weeks before, during, and after implementing the intervention. |
| Measures | Rates of HIV and HCV screening in the emergency department. |
| Results |
* statistically significant |
Source: Zucker J, Purpura L, Sani F, et al. Individualized provider feedback increased HIV and HCV screening and identification in a New York City emergency department. AIDS Patient Care STDS. 2022;36(3):106–114.
Data dashboards. Institutional HIV/HCV testing dashboards to provide near real time HIV/HCV testing results were developed in the pre-intervention period. These dashboards included real-time HIV/HCV testing results from the emergency department available for review at the provider level. Providers’ ability to compare their performance to their peers, as well as to flag gaps in care, alleviated their concerns about the accuracy of intervention feedback.
Staffing. A care coordinator led the HIV/HCV testing and response team. This care coordinator followed up with people who tested positive for HIV and/or HCV and assigned them to providers who were available for consultation. The intervention also identified a physician champion to provide email and text-based individualized HIV/HCV screening feedback to providers.
HIV/HCV testing in the emergency departments is still ongoing, however the physician champion feedback is not currently being provided.
- Some providers were surprised or skeptical that their personal testing rates were so low. The development of a quality check dashboard that allowed providers to see granular provider-specific patient-level testing data and understand gaps in care alleviated provider concerns regarding overall accuracy of the feedback.
- To alleviate the burden on emergency department staff, who were concerned with time constraints, a dedicated HIV/HCV testing and response team was responsible for linkage to care activities. This team documented patient follow-up in the electronic health record so emergency department staff could see that patients with a positive test received follow-up care.