Integrating Evidence-Based Practice Into QI to Improve Patient Outcomes in HIV: Viral Load Suppression

Victoria Lieb, ACRN, MPH; Carla Rossi, MD; Jaime Bloss, CRNP, MSN; Christa DeLong, MA; Rebecca Haffner, MA; & Kailly Muthard, MSW

Background & Purpose

Viral load (VL) suppression is key to both improving patient outcomes in HIV and to decreasing community viral load. Patient adherence to antiretroviral therapy (ART) is crucial in achieving VL suppression and preventing viral resistance.

The Easton Community HIV/AIDS Organization (ECHO), a Ryan White Part C program in eastern Pennsylvania, began to participate in the National Quality Center’s In+Care program in October 2011. Viral Load (VL) Suppression is defined by In+Care as a VL <200 copies/ml.• ECHO Baseline VL Suppression Rate: 67%• National Benchmark Data:

81.9% (top 25%) 86.5% (top 10%).

Goals of ECHO’s quality improvement project: • Increase the percent of patients with a

suppressed viral load • Incorporate evidence-based practices into

patient care• Develop standardized processes for the

management of unsuppressed patients

Evidence-Based Strategies Utilized

• Individualized patient-centered approach • Adherence assessments by phone or in

person for unsuppressed patients conducted by RN within 2 weeks

• Motivational interviewing techniques utilized in adherence counseling

• Adherence tools: alarmed pill boxes, cell phone alarms, phone call reminders, office-based pill box refills, and frequent phone call follow-up.

• Brief adherence intervention during yearly wellness visits.

MethodsWe convened a multidisciplinary team (MD, NP, RN, CM, MA’s) which:• Conducted a literature search to

determine best practices • Utilized DHHS guidelines and IAPAC

guidelines• Completed process flow diagrams for

clinical & non-clinical processes • Incorporated evidence-based strategies

into an adherence program• Developed an algorithm for clinical

management of unsuppressed patients

ResultsViral load suppression increased 19%, from 67% of all patients to 79%.

Conclusions

An individualized, patient-centered approach incorporating evidence-based clinical guidelines is effective in achieving viral load suppression for many patients. We developed a clinical management guideline based on Department of Health and Human Services (DHHS) guidelines and adherence guidelines published by the International Association of Physicians in AIDS Care (IAPAC) and other published studies. Our results indicate that a combination of current clinical practice guidelines and adherence counseling which utilizes motivational interviewing techniques can help patients to improve and maintain adherence to ART.

Oct 20

11

Dec 20

11

Feb 2

012

Apr 20

12Ju

ne 20

12

Aug 20

12

Oct 20

12

Dec 20

12

Feb 2

013

Apr 20

13

Jun 2

013

Aug 20

13

Oct 20

13

60%62%64%66%68%70%72%74%76%78%80%

67%

69%

73%

75%

74%

75%

77%

75%

79%

77%

73%

79%

Easton Community HIV Organization Percent of Patients with Suppressed Viral Load

October 2011 - October 2013

Formulate & Implement

Adherence Plan

2nd VL >200

Adherence Assessment at Next

Appointment

Recheck VL in 3 months

or less

2nd VL <200

Adherence Assessment by

phone or in-person within 2 weeks

Viral Load < 200 Viral Load > 200

Adherence Issues

Identified

No Adherence

Issues

No Adherence

Issues

Consider /Do Genotype

Consider/Do Tropism & HLAB5701

Evaluate for Drug-Drug Interactions

Consider/ Make Med

Easton Community HIV/AIDS OrganizationGuideline for Management of Unsuppressed

Viral Load

Ongoing Adherence Monitoring and VL

Testing at 2-3 Month Intervals Until Undetectable

Routine VL Monitoring Every 3-4 Months

ReferencesInternational Association of Physicians in AIDS Care. (2012). Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care Panel. Retrieved from Agency for Healthcare Research and Quality website: http://www.guideline.gov/content.aspx?id=36947&search=iapacInternational Association of Physicians in AIDS Care website. (n.d.). http://www.iapac.org/AboutUs01.html

Panel on Antiretroviral Guidelines for Adults and Adolescents. (2012). Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. Retrieved from AIDSinfo website: http://www.aidsinfo.nih.gov/contentfiles/guidelines/adultandadolescentgl.pdf

Rollnick, S., Miller, W., & Butler, C. (2008). Motivational interviewing in health care. New York, NY: Guilford .

Simoni, J. M., Amico, R., Pearson, C., & Malow, R. (2008). Strategies for promoting adherence to antiretroviral therapy: A review of the literature. Current Infectious Disease Reports, 10, 515-521.

Adherence Counseling Using Motivational Interviewing Techniques (OARS)

Open-Ended Questions: “It’s hard for many people with HIV to take their medications. So tell me how you find that it’s going for you.”Affirmations: “You’ve done really well over the past year in coming to appointments and getting your lab work done.”Reflective Listening: “It sounds like you’re trying to juggle a lot of things right now and sometimes it’s hard for you to remember to take your pills.”Summaries: “ You’ve had to deal with some unexpected things in your personal life lately that have kind of taken your focus off of taking good care of yourself., But you’re willing to try some new things to help you remember to take your medicines and to keep in contact with us more frequently over the next several months until you’re back on track. Let’s check back in a month and see how it’s going.”