By Andy Skean
Numerous studies have illustrated the ability of antiretroviral therapy (ART) to effectively treat patients with HIV and prevent transmission to sexual partners, by suppressing the virus to “undetectable” levels in the blood. However, lack of access to, and adherence with, ART leads to less-than-optimal outcomes in many patients, particularly African Americans and Hispanics, who are also disproportionately affected by the infection when compared with Caucasians with HIV. Latinos suffer from similar disparities, but to a lesser extent and perhaps for different reasons. “At the same time, use of information technology (IT) tools is increasing in critical settings to help organize physician care of patients,” says William Cunningham MD, MPH. “My colleagues and I sought to determine if use of certain IT tools helps improve the delivery of ART, and in turn, improve the suppression of viral replication. Viral suppression is key because it not only improves the patient’s health, but also reduces the transmission of HIV to infected patients’ partners and further into the community.”
Testing Laboratory HIE
For a study published in the Journal of Acquired Immune Deficiency Syndrome, Dr. Cunningham and colleagues tested the effects of a bidirectional laboratory health information exchange (HIE) intervention on ART use, viral suppression, and racial/ethnic disparities along the continuum of care. Operating at both the system and provider levels, the intervention worked through an existing EMR system at a comprehensive HIV/AIDS clinic in Southern California. “Providers used the EMR system to order labs, often while seeing the patient,” explains Dr. Cunningham. “Upon receiving the electron requisition, the labs performed the necessary test(s), entered the results back into the system, and sent a message to the physician’s EMR on that patient so that the next time that patient visited their physician, the results were there.”
Prior to following a cohort of more than 1,000 HIV-positive patients between December 2007 and November 2011, the researchers trained staff and physicians on how to use the new system and arrange workflow changes. “They had an existing system that included faxing and paper records for tracking laboratory results,” adds Dr. Cunningham. “With the laboratory HIE, we could flag abnormal lab results right in the EMR, alleviating the need for paper records or phone calls to obtain test results.”
When compared with baseline rates, use of the intervention was associated with a more than doubling of ART use overall, as well as 16% and 12% increased odds of viral suppression in bivariate and fully adjusted models, respectively. “Prior to the intervention, African-American patients had much lower rates of ART use and viral suppression when compared with Caucasians,” Dr. Cunningham says. “After implementing the intervention, rates of ART use and viral suppression increased among all participants to the point that the gap between African Americans and Caucasians in these measures was essentially eliminated. This intervention, that was not specifically designed to address disparities, in fact, improved care for everyone in the clinic and narrowed the gap at the same time.”
In attempting to answer how the intervention achieved both the intended and unintended outcomes, the study team hypothesized that it helped improve communication between patients and clinicians about ART and patients’ health status, motivating those with HIV to increase medication adherence and, therefore, obtain improved health outcomes. “To test this hypothesis, we asked patients about communication with their physician with a series of questions and assessed the results by race/ethnicity,” says Dr. Cunningham (Table). “The results mirrored those noted above: big improvements overall and a virtual elimination of disparities between races/ethnicities in communication. Our findings show that systems such as laboratory HIE are promising for not only improving care overall but also reducing disparities, two key goals of the National HIV/AIDS Strategy.”
Cunningham W, Ford C, Kinsler J, et al. Effects of a Laboratory Health Information Exchange Intervention on Antiretroviral Therapy Use, Viral Suppression and Racial/Ethnic Disparities. J Acquir Immune Defic Syndr. 2017:75:290-298. Available at https://insights.ovid.com/pubmed?pmid=28368951.