New measures assess patient retention, infection screening and prophylaxis, immunization, and initiation and monitoring of antiretroviral therapy.
In 2007, the National Committee for Quality Assurance (NCQA) and other stakeholder groups convened an expert HIV/AIDS Work Group to draft national HIV/AIDS performance measures for individual patient-level and system-level quality improvement. The perceived need for standardized measures resulted from recognition of quality care gaps seen across many platforms and practice systems. This was an attempt to harmonize HIV quality measures across entities and platforms.
The result was 17 measures for use in assessing processes and outcomes of HIV/AIDs care for patients “established in care,” which was defined as at least two visits in a 12-month period. Overall, the measures allow for assessment of a broad range of care relative to patient retention, screening and prophylaxis for opportunistic infections, immunization and initiation and monitoring of potent antiretroviral therapy. Adopted in 2008, these new guidelines are now being beta tested by several organizations across the country.
During his presentation at the 48th annual meeting of the IDSA in Vancouver, Michael A. Horberg, MD, MAS, HIV Interregional Initiative, Kaiser Permanente, Oakland, CA, reviewed these measures, and provided insight into how to develop and use additional HIV quality measures within clinical practice.
The measures developed by the working group include many mainstay screening measures such as tuberculosis, sexually transmitted diseases, hepatitis B and C, injection drug use, and high-risk sexual behaviour. The process measures include medical visits, CD4 counts, pneumocystis pneumonia prophylaxis, influenza immunization, and other appropriate vaccines.
Horberg said the measures also include several outcome measures, “such as whether or not the HIV viral load is maximally controlled. "Stage of disease at diagnosis, accessing care, hospitalization rates, and mortality rates are other potential measures," Horberg said.
The measures can be implemented for a whole system, a small clinic, or an individual provider. "If you are starting out, I would recommend that you keep the group on the smaller side, and involve the entire staff in their development and implementation, as everyone will then have a vested interest in making it work," Horberg said.
He also stressed the importance of considering the complexity of measures when developing them for implementation. To that end, there are several "off the shelf" or standardized indicator sets that have been developed by NCQA, HIV/AIDS Bureau of the Health Resources and Services Administration (HRSA), and HIVQUAL. "The HIVQUAL measures that are being beta tested by the Ryan White HIV/AIDS Program for HRSA are one of the more complex sets of measurements," Horberg said. "While each set of indicators has its own pros and cons, it may be harder to develop and get buy in from others using measures based on individual clinical experience," he said.
For clinicians making their own measures the advice is to "start simple" but make the query as specific as possible. "Decide what's most important for your practice," Horberg said. "If you're making your own measurements define your numerator, denominator and your population very carefully. If you don't have electronic health records, do a random sample of the charts." He also said that clinicians who use these measures should allow plenty of time to do the measures and expect revisions. On a positive note, Horberg stressed that ultimately these measurements are about improving patient care, and it can be exciting to see practice changes as a result of the program.