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Abstract
Background In 2018, 26% of new HIV diagnoses in the US were among youth 13–24 years of age; more than 50% had undiagnosed infections and were unaware they had HIV. Routine screening and targeted HIV testing is recommended for adolescents. Providers at the Adolescent and Young Adult Clinic at Vanderbilt order HIV testing based on standardized guidelines and clinical indicators, but completion of the laboratory test is not universal.
Objectives To improve the percentage of completed HIV tests within 1 week of ordering from 71.4% to >95% in the clinical setting by June 30, 2019.
Methods Interventions were tested and implemented over an 8-month period based on a key driver diagram created by the improvement team (figure 1). The primary outcome was percentage of adolescents aged 12 to 22 years who had HIV testing ordered and successfully completed the test within one week of order entry. Data was followed prospectively following the initiation of the project. Statistical process control charts were used to view and analyze data with special cause variation identified using Nelson rules.
Results 71.4% of patients completed the ordered HIV test at baseline (July-September 2018). Adolescent-specific educational and behavioral modification strategies were tested to improve laboratory completion rates. Provision of in-clinic phlebotomy services as well as oral HIV testing facilitated project success. After several plan-do-study-act cycles, which included behavioral interventions as well as clinic-wide system modifications, special cause variation was achieved and 96.1% of patients completed HIV testing within 1 week of order entry. This completion rate has been successfully maintained for more than 12 months post-interventions (figure 2).
Key driver diagram
Control chart
Conclusions Educational interventions in the absence of robust behavioral modification tools may have limited availability in practice. Data can drive patient improved outcomes and allow teams to expand in-clinic services to improve the delivery of care.