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The State of Care for Veterans with HIV/AIDS: Assessing Quality of Care

for Health Care Providers

Chapter 6 - Assessing Quality of Care

Introduction

As indicated above, the VHA's electronic medical record (EMR) can be used to track and report on specific aspects of quality at the national, VISN, and local healthcare system levels, as well as provide supporting tools to remind and assist clinicians in improving performance on these quality indicators. Beginning in 2006, PHSHG began reviewing data on a select number of clinical topics important in the care of Veterans with HIV/AIDS. The following clinical topics related to the quality of care are considered for 2008: CD4+ lymphocyte count and HIV viral load testing, Pneumocystis jiroveci pneumonia (PCP) prophylaxis, Mycobacterium avium complex (MAC) prophylaxis, influenza and pneumococcal vaccination, hepatitis B screening and vaccination, hepatitis C screening, tuberculosis screening, syphilis screening, lipid testing, and tobacco cessation. The results of these assessments are presented below for 2008.

A note on the limitations of these care quality measures is warranted. Like any measure, they are dependent on the availability of accurate, complete, and standardized data. Data not captured by the EMR, captured in a non-standard fashion, or recorded using non-standard terms, limits the reliability and validity of the measure. For example, if a Veteran receives a flu vaccination from a neighborhood pharmacy, such a vaccination may not be recorded in the VHA EMR. Further, VHA providers who document diagnoses, outside VHA medications, and other activities only within a progress note will not have that information counted in reports such as these.

6.1 CD4+ Lymphocyte Count and HIV RNA Testing

The CD4+ lymphocyte count serves as the major clinical indicator of immune suppression in patients with HIV infection. It is the most important factor in deciding whether to initiate antiretroviral therapy and opportunistic infection prophylaxis and is a strong predictor of HIV disease progression and survival. Plasma HIV RNA serves as a surrogate marker for antiviral treatment response and can be useful in predicting clinical progression.1 The Department of Health and Human Services (DHHS) Guidelines recommend that CD4 counts and HIV RNA levels be determined every three to four months.2 For patients adherent to treatment and exhibiting a stable, sustained response to therapy, the frequency of CD4 count and HIV RNA monitoring may be extended to every six months.

For HIV infected Veterans receiving care in VHA in the last six months of 2008, 79% had both CD4+ lymphocyte count and HIV RNA testing performed at least once in that six month period. The rates across the VISNs ranged from 69% to 86% (Table 8). The percentage of Veterans receiving CD4+ lymphocyte count and HIV RNA testing at least every six months has increased from 74% to 79% over the past 4 years.

Table 8. CD4+ Lymphocyte Count and HIV RNA Testing: July through December 2008
Number in CarePercent with CD4 OnlyPercent with HIV RNA OnlyPercent with Both
Nation22,2942%1%79%
VISN (number)
VA New England Healthcare System (1)5882%1%75%
VA Healthcare Network Upstate New York (2)3181%3%71%
VA NY/NJ Veterans Healthcare Network (3)1,7402%1%80%
VA Healthcare - VISN 4 (4)9783%3%74%
VA Capitol Health Care Network (5)1,4622%1%81%
VA Mid-Atlantic Health Care Network (6)1,4403%1%77%
VA Southeast Network (7)2,2942%1%81%
VA Sunshine Healthcare Network (8)2,8662%1%82%
VA MidSouth Healthcare Network (9)7783%1%78%
VA Healthcare System of Ohio (10)50710%1%73%
Veterans in Partnership - VISN 11 (11)7251%1%81%
VA Great Lakes Health Care System (12)7332%2%80%
VA Heartland Network (15)5163%5%69%
South Central VA Health Care Network (16)1,9292%3%76%
VA Heart of Texas Health Care Network (17)1,1202%1%83%
VA Southwest Health Care Network (18)7071%1%86%
VA Rocky Mountain Network (19)3983%2%79%
VA Northwest Network (20)6723%2%75%
VA Sierra Pacific Network (21)1,0802%2%76%
VA Desert Pacific Healthcare Network (22)1,8521%1%84%
VA Midwest Health Care Network (23)3461%1%86%

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6.2 Prophylaxis against PCP and MAC Infections

For over a decade, DHHS and the Kaiser Family Foundation have published preventative practice guidelines for a number of opportunistic infections that can occur with severe immune suppression in HIV, including Pneumocystis jiroveci pneumonia (formerly PCP) and Mycobacterium avium complex (MAC). According to current DHHS guidelines, HIV infected individuals with CD4 counts of less than 200 cells/mm3 should receive prophylaxis for PCP and individuals with CD4 counts less than 50 cells/mm3 should receive prophylaxis for MAC.3 Assessment of prophylaxis against these two infections in Veterans with CD4 counts below these thresholds is part of the PHSHG's annual CCR reporting. HIV infected Veterans who meet the threshold criteria are considered to have received prophylaxis if they had at least one outpatient prescription with a minimum of twenty-seven day supply during the year.

Just over two thousand HIV infected Veterans (9% of those in care) met the threshold criterion for initiation of PCP prophylaxis in 2008. Of these, 86% of Veterans received prophylaxis for PCP through the VHA (Table 9). The range for the 21 VISNs was from 77% to 94%. The number of Veterans meeting the PCP prophylaxis criterion has marginally decreased since 2005 and the proportion receiving PCP prophylaxis has remained between 86% and 88%.

A total of 434 Veterans (1.8% of those in care) met the threshold criterion for MAC prophylaxis in 2008 and 75% of those eligible veterans received the VHA medications recommended for MAC prophylaxis (Table 9). Across the 13 VISNs with at least 10 patients meeting the criterion for MAC prophylaxis, the VHA MAC prophylaxis rates ranged from 50% to 94%. Though the number of eligible Veterans meeting the MAC prophylaxis criterion has decreased slightly over the past few years, the proportion of Veterans receiving MAC prophylaxis has remained around 75%.

Table 9. PCP and MAC Prophylaxis Rates in HIV Infected Veterans in VHA Care in 2008
Percent Meeting PCP Criterion Who Received VHA ProphylaxisPercent Meeting MAC Criterion Who Received VHA Prophylaxis
* VISNs with 10 or less Veterans eligible for MAC prophylaxis in 2008. Caution should be used when interpreting these rates
Nation86%75%
VISN(number)
VA New England Healthcare System (1)87%100%*
VA Healthcare Network Upstate New York (2)85%50%*
VA NY/NJ Veterans Healthcare Network (3)86%78%
VA Healthcare - VISN 4 (4)81%50%*
VA Capitol Health Care Network (5)89%70%
VA Mid-Atlantic Health Care Network (6)84%64%
VA Southeast Network (7)86%71%
VA Sunshine Healthcare Network (8)82%70%
VA MidSouth Healthcare Network (9)90%91%
VA Healthcare System of Ohio (10)91%94%
Veterans in Partnership - VISN 11 (11)92%67%
VA Great Lakes Health Care System (12)89%73%
VA Heartland Network (15)93%89%*
South Central VA Health Care Network (16)89%91%
VA Heart of Texas Health Care Network (17)88%86%
VA Southwest Health Care Network (18)94%60%*
VA Rocky Mountain Network (19)87%88%*
VA Northwest Network (20)77%33%*
VA Sierra Pacific Network (21)78%67%*
VA Desert Pacific Healthcare Network (22)86%67%
VA Midwest Health Care Network (23)77%75%*

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6.3 Influenza and Pneumococcal Vaccinations

Each year, VHA conducts a national campaign to maximize influenza vaccination among Veterans and staff. The VHA bases its influenza vaccination program on recommendations of the CDC's Advisory Committee on Immunization Practices (ACIP).4 One target group for annual influenza vaccination as identified in these recommendations is persons who have immune suppression, including immune suppression caused by HIV.4 During the 2007/2008 flu season, 59% of HIV infected Veterans in VHA care had CCR documentation that they received an influenza vaccination. The rate of vaccination ranged from 50% to 67% across the VISNs (Table 10). These vaccination rates likely underestimate the number of HIV infected Veterans vaccinated. VHA providers may not consistently document influenza vaccinations received outside of VHA (e.g. in a community program or from a pharmacy). The observed rate of influenza vaccination in HIV infected Veterans is lower than the national rates of influenza vaccination for the general Veteran population which ranged from 69% in Veterans aged 50-64 years to 84% in Veterans aged 65 and older.5 However, the national rates are ascertained by chart review which is likely to be more complete since the reviewer can identify vaccinations documented in non-standardized data fields not currently extracted for the CCR.

Table 10. Influenza and Pneumococcal Vaccination Rates in HIV infected Veterans in VHA Care in 2008
Percent with VHA Flu Vaccine during Oct 07 - March 08*Percent with VHA Pneumococcal Vaccine Ever*
*Veterans with documented allergy to the influenza vaccine or eggs are considered ineligible for the influenza vaccine
Nation59%72%
VISN (number)
VA New England Healthcare System (1)59%70%
VA Healthcare Network Upstate New York (2)59%65%
VA NY/NJ Veterans Healthcare Network (3)58%71%
VA Healthcare - VISN 4 (4)65%70%
VA Capitol Health Care Network (5)64%77%
VA Mid-Atlantic Health Care Network (6)66%78%
VA Southeast Network (7)65%75%
VA Sunshine Healthcare Network (8)57%76%
VA MidSouth Healthcare Network (9)58%70%
VA Healthcare System of Ohio (10)52%73%
Veterans in Partnership - VISN 11 (11)59%64%
VA Great Lakes Health Care System (12)59%70%
VA Heartland Network (15)57%71%
South Central VA Health Care Network (16)54%63%
VA Heart of Texas Health Care Network (17)65%74%
VA Southwest Health Care Network (18)50%69%
VA Rocky Mountain Network (19)56%59%
VA Northwest Network (20)54%61%
VA Sierra Pacific Network (21)56%72%
VA Desert Pacific Healthcare Network (22)55%78%
VA Midwest Health Care Network (23)67%71%

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HIV infected persons have a significantly increased incidence of pneumococcal pneumonia6 which prompted the CDC's ACIP to include HIV infection as an indication for pneumococcal vaccination. HIV infected persons should be vaccinated as soon as possible after diagnosis with strong consideration for a single revaccination after five years.7 Similar to influenza vaccination, the VHA models its pneumococcal vaccination program on the recommendations set forth by the CDC's ACIP. Among HIV infected Veterans in care in 2008, 72% had a VHA record of receiving a pneumococcal vaccine while in VHA care, an increase of 4% from the previous year (Table 10). Rates by VISN ranged from 59% to 78%. It is somewhat less likely that HIV infected Veterans would have received pneumococcal vaccination outside of VHA than influenza vaccination. However, some Veterans may have received pneumococcal vaccine from a non-VHA provider and thus rates of pneumococcal vaccination may also be underestimated. The VISNs with the highest pneumococcal vaccination rates also were more likely to have higher rates for influenza vaccination.

6.4 Hepatitis B Screening, Diagnosis and Prevention

Hepatitis B is a blood-borne and sexually transmitted disease with risk factors for acquisition similar to those for HIV.8 Once infected with hepatitis B, HIV infected persons are significantly more likely to become chronic hepatitis B carriers and are more likely to have higher levels of hepatitis B viremia than HIV negative persons; thus, HIV infected persons are more likely to infect others with hepatitis B.9 Many patients with HIV/AIDS are at risk for acquiring hepatitis B and could benefit from effective hepatitis B vaccination.

Screening for hepatitis B and subsequent vaccination, if indicated, is part of comprehensive HIV medical care recommended by the CDC's ACIP. Ninety-two percent of HIV infected Veterans in VHA care in 2008 were screened for hepatitis B infection. Veterans who do not have VHA evidence of chronic hepatitis B infection during screening are considered eligible for the hepatitis B vaccination. In 2008, of the HIV infected Veterans considered eligible, 77% had either VHA laboratory evidence of hepatitis B immunity (indicating likely prior hepatitis B vaccination) or had received at least one dose of a hepatitis B vaccine from the VHA . The 2008 rate represents an increase of 14% from the prior year. Part of this increase may have been in response to a CQMPH project in early 2008 to notify VHA HIV clinicians of their 2007 hepatitis B screening and vaccination rates. The VISN rates for hepatitis B screening and vaccination in 2008 ranged from 66% to 89% (Table 11).

Table 11. Hepatitis B Screening and Vaccination Rates in HIV Infected Veterans in VHA Care in 2008
Eligible Number in Care*Percent with VHA Hepatitis B Vaccine or Hepatitis B Immunity
* A Veteran was ineligible if he or she had VHA laboratory evidence of chronic hepatitis B infection.
Nation21,81477%
VISN (number)
VA New England Healthcare System (1)59372%
VA Healthcare Network Upstate New York (2)33566%
VA NY/NJ Veterans Healthcare Network (3)1,78281%
VA Healthcare - VISN 4 (4)97180%
VA Capitol Health Care Network (5)1,45084%
VA Mid-Atlantic Health Care Network (6)1,43376%
VA Southeast Network (7)2,26276%
VA Sunshine Healthcare Network (8)2,82474%
VA MidSouth Healthcare Network (9)79067%
VA Healthcare System of Ohio (10)51475%
Veterans in Partnership - VISN 11 (11)72373%
VA Great Lakes Health Care System (12)74580%
VA Heartland Network (15)50775%
South Central VA Health Care Network (16)1,90573%
VA Heart of Texas Health Care Network (17)1,11883%
VA Southwest Health Care Network (18)71079%
VA Rocky Mountain Network (19)39776%
VA Northwest Network (20)67969%
VA Sierra Pacific Network (21)1,11382%
VA Desert Pacific Healthcare Network (22)1,88189%
VA Midwest Health Care Network (23)34270%

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The national rate for co-infection with chronic hepatitis B (as indicated by a VHA laboratory record of positive hepatitis B surface or 'e' antigen or detectable hepatitis B viral load) was 7%. This is likely an underestimate as approximately 8% of HIV infected Veterans in care in 2008 have not had their hepatitis B infection status assessed and some Veterans only have negative hepatitis B viral load results while receiving antiretroviral medications with activity against hepatitis B. More information on hepatitis B can be found at www.hepatitis.va.govLink will take you to our Viral Hepatitis internet site.

6.5 Hepatitis C Screening and Diagnosis

Hepatitis C is the most common chronic blood borne infection in the United States and shares several risk factors for acquisition with HIV. Several national guidelines, including those from the U.S. Public Health Service, the Infectious Diseases Society of America, the VHA Hepatitis C Resource Center Program, and National Hepatitis C Program Office recommend that all HIV patients be tested for hepatitis C.10, 11 Unlike hepatitis A and B, there is no vaccine available to prevent hepatitis C. Patients infected with both HIV and hepatitis C may be at greater risk for liver disease progression than those with hepatitis C infection alone and thus the need for diagnosis and treatment of these individuals is high11. In VHA, 96% of HIV infected Veterans in VHA care in 2008 had been screened for hepatitis C; VISN hepatitis C testing rates ranged from 90% to 98% (Table 12). The high screening rate indicates that VHA organizational initiatives to promote hepatitis C screening among all Veterans, along with specific emphasis on testing HIV infected Veterans for hepatitis C have been successful.

Over 5,400 (24%) of HIV infected Veterans tested for hepatitis C in 2008 had evidence of chronic hepatitis C demonstrated by at least one detectable hepatitis C viral load or an identifiable hepatitis C genotype. At the VISN level, the rate of hepatitis C co-infection in Veterans with HIV/AIDS ranged from 13% to 40% in VISNs 23 and 3, respectively. Four VISNs (numbers 1, 3, 4, and 5), all located in the Northeastern U.S. had rates of co-infection with HIV and chronic hepatitis C above 30%.

Table 12. Hepatitis C Screening Rates in HIV Infected Veterans in VHA Care in 2008
Number in CarePercent with VHA Hepatitis C Screening Ever
Nation23,46396%
VISN (number)
VA New England Healthcare System (1)63693%
VA Healthcare Network Upstate New York (2)35490%
VA NY/NJ Veterans Healthcare Network (3)1,91097%
VA Healthcare - VISN 4 (4)1,05595%
VA Capitol Health Care Network (5)1,55996%
VA Mid-Atlantic Health Care Network (6)1,53596%
VA Southeast Network (7)2,45996%
VA Sunshine Healthcare Network (8)3,10097%
VA MidSouth Healthcare Network (9)85295%
VA Healthcare System of Ohio (10)54495%
Veterans in Partnership - VISN 11 (11)77595%
VA Great Lakes Health Care System (12)78796%
VA Heartland Network (15)55094%
South Central VA Health Care Network (16)2,06097%
VA Heart of Texas Health Care Network(17)1,19797%
VA Southwest Health Care Network (18)74998%
VA Rocky Mountain Network (19)42495%
VA Northwest Network (20)71995%
VA Sierra Pacific Network (21)1,18294%
VA Desert Pacific Healthcare Network (22)2,02598%
VA Midwest Health Care Network (23)36994%

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6.6 Tuberculosis Screening

According to the CDC, the overall number of tuberculosis (TB) cases in the United States has declined from 84,304 in 1953 to 12,904 in 2008. Sixty-two percent of the tuberculosis patients reported to CDC in 2008 (8,010) had HIV test results available and of this subgroup, 10.2% were HIV positive. The rate may be actually be higher for TB/HIV co-infection since the HIV status was not identified to the CDC for 38% of tuberculosis patients nationally.12 The likelihood of progression from latent TB to active TB has been reported to be from 2.5 to 12 times higher in HIV infected individuals than in those who are not infected.3

The DHHS guidelines for the Prevention of Opportunistic Infections recommend that HIV infected persons be screened for latent tuberculosis infection (LTBI) at the time of HIV diagnosis regardless of other risk factors for TB.3 Screening can be accomplished by traditional tuberculin skin testing or via the newer interferon-gamma release assays. In 2008, just under one thousand (4%) of HIV infected Veterans had a history of TB documented in their VHA electronic medical record and forty had a history of a tuberculin allergy-either of which makes them ineligible for LTBI screening. Among HIV infected Veterans in care in 2008 who were eligible for LTBI screening, 59% had a CCR record of a tuberculin skin test or an interferon gamma release assay ever performed by the VHA (Table 13). VISN rates for LTBI screening varied from 41% to 79%. Given the known inconsistencies in documentation of tuberculin skin testing in the electronic medical record, these percentages likely underestimate LTBI screening rates. It is possible that many HIV infected Veterans have LTBI screening done prior to entering VHA care and those test results are documented in clinic notes which are not captured by the current CCR.

Table 13. Latent Tuberculosis Infection Screening Rates for HIV infected Veterans in VHA Care in 2008
Number in CarePercent with VHA LTBI Screening Ever
Nation23,46359%
VISN (number)
VA New England Healthcare System (1)63655%
VA Healthcare Network Upstate New York (2)35456%
VA NY/NJ Veterans Healthcare Network (3)1,91060%
VA Healthcare - VISN 4 (4)1,05557%
VA Capitol Health Care Network (5)1,55976%
VA Mid-Atlantic Health Care Network (6)1,53553%
VA Southeast Network (7)2,45946%
VA Sunshine Healthcare Network (8)3,10061%
VA MidSouth Healthcare Network (9)85251%
VA Healthcare System of Ohio (10)54474%
Veterans in Partnership - VISN 11 (11)77546%
VA Great Lakes Health Care System (12)78767%
VA Heartland Network (15)55059%
South Central VA Health Care Network (16)2,06057%
VA Heart of Texas Health Care Network (17)1,19779%
VA Southwest Health Care Network (18)74962%
VA Rocky Mountain Network (19)42464%
VA Northwest Network (20)71942%
VA Sierra Pacific Network (21)1,18269%
VA Desert Pacific Healthcare Network (22)2,02559%
VA Midwest Health Care Network (23)36941%

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6.7 Syphilis Screening

The link between syphilis and HIV is related to high-risk behaviors. The resurgence of syphilis among HIV infected individuals in the United States underscores the importance of prevention and screening.3 Furthermore, co-existent HIV and syphilis can impact the diagnosis and natural history of syphilis; clinical manifestations may be more apparent and progression of syphilitic disease may be accelerated.13 Routine serologic screening for syphilis is recommended at least annually for all sexually active HIV infected persons, and various guidelines recommend more frequent testing on the basis of clinical history (e.g. ongoing risk behavior).14 In 2008, 48% of Veterans with HIV/AIDS received a screening test for syphilis in that same year, this rate was 3% higher than the previous year. Rates of annual syphilis testing across VISNs ranged from 27% to 68% (Table 14).

Syphilis is a recognized issue in the VHA HIV/AIDS population as indicated by the fact that 96% of the HIV infected Veterans in VHA care in 2008 had documentation of at least one syphilis test ever and a median of four tests while in VHA HIV care with testing repeated a median of every 1.87 years. The large variation among VISNs and the low overall annual testing rates nationally indicate that efforts to improve routine syphilis screening across VHA are warranted.

Table 14. Annual Syphilis Screening Rates in HIV Infected Veterans in VHA Care in 2008
Number in CarePercent with VHA Syphilis Test in 2008
Nation23,46348%
VISN (number)
VA New England Healthcare System (1)63627%
VA Healthcare Network Upstate New York (2)35430%
VA NY/NJ Veterans Healthcare Network (3)1,91032%
VA Healthcare - VISN 4 (4)1,05542%
VA Capitol Health Care Network (5)1,55960%
VA Mid-Atlantic Health Care Network (6)1,53549%
VA Southeast Network (7)2,45967%
VA Sunshine Healthcare Network (8)3,10051%
VA MidSouth Healthcare Network (9)85232%
VA Healthcare System of Ohio (10)54450%
Veterans in Partnership - VISN 11 (11)77536%
VA Great Lakes Health Care System (12)787 61%
VA Heartland Network (15)55051%
South Central VA Health Care Network (16)2,06048%
VA Heart of Texas Health Care Network (17)1,19767%
VA Southwest Health Care Network (18)74936%
VA Rocky Mountain Network (19)42431%
VA Northwest Network (20)71937%
VA Sierra Pacific Network (21)1,18238%
VA Desert Pacific Healthcare Network (22)2,02568%
VA Midwest Health Care Network (23)36943%

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6.8 Lipid Testing

Several antiretroviral medications, including most protease inhibitors and efavirenz, have been shown to contribute to the elevation of serum lipids.15 Since these medications are commonly used, hyperlipidemia occurs in a high proportion of HIV infected Veterans, many of whom have other conditions and characteristics that put them at high risk for coronary heart disease, such as diabetes, hypertension, tobacco use, and being a male over age 45. Once antiretroviral therapy has been initiated, the DHHS Guidelines recommend routine monitoring of key laboratory tests to assess toxicity, including lipid testing (low density cholesterol (LDL) and triglycerides).2

Frequency of monitoring is dictated by a drug's known side effect profile, the expected time of onset, and duration of use. These guidelines recommend monitoring when initiating antiretroviral therapy, 3 to 6 months after starting a new regimen, then annually or more frequently in high risk patients or patients with abnormal baseline levels. The National Cholesterol Education Program (NCEP) recommends HIV-infected persons at high risk of coronary heart disease receive lipid monitoring every four to six months.16

Using the more conservative NCEP lipid screening recommendations, 65% of HIV infected Veterans on antiretroviral therapy underwent VHA lipid testing in the last six months of 2008 (July through December). VISN rates ranged from 48% to 83% (Table 15). The percentage of Veterans on antiretroviral therapy who had semi-annual lipid testing has increased by 5% since these rates were first reported in 2005. Although the average rate has increased slightly compared to 2005, there is still a range of 35% between VISNs. Further investigation of local health care systems with lower lipid testing rates is warranted to identify knowledge gaps or process issues impairing higher lipid testing rates.

Table 15. Lipid Testing Rates in HIV Infected Veterans with Antiretrovirals in VHA Care in July-December 2008
Number on AntiviralsPercent with VHA Lipid Test
Nation17,66565%
VISN (number)
VA New England Healthcare System (1)43665%
VA Healthcare Network Upstate New York (2)23054%
VA NY/NJ Veterans Healthcare Network (3)1,34375%
VA Healthcare - VISN 4 (4)75257%
VA Capitol Health Care Network (5)1,09864%
VA Mid-Atlantic Health Care Network (6)1,12054%
VA Southeast Network (7)1,84063%
VA Sunshine Healthcare Network (8)2,30672%
VA MidSouth Healthcare Network (9)60848%
VA Healthcare System of Ohio (10)39161%
Veterans in Partnership - VISN 11 (11)60454%
VA Great Lakes Health Care System (12)56166%
VA Heartland Network (15)41861%
South Central VA Health Care Network (16)1,59563%
VA Heart of Texas Health Care Network (17)90869%
VA Southwest Health Care Network (18)58883%
VA Rocky Mountain Network (19)32953%
VA Northwest Network (20)55155%
VA Sierra Pacific Network (21)86564%
VA Desert Pacific Healthcare Network (22)1,48576%
VA Midwest Health Care Network (23)28576%

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6.9 Tobacco Cessation

Tobacco dependence is prevalent among HIV infected Veterans; 44% of them have a VHA diagnosis of tobacco use ever (Table 16). Twenty-four percent had a current diagnosis of tobacco dependence in 2008, which is slightly higher than the 22% prevalence in the overall Veteran population and the 21% prevalence in the general population.17 The 2008 Update of the Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence states that it is essential for clinicians and healthcare delivery systems to consistently identify and document tobacco use status and treat every tobacco user seen in a healthcare setting. Nearly 36% of HIV infected Veteran smokers have ever received a medication to treat their tobacco dependence and 14% received tobacco cessation medications in 2008 (Table 16). VISN rates for treatment with tobacco cessation medications in 2008 were between 12% and 29%. Work is needed to determine how best to assist VHA providers and HIV infected Veterans in achieving higher levels of treatment and tobacco cessation.

Table 16. Tobacco Use and Pharmacotherapy in HIV infected Veterans in VHA Care in 2008
Number in CarePercent with VHA DX of Tobacco Use EverPercent with VHA DX of Tobacco Use in 2008Percent with VHA Drug Therapy EverPercent with VHA Drug Therapy in 2008
Nation23,46344%24%36%14%
VISN (number)
VA New England Healthcare System (1)63654%28%46%23%
VA Healthcare Network Upstate New York (2)35459%30%47%20%
VA NY/NJ Veterans Healthcare Network (3)1,91041%21%35%14%
VA Healthcare - VISN 4 (4)1,05548%28%43%15%
VA Capitol Health Care Network (5)1,55941%20%40%15%
VA Mid-Atlantic Health Care Network (6)1,53545%26%36%16%
VA Southeast Network (7)2,45939%20%33%14%
VA Sunshine Healthcare Network (8)3,10047%29%31%12%
VA MidSouth Healthcare Network (9)85249%28%35%15%
VA Healthcare System of Ohio (10)54462%39%44%20%
Veterans in Partnership - VISN 11 (11)77551%32%38%15%
VA Great Lakes Health Care System (12)78751%26%40%15%
VA Heartland Network (15)55054%34%41%15%
South Central VA Health Care Network (16)2,06043%19%35%13%
VA Heart of Texas Health Care Network(17)1,19735%19%33%13%
VA Southwest Health74949%30%34%12%
Care Network (18)
VA Rocky Mountain Network (19)42443%23%36%17%
VA Northwest Network (20)71949%26%42%15%
VA Sierra Pacific Network (21)1,18243%23%34%14%
VA Desert Pacific Healthcare Network (22)2,02540%22%32%12%
VA Midwest Health Care Network (23)36950%34%50%29%

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Methods

  1. CD4+ lymphocyte count and HIV Viral Load testing. Veterans who had an inpatient admission, outpatient prescription, or outpatient visit between July and December 2008 were assessed for receipt of a CD4+ lymphocyte count and for a HIV viral load in the July through December 2008 period.
  2. PCP and MAC prophylaxis. Veterans with CD4+ lymphocyte counts below specific thresholds were assessed for receipt of a medication recommended by DHHS Guidelines for Prevention and Treatment with at least a 27 day supply. For PCP, the CD4+ lymphocyte threshold was less than 180 cells/mm3 and qualifying medications included atovaquone, dapsone, and aerosolized pentamidine. For MAC, the CD4+ lymphocyte count threshold was less than 45 cells/mm3 and qualifying medications included sulfamethoxazole/trimethoprim azithromycin, clarithromycin, and rifabutin.
  3. Influenza and pneumococcal vaccination. For the Influenza vaccination report, veterans with an inpatient admission, outpatient prescription, or outpatient visit during the October 2007 through March 2008 vaccination campaign were assessed for the receipt of a VHA vaccination, documentation that an offer to vaccinate was declined, history of allergy to the vaccine or to eggs, or documentation of vaccination outside of VHA. For pneumococcal vaccination, all veterans with an admission, outpatient prescription, or outpatient visit in 2008, were assessed for the receipt of a VHA vaccination documentation that an offer to vaccinate was declined, or history of allergy to the vaccine or to phenol during or prior to 2008.
  4. Hepatitis B. Veterans with an inpatient admission, outpatient prescription, or outpatient visit in 2008 were first assessed for the receipt of testing for active hepatitis B infection (positive result for hepatitis B viral load, e antigen, or surface antigen), hepatitis B exposure, or previous vaccination (antibodies to hepatitis B surface or core antigens). Next, those with no evidence of past exposure to hepatitis B, or immune response to prior disease were assessed for the receipt of hepatitis B vaccine. CCR inpatient and outpatient prescription records were reviewed for receipt of hepatitis B vaccine or combination products containing hepatitis B vaccine during or prior to 2008.
  5. Hepatitis C. Veterans with an inpatient admission, outpatient prescription, or outpatient visit in 2008 were assessed for the receipt of a laboratory test for hepatitis C during or prior to 2008.
  6. Tuberculosis screening. Veterans with an inpatient admission, outpatient prescription, or outpatient visit in 2008 were first assessed for a history of tuberculosis using ICD-9 diagnosis codes or a history of allergy to tuberculin. Each Veteran without a history of TB infection or allergy was assessed for the receipt of a TB skin test or an interferon gamma release assay during or prior to 2008.
  7. Syphilis screening. Veterans with an admission, outpatient prescription, or outpatient visit in 2008 were assessed for the receipt of a syphilis test in 2008.
  8. Lipid screening. Veterans with an outpatient prescription fill for an antiretroviral medication in July through December 2008 were assessed for the receipt of a low density lipoprotein (LDL) or triglyceride (TG) test in that same period.
  9. Tobacco cessation. Veterans with an admission, outpatient prescription, or outpatient visit in 2008 were assessed for a history of a tobacco dependence diagnosis from ICD-9 codes linked to outpatient visits or admissions. Medications for tobacco cessation included nicotine replacement therapy, bupropion (approved formulations and strengths), and varenicline.

References

  1. US Public Health Service and Infectious Disease Society of America (IDSA). USPHS/IDSA guidelines for the management of opportunistic infections in persons infected with HIV, 2001.
  2. Panel on Antiretroviral Guidelines for Adult and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. November 3, 2008; pp 1-139 Available at http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed 05-Oct-2009.
  3. Centers for Disease Control and Prevention. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. MMWR 2009;58 (No. RR-4) April 10, 2009. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr58e324a1.htmLink will take you outside the VA website.
  4. Fiore AE, Shay DK, Broder K. Prevention and control of influenza: recommendations of the advisory committee on immunization practices (ACIP), 2008. MMWR August 8, 2008; 57(RR07); 1-60. Available at http://www.ncbi.nlm.nih.gov/pubmed/18685555Link will take you outside the VA website.
  5. Internal data, Department of Veterans Affairs, Office of Quality Performance.
  6. Selwyn PA, Feingold AR, Hartel D, et al. Increased risk of bacterial pneumonia in HIV-infected intravenous drug users without AIDS. AIDS 1988;2:267-272. Available at http://www.ncbi.nlm.nih.gov/pubmed/3140832Link will take you outside the VA website.
  7. Centers for Disease Control. MMWR. Prevention of Pneumococcal Disease: recommendations of the advisory committee on immunization practices (ACIP). April 4, 1997; 46(RR-08);1-24. Available at http://www.ncbi.nlm.nih.gov/pubmed/9132580Link will take you outside the VA website.
  8. Center for Disease Control. Hepatitis B Virus FAQ. Http://www.cdc.gov/hepatitis/HBV/HBVFaq.htm#treatmentLink will take you outside the VA website.. Accessed 05-Oct-2009.
  9. Hyams KC. Risk of chronicity following acute hepatitis B virus infection: a review. Clin Infect Dis 1995; 20:992-1000. Available at http://www.ncbi.nlm.nih.gov/pubmed/7795104Link will take you outside the VA website.
  10. National Institutes of Health Consensus. Development Conference Panel Statement: Management of Hepatitis C: 2002-June 10, 2002. Hepatology 2002;36(5 Suppl 1):S3-20.
  11. Management and Treatment of Hepatitis C Virus Infection in HIV-Infected Adults: Recommendations from the Veterans Affairs Hepatitis C Resource Center Program and National Hepatitis C Program Office. Am J Gastroenterol. 2005 Oct;100(10):2338-54. Available at http://www.hiv.va.gov/provider/guidelines/hcv-coinfection
  12. CDC. Reported Tuberculosis in the United States, 2008. Atlanta, GA: U.S. Department of Health and Human Services, CDC, September 2009.
  13. Rompalo AM, Lawor J, Seaman P, et.al. Modification of Syphililic Genital Ulcer Manifestations by Coexistent HIV Infection. Sex Trans Dis 2001;28:448-54. Available at http://www.ncbi.nlm.nih.gov/pubmed/11473216Link will take you outside the VA website.
  14. Centers for Disease Control. Workowski KA, Berman SM: Sexually Transmitted Disease Treatment Guidelines. MMWR 2006;55 (No. RR-11)
  15. Levy AR, Hogg RS, Harrigan PR, et.al. Impact of Highly Active Antiretroviral Therapy on Lipid Metabolism Among Persons Treated for HIV/AIDS. Antivir Ther 2003; 8(suppl): abstract 720
  16. NHLBI National Cholesterol Education Program Expert Panel. Detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panes III). NIH Publication No. 02-5215. September 2002. Available at: http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htmLink will take you outside the VA website.
  17. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008