Decreasing Disparities Using a Clinical Decision Support Tool

From the 2023 HVPA National Conference

Leora Aquino MD (NYU Langone Health), Isaac Dapkins MD, Jennifer Norton PhD, Chase McCaleb MS, Judd Anderman MS

Background:
Patients who enter medical care late in their HIV disease have substantially higher direct medical treatment expenditures than those who enter at earlier stages. Successful efforts to link patients with medical care earlier in the disease course may yield cost savings. Getting tested for HIV is the first step in prevention and treatment. In 2016 approximately 80% of new HIV infections in the United States were transmitted from the 38% percent of people with HIV who either did not know they had HIV or received a diagnosis but were not engaged in treatment. Black/African American and Hispanic communities are disproportionately affected by HIV compared with other racial and ethnic groups. Clinical decision support (CDS) tools have shown promise in reducing healthcare disparities in health outcomes and we aim to use this tool to target HIV screening disparities and increase screening rates.

Objective:
To reduce racial healthcare disparities and increase the HIV screening rates through a CDS tool among internal medicine and family medicine providers servicing diverse, medically underserved patients at urban federally qualified health centers in the Northeastern United States.

Methods:
A CDS tool through EPIC was widely implemented across Internal Medicine and Family Medicine clinics to remind providers to order an HIV test for a patient due for HIV screening. We used a Pearson Chi-Square test to determine if there was a statistically significant difference in HIV screening rates between providers that ignored the CDS alert, only acknowledged the CDS alert, or ordered an HIV test through the CDS tool stratified by patient race (White, Black, Asian, American Indian, Native Hawaiian/Pacific Islander, Multiple Race, Unknown). The outcome we assessed was whether encounters where a patient due for an HIV test had an HIV test ordered in the next month.

Inclusion Criteria: Encounters at Internal Medicine or Family Medicine departments (9/2019 – 1/2023) where a patient was not screened for HIV at the start of the visit (n=34,324).

Exclusion Criteria: Pediatric and Obstetrics/Gynecology encounters.

Results:
Overall Internal Medicine and Family Medicine providers that used the CDS tool were more likely to order an HIV test for patients due for HIV screening (p<0.0001). When the data were stratified by patient race, there was a statistically significant difference where providers that used the CDS tool compared to providers that did not use the CDS tool were more likely to order an HIV test for patients of a White (p<0.0001), Black (p<0.0001), Asian (p<0.0001), American Indian (p<0.0001), Unknown (p<0.0001), and Native Hawaiian/Pacific Islander (p=0.0145) racial background. This statistical significance was not observed in patients of multiple races (p=0.94).

Conclusions:
CDS tools are useful in increasing rates of evidence-based screening and help to reduce healthcare disparities.

Clinical Implications:
CDS support tools are a viable strategy in targeting healthcare disparities, averting the patient burden of advanced complications of the disease, and promoting cost savings through population-level prevention.

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