Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study

BackgroundThe United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).Methods and findingsData were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014–2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37–54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p p p p p p ConclusionsIn this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.

研究背景 美国艾滋病护理医护人力规模正逐步缩减，这可能会为人类免疫缺陷病毒感染者（People Living with HIV, PLWH）的护理服务交付带来挑战。本研究聚焦于医护人力能力建设倡议（Workforce Capacity Building Initiative）框架下的示范项目站点，探讨了诊疗模式转型——即优化护理结构与服务交付效率——对其产生的影响。该倡议隶属于美国卫生资源和服务管理局（Health Resources and Services Administration, HRSA）旗下的瑞安·怀特艾滋病项目国家重点专项项目（Special Projects of National Significance, SPNS）。

研究方法与结果
本研究的数据采集自7个州及哥伦比亚特区的14个示范项目站点。各站点在诊疗模式实施前完成1次机构评估，实施后完成4次机构评估。评估覆盖三类转型实践路径：一是扩充艾滋病护理医护人力规模，即通过增加参与PLWH护理的现有医护人员数量来提升服务能力；二是分工协作诊疗模式，即采用团队化护理模式，赋予中级医护人员及工作人员更多诊疗职责；三是提升感染者在艾滋病基础护理中的参与度，以减少急诊与住院护理需求（例如通过护理协调服务）。
我们还从各站点获取了2014至2016日历年（对应转型前、转型中与转型后阶段）的瑞安·怀特艾滋病项目服务报告（Ryan White HIV/AIDS Program Services Reports, RSRs），该报告包含PLWH的护理留存率、抗逆转录病毒治疗（Antiretroviral Therapy, ART）处方情况以及病毒抑制情况相关数据。本研究采用广义估计方程（Generalized Estimating Equation, GEE）模型，对实施各类诊疗模式转型的站点的变化情况进行分析。
示范项目的处方医师平均数量为18.5名（标准差SD=23.5），各站点每年上报的感染者数据超过13500例（平均每个站点969例，标准差SD=1351）。研究对象的人口统计学特征随时间推移保持稳定：2014年，绝大多数感染者为男性（占比71%，女性占28%，跨性别者占0.2%），平均年龄为47岁（四分位距IQR=37~54）；种族/族裔特征方面，非裔美国人占48%、西班牙裔/拉丁裔占31%、白人占14%；艾滋病感染风险因素分布为：男男同性性行为占31%、异性性行为占31%、注射吸毒占7%。近四成感染者享受医疗救助计划（Medicaid）福利（占比41%）。
各站点在符合扩充艾滋病护理医护人力规模的诊疗实践中参与度显著提升（增幅达18%，原文此处p值缺失）。

研究结论
本研究发现，诊疗模式转型是应对艾滋病护理医护人力预期短缺问题的潜在策略。该模式有望优化医护人力配置，确保为所有有需求的PLWH提供护理服务，同时可能改善艾滋病护理连续照护的结局指标。