EHR-based intervention increases PrEP initiation among some primary care patients

March 18, 2024

2 min read

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Key takeaways:

• An EHR-based intervention did not have an overall significant increase in PrEP initiation among primary care patients.
• There was an increase, however, among primary care practices that see patients with HIV.

Use of an electronic health record-based intervention significantly increased PrEP use among patients of primary care physicians who care for people with HIV, a randomized trial found.

However, the trial showed no significant overall increase when physicians who do not regularly care for people with HIV were included, researchers found.

In the intervention, physicians were notified via the EHR when a patient had an elevated risk for HIV.

“PrEP is highly effective in preventing acquisition of HIV, but many individuals who could benefit are not accessing this treatment,” Jonathan E. Volk, MD, MPH, a physician in the department of infectious diseases at Kaiser Permanente San Francisco, told Healio. “This study tested a clinical decision support intervention — an email alert via a secure staff messaging system — that alerted providers about upcoming visits with patients predicted to be at high risk for acquiring HIV.”

According to Volk, the risk evaluation was based on a previously validated prediction model — the development of which was led by Julia Marcus, PhD, MPH, a coauthor of the new study, an infectious disease epidemiologist at Harvard Medical School and former Kaiser Permanente research fellow. Volk said the machine learning model used more than 40 data elements from the Kaiser Permanente EHR to identify patients predicted to be at higher risk for HIV acquisition.

“Previous research has shown this model to be more accurate than other HIV risk prediction models, including better discrimination of HIV risk across all races and ethnicities,” he said.

The researchers conducted a cluster randomized trial evaluating the effectiveness of the clinical decision support intervention. They randomly assigned primary care providers (PCPs) to usual care or an intervention in which they received the EHR message with prompts to discuss HIV prevention and PrEP before upcoming in-person or video visits with patients whose predicted 3-year HIV risk was above a prespecified threshold. The primary outcome of the study was initiation of PrEP care within 90 days.

In total, 121 PCPs had 5,051 appointments with eligible patients — 2,580 who received usual care and 2,471 who were treated according to the intervention. Overall, the researchers found a nonsignificant increase in PrEP initiation among patients treated according to the intervention compared with usual care (6% vs. 4.5%; HR = 1.32; 95% CI, 0.84-2.1).

However, they did find a significant difference in interaction based on HIV provider status. Specifically, patients of providers who also care for people with HIV were more than twice as likely to initiate PrEP (HR = 2.59; 95% CI, 1.3-5.16). The intervention did not show a benefit in PrEP initiation among providers who do not regularly care for patients with HIV (HR = 0.89; 95% CI, 0.59-1.35).

“Identifying patients who may be at higher risk for HIV is a valuable effort, and we can design clinical decision support tools to reach busy primary care physicians and influence care,” Volk said. “We found our intervention to be more effective with clinicians who have experience with caring for people with HIV, suggesting that a low-intensity, EHR-embedded intervention can improve PrEP provision among providers already familiar with PrEP, whereas more involved interventions are likely needed for primary care providers with less familiarity with PrEP and HIV care.”

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