Department of Infectious Diseases, Kaiser Permanente San Francisco, San Francisco, CA.
Division of Research, Kaiser Permanente Northern California, Oakland, CA.
J Acquir Immune Defic Syndr. 2024 Apr 1;95(4):362-369. doi: 10.1097/QAI.0000000000003376.
Preexposure prophylaxis (PrEP) use remains limited and inequitable, and strategies are needed to improve PrEP provision in primary care.
We conducted a cluster randomized trial at Kaiser Permanente, San Francisco, to evaluate the effectiveness of a clinical decision support intervention guided by an electronic health record (EHR)-based HIV risk prediction model to improve PrEP provision. Primary care providers (PCPs) were randomized to usual care or intervention, with PCPs who provide care to people with HIV balanced between arms. PCPs in the intervention arm received an EHR-based staff 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 main study outcome was initiation of PrEP care within 90 days, defined as PrEP discussions, referrals, or prescription fills.
One hundred twenty-one PCPs had 5051 appointments with eligible patients (2580 usual care; 2471 intervention). There was a nonsignificant increase in initiation of PrEP care in the intervention arm (6.0% vs 4.5%, HR 1.32, 95% CI: 0.84 to 2.1). There was a significant interaction by HIV provider status, with an intervention HR of 2.59 (95% CI: 1.30 to 5.16) for HIV providers and 0.89 (95% CI: 0.59 to 1.35) for non-HIV providers (P-interaction <0.001).
An EHR-based intervention guided by an HIV risk prediction model substantially increased initiation of PrEP care among patients of PCPs who also care for people with HIV. Higher-intensity interventions may be needed to improve PrEP provision among PCPs less familiar with PrEP and HIV care.
暴露前预防（PrEP）的使用仍然有限且不公平，因此需要采取策略来改善初级保健中的 PrEP 供应。
我们在 Kaiser Permanente，旧金山进行了一项集群随机试验，以评估基于电子健康记录（EHR）的 HIV 风险预测模型指导的临床决策支持干预措施对改善 PrEP 供应的有效性。将初级保健提供者（PCP）随机分配至常规护理或干预组，在这两个组中，HIV 护理提供者的 PCP 是平衡的。干预组的 PCP 收到了基于 EHR 的员工信息，其中包含在与预测 3 年 HIV 风险高于预设阈值的患者进行面对面或视频就诊之前，讨论 HIV 预防和 PrEP 的提示。主要研究结果是在 90 天内开始接受 PrEP 护理，定义为 PrEP 讨论、转诊或处方填写。
121 名 PCP 与符合条件的患者进行了 5051 次预约（2580 名常规护理；2471 名干预）。干预组中开始接受 PrEP 护理的人数略有增加（6.0%比 4.5%，HR 1.32，95%CI：0.84 至 2.1）。HIV 提供者状态存在显著的交互作用，HIV 提供者的干预 HR 为 2.59（95%CI：1.30 至 5.16），非 HIV 提供者的 HR 为 0.89（95%CI：0.59 至 1.35）（P 交互作用<0.001）。
基于 HIV 风险预测模型的 EHR 干预措施大大增加了同时为 HIV 患者提供护理的 PCP 的患者开始接受 PrEP 护理的机会。对于不太熟悉 PrEP 和 HIV 护理的 PCP，可能需要更强化的干预措施来改善 PrEP 的供应。
