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. 2020 Mar 25;ciaa299.
doi: 10.1093/cid/ciaa299. Online ahead of print.

New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision-Support Versus Guidelines for HIV Treatment Selection by Trainees

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New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision-Support Versus Guidelines for HIV Treatment Selection by Trainees

Jesus A Ramirez et al. Clin Infect Dis. .

Abstract

Background: Support for clinicians in HIV medicine is critical given national HIV-provider shortages. Department of Health and Human Services (DHHS) guidelines are comprehensive but complex to apply for antiretroviral therapy (ART) selection. HIV-ASSIST (www.hivassist.com) is a free tool providing ART decision-support that could augment implementation of clinical practice guidelines.

Methods: We conducted a randomized study of medical students and residents at Johns Hopkins University, in which participants were asked to select an ART regimen for 10 HIV case-scenarios through an electronic survey. Participants were randomized to receive either DHHS guidelines alone (with video tutorial), or DHHS guidelines and HIV-ASSIST (with video tutorial) to support their decision-making. ART selections were graded 'appropriate' if consistent with DHHS guidelines, or concordant with regimens selected by HIV experts at four academic institutions.

Results: Among 118 trainees, participants randomized to receive HIV-ASSIST had significantly higher percentage of appropriate ART selections compared to those receiving DHHS guidelines alone (% appropriate responses in DHHS vs HIV-ASSIST arms: median 40% [Q1, Q3: 30%, 50%] vs 90% [80%, 100%], p<0.001). This difference was consistent among both medical students (median 40% vs 90%, p<0.001) and residents (median 40% vs 90%, p<0.001). The effect was seen for all case-types, but most pronounced for complex cases involving ART-experienced patients with ongoing viremia (DHHS vs HIV-ASSIST: median 0% [0%, 33%] vs 100% [66%, 100%]).

Conclusion: Trainees using HIV-ASSIST were significantly more likely to choose appropriate ART regimens compared to those using guidelines alone. Interactive decision-support tools may be important to ensure appropriate implementation of HIV guidelines.

Keywords: Decision-Analysis; Guidelines; HIV.

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