Compliance with laboratory monitoring guidelines in outpatient HIV care: a qualitative study in the Netherlands

Figures & data

Table 1. Level of guideline compliance for laboratory assessment by centre, in 2012–2014 (van Sighem et al., 2016).

Tests	Compliance with recommended testing, before cART initiation^a / % patients tested		Compliance with recommended test within 12 months of cART initiation^a / % patients tested		Variation in requesting recommended tests for men who have sex with men (MSM)^b / % patients tested
	High	Low	Low	High	High	Low
CD4 cell count	78	100	78	100	NA
HIV RNA viral load	55	100	90	100	NA
Cholesterol level	50	100	16	100	NA
Hepatitis B	50	100	NA		NA
Hepatitis C	20	100	NA		21	100
Syphilis	73	100	NA		56	100
Alanine aminotransferase (ALAT) level	90	100	85	100	NA

^aBetween 2012 and 2014.

^bMSM who entered care in 2012 and 2013.

Figure 1. Conceptual framework for guideline compliance in HIV care.

Table 2. Coding scheme with definitions.

Code	Concept	Definition of concept
GF	Guideline factors	The content of guidelines can be divided in the accessibility and feasibility of the recommended test according to the guidelines. It was hypothesized that low accessibility and low feasibility result in low intention to comply with guidelines.
PC	Patient factors	Patient factors include sex, age, ethnicity, socio-economic status, clinical facts and behaviour of the patient. It was hypothesized that they would be taken into account in the intention to comply with guidelines.
PF	Physician factors	It was hypothesized that physicians’ awareness and agreement of the content of clinical guidelines influence the intention to comply with the guidelines.
EF	Environmental factors	Organization of the health system, affordability and feasibility of tests were expected to influence the intention to comply with guidelines. For example, are tests financially covered by national health insurance or do health centres and/or patients themselves pay for tests?

Table 3. Patient characteristics of the present study.

Participant (no.)	Centre-size^a	Age group / years	Specialization	Sex
1	Large	40–50	Epidemiologist	Male
2	Large	60–70	Internist-infectious disease physician	Male
3	Large	60–70	Internist	Female
4	Small	50–60	Internist-infectious disease physician	Male
5	Large	40–50	Internist-infectious disease physician	Male
6	Large	50–60	Internist	Male
7	Large	40–50	Internist-infectious disease physician	Male
8	Large	40–50	Internist-infectious disease physician	Male
9	Large	50–60	Internist-infectious disease physician	Female
10	Mid-size	40–50	Internist	Female
11	Mid-size	40–50	Internist-infectious disease physician	Female
12	Mid-size	60–70	Internist	Male

^aSmall < 300 patients in care. Mid-size = 300–600 patients in care. Large ≥ 600 patients in care.

Table 4. Quotation table.

Concept	Quotation
Guideline factors	“We have set up the clinical work-up in such a way that a standard set of laboratory tests is obtained from each patient, including serology. The viral load, creatinine and ALAT are tested in the consultations in between. On indication we do an extra syphilis or other test. But of course, for the standard package we used the [NVHB] guidelines.” Participant 5
Patient factors	“The guidelines are useful. Where necessary, and if substantiated, you can deviate from these guidelines [and not request lab tests]. What a patient wants is a key factor in this decision; it’s about the patient’s wishes.” Participant 1. “High risk MSM, bisexuals, swingers and vulnerable migrants, those are the most important risk groups. I assess this by asking if people have these (sexual) contacts. I do not only look at someone to make judgements.” Participant 4. “I perform all tests with MSM, but I also have patients in care that I have known for 15 years. They don’t have sex and if they are 75 years old, I don’t do the tests. For others [of those patients] I make the tests easily accessible, especially because you don’t know what the patients’ partners do.” Participant 7.
Physician factors	“I prepare the outpatient visits by looking at earlier deviations in lab results. When requesting the lab tests for the next consultation, after half a year, I check whether I have to request extra tests derived from the previous lab results. If that is not the case, I do the standard lab tests that are in our computer software.” Participant 3
Environmental factors	“When I believe that a test is necessary, I request the test. But there are also tests that patients get twice a year, and I do pay attention so that we do not simply routinely do the expensive tests.” Participant 6 “By looking at ALAT you can detect 80% or 90% of all the acute hepatitis C […] But, ideally, you should test [HCV] RNA in everyone. However, that’s very expensive and not cost-effective.” Participant 8.

van Sighem, A. I., Smit, C., Wit, F. W. N. M., Boender, T. S., Matser, A., & Reiss, P. (2016). Monitoring Report 2016. Human Immunodeficiency Virus (HIV) Infection in the Netherlands. Amsterdam.

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