Physician specialization and antiretroviral therapy for HIV

Unmet Needs for Ancillary Services by Provider Type Among People With Diagnosed Human Immunodeficiency Virus

Background

Unmet needs for ancillary services are substantial among people with human immunodeficiency virus (PWH), and provider type could influence the prevalence of unmet needs for these services.

Methods

Data from a national probability sample of PWH were analyzed from the Centers for Disease Control and Prevention's Medical Monitoring Project. We analyzed 2019 data on people who had ≥1 encounter with a human immunodeficiency virus (HIV) care provider (N = 3413) and their care facilities. We assessed the proportion of needs that were unmet for individual ancillary services, overall and by HIV care provider type, including infectious disease (ID) physicians, non-ID physicians, nurse practitioners, and physician assistants. We calculated prevalence differences (PDs) with predicted marginal means to assess differences between groups.

Results

An estimated 98.2% of patients reported ≥1 need for an ancillary service, and of those 46% had ≥1 unmet need. Compared with patients of ID physicians, needs for many ancillary services were higher among patients of other provider types. However, even after adjustment, patients of non-ID physicians had lower unmet needs for dental care (adjusted PD, -5.6 [95% confidence interval {CI}, -9.9 to -1.3]), and patients of nurse practitioners had lower unmet needs for HIV case management services (adjusted PD, -5.4 [95% CI, -9.4 to -1.4]), compared with patients of ID physicians.

Conclusions

Although needs were greater among patients of providers other than ID physicians, many of these needs may be met by existing support systems at HIV care facilities. However, additional resources may be needed to address unmet needs for dental care and HIV case management among patients of ID physicians.

Provider Specialization in Inflammatory Bowel Diseases: Quality of Care and Outcomes

BACKGROUND & AIMS

Management of inflammatory bowel diseases (IBD) is complex and variation in care has been well-documented. However, the drivers of practice variation remain unexplored. We examined variation based on the treating gastroenterologist's IBD focus (proportion of outpatient visits for IBD).

METHODS

We conducted a retrospective cohort of newly diagnosed patients with IBD using data from Optum's deidentified Clinformatics Data Mart Database (2000-2020). The exposure variable was whether the treating gastroenterologist had an IBD focus (>90th percentile of IBD visits/total outpatient visits). We used adjusted regression models to evaluate associations between provider IBD focus and process measures (use of mesalamine, corticosteroid, biologic, and narcotic medications and endoscopic or radiographic imaging) and clinical outcomes (time to IBD-related hospitalization and bowel resection surgery). We tested for change in treatment patterns over time by including an interaction term for study era (2004-2012 vs 2013-2020).

RESULTS

The study included 772 children treated by 493 providers and 2864 adults treated by 2076 providers. In children, none of the associations between provider focus and process or outcome measures were significant. In adults, care from an IBD-focused provider was associated with more use of biologics, combination therapy, and imaging and endoscopy, and less mesalamine use for Crohn's disease (P < .05 for all comparisons) but not with other process measures. Biologics were prescribed more frequently and narcotics less frequently during the later era (P < .05 for both). Hospitalization and surgery rates were not associated with IBD focus or era.

CONCLUSIONS

IBD care for adults varies by provider specialization. Given the evolving complexity, novel methods may be needed to standardize care.

Direct and Indirect Effects of a Project ECHO Longitudinal Clinical Tele-Mentoring Program on Viral Suppression for Persons With HIV: A Population-Based Analysis

BACKGROUND

Project Extension for Community Health Outcomes (ECHO) aims to connect community providers to academic specialists, deliver longitudinal clinical mentorship and case consultations, plus encourage dissemination of knowledge and resources. The impact on outcomes for persons with HIV (PWH) is uncertain.

SETTING

PWH in Washington and Oregon outside of the Seattle and Portland metro areas, January 2011 to March 2018.

METHODS

Using viral load (VL) surveillance data, we assessed difference in the percentage of PWH who were virally suppressed among PWH whose providers participated versus did not participate in Project ECHO. Analyses included multiple mixed-effects regression models, adjusting for time and for patient, provider, and clinic characteristics.

RESULTS

Based on 65,623 VL results, Project ECHO participation was associated with an increase in the percentage of patients with VL suppression (13.7 percentage points greater; P < 0.0001), although the effect varied by estimated provider PWH patient volume. The difference was 14.7 percentage points ( P < 0.0001) among patients of providers who order <20 VL's/quarter and 2.3 and -0.6 percentage points among patients of providers who order 20-40 or >40 VL's/quarter, respectively ( P > 0.5). The magnitude of difference in VL suppression was associated with the number of sessions attended. Among patients of lower-volume providers who did not participate, VL suppression was 6.2 percentage points higher if providers worked in a clinic where another provider did participate ( P < 0.0001).

CONCLUSION

Project ECHO is associated with improvement in VL suppression for PWH whose providers participate or work in the same clinic system as a provider who participates, primarily because of benefits for patients of lower-volume providers.

Association between HIV clinic caseloads and viral load suppression in New York City

The relationship between HIV patient caseload and a clinic's ability to achieve viral load suppression (VLS) in their HIV patient population is not understood. The New York City Department of Health and Mental Hygiene (NYCDOHMH) administered a survey to clinics providing HIV care to people living with HIV (PLWH) in NYC in 2016. Clinics were stratified by quartiles of HIV patient caseload and dichotomized by whether ≥85% (n = 36) or <85% (n = 74) of their patients achieved VLS. Multivariable logistic regression adjusted for confounders of age, sex, ethnicity, and race. Provider to patient ratios (PPR) were calculated for each clinic as staffing full time equivalents per 100 HIV patients.

Physician network connections to specialists and HIV quality of care

OBJECTIVE

To estimate novel measures of generalist physicians' network connectedness to HIV specialists and their associations with two dimensions of HIV quality of care.

DATA SOURCES

Medicare and Medicaid claims and the American Medical Association Masterfile data on people living with HIV (PLWH) and the physicians providing their HIV care in California between 2007 and 2010.

STUDY DESIGN

I construct regional patient-sharing physician networks from the shared treatment of PLWH and calculate (a) measures of network connectedness to all physician types and (b) specialty-weighted measures to describe connectedness to HIV specialists. Two HIV quality of care outcomes are then evaluated: medication quality (prescribing antiretroviral drugs from at least two drug classes) and monitoring quality (at least two annual HIV virus monitoring scans). Linear probability models estimate the associations between network statistics and the two dimensions of HIV quality of care, and a policy simulation demonstrates the importance of these statistical relationships. These analyses include 16 124 PLWH, 3240 generalists, and 1031 HIV specialists.

DATA COLLECTION/EXTRACTION METHODS

PLWH are identified from claims for patients with any indication of HIV using an existing algorithm from the literature.

PRINCIPAL FINDINGS

Generalists' network connectedness to HIV specialists is positively related with their own HIV medication quality; one additional HIV specialist connection is associated with a 1.46 percentage point (SE 0.42, P < .01) increase in generalist's medication quality. Based on the estimated associations, a simulated policy that increases connectedness between generalists and HIV specialists reduces the annual rate of HIV infections by up to 6%, roughly 290 fewer infections per year. Only network connectedness to all physician types is associated with improved monitoring quality.

CONCLUSIONS

Network connectedness to HIV specialists is positively associated with generalists' HIV medication quality, which suggests that specialists provide clinical support through patient-sharing for complex treatment protocol.

The association of provider and practice factors with HIV antiretroviral therapy adherence

OBJECTIVE

While antiretroviral therapy (ART) is essential to patients with HIV, there is substantial variation in adherence nationally. We assess how provider and practice factors contribute to successful HIV ART adherence.

DESIGN

We used Medicaid Analytic Extract claims from 2008 to 2012. We attributed patients with HIV to the provider that provided the plurality of HIV-related services or primary care in a given year and assigned these providers to a medical practice based on the National Provider Identifier registry file. We fit successive linear hierarchical models with patient, provider, and practice characteristics to partition the variation in adherence driven by each factor. Our unit of analysis was the patient-year.

SETTING

Fourteen US states with the highest HIV prevalence.

PARTICIPANTS

A total of 111 013 patient-years representing 60 496 Medicaid enrollees living with HIV attributed to 4930 providers and 1960 practices.

MAIN OUTCOME MEASURE

Percentage of year individual patients were adherent to an ART regimen.

RESULTS

Provider and practice random effects jointly explained 6.8% of variation in adherence with patient differences accounted for 45.2% of the variation. Patients seen by generalists and other specialists had a 1.6 [95% confidence interval (CI): 0.6-2.5] and 5.1 (95% CI: 4.1-6.1) percentage point greater adherence than those seen by infectious disease specialists (P < 0.001). Every additional year a patient saw the same provider was associated with a 6% increase in adherence (95% CI: 5.7-6.3).

CONCLUSION

There is substantial variation in ART adherence attributable to providers and practices and between provider specialties. To improve ART adherence for patients living with HIV, structural aspects of care should be considered.

How the delivery of HIV care in Canada aligns with the Chronic Care Model: A qualitative study

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada.

Structural barriers to comprehensive, coordinated HIV care: geographic accessibility in the US South

Structural barriers to HIV care are particularly challenging in the US South, which has higher HIV diagnosis rates, poverty, uninsurance, HIV stigma, and rurality, and fewer comprehensive public health programs versus other US regions. Focusing on one structural barrier, we examined geographic accessibility to comprehensive, coordinated HIV care (HIVCCC) in the US South. We integrated publicly available data to study travel time to HIVCCC in 16 Southern states and District of Columbia. We geocoded HIVCCC service locations and estimated drive time between the population-weighted county centroid and closest HIVCCC facility. We evaluated drive time in aggregate, and by county-level HIV prevalence quintile, urbanicity, and race/ethnicity. Optimal drive time was ≤30 min, a common primary care accessibility threshold. We identified 228 service locations providing HIVCCC across 1422 Southern counties, with median drive time to care of 70 min (IQR 64 min). For 368 counties in the top HIV prevalence quintile, median drive time is 50 min (IQR 61 min), exceeding 60 min in over one-third of these counties. Among counties in the top HIV prevalence quintile, drive time to care is six-folder higher for rural versus super-urban counties. Counties in the top HIV prevalence quintiles for non-Hispanic Blacks and for Hispanics have >50% longer drive time to care versus for non-Hispanic Whites. Including another potential care source-publicly-funded health centers serving low-income populations-could double the number of high-HIV burden counties with drive time ≤30 min, representing nearly 35,000 additional people living with HIV with accessible HIVCCC. Geographic accessibility to HIVCCC is inadequate in the US South, even in high HIV burden areas, and geographic and racial/ethnic disparities exist. Structural factors, such as geographic accessibility to care, may drive disparities in health outcomes. Further research on programmatic policies, and evidence-based alternative HIV care delivery models improving access to care, is critical.

Association of Healthcare Plan with atrial fibrillation prescription patterns

BACKGROUND

Atrial fibrillation (AF) is treated by many types of physician specialists, including primary care physicians (PCPs). Health plans have different policies for how patients encounter these providers, and these may affect selection of AF treatment strategy.

HYPOTHESIS

We hypothesized that healthcare plans with PCP-gatekeeping to specialist access may be associated with different pharmacologic treatments for AF.

METHODS

We performed a retrospective cohort study using a commercial pharmaceutical claims database. We utilized logistic regression models to compare odds of prescription of oral anticoagulant (OAC), non-vitamin K-dependent oral anticoagulant (NOAC), rate control, and rhythm control medications used to treat AF between patients with PCP-gated healthcare plans (eg, HMO, EPO, POS) and patients with non-PCP-gated healthcare plans (eg, PPO, CHDP, HDHP, comprehensive) between 2007 and 2012. We also calculated median time to receipt of therapy within 90 days of index AF diagnosis.

RESULTS

We found similar odds of OAC prescription at 90 days following new AF diagnosis in patients with PCP-gated plans compared to those with non-PCP-gated plans (OR: OAC 1.01, P = 0.84; warfarin 1.05, P = 0.08). Relative odds were similar for rate control (1.17, P < 0.01) and rhythm control agents (0.93, P = 0.03). However, PCP-gated plan patients had slightly lower likelihood of being prescribed NOACs (0.82, P = 0.001) than non-gated plan patients. Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups across drug classes.

CONCLUSIONS

Pharmaceutical claims data do not suggest that PCP-gatekeeping by healthcare plans is a structural barrier to AF therapy, although it was associated with lower use of NOACs.

Antiretroviral Therapy: Racial Disparities among Publicly Insured Californians with HIV

Only 43% of Americans with HIV are virally suppressed; the rate is lower for African Americans, even among insured populations. This study uses 2010 Medicare and Medicaid data for HIV-positive Californians to examine how antiretroviral treatment (ART) relates to patient and provider characteristics. Logistic regressions isolated the effect of race/ethnicity on receipt of ART. Over 90% of the full sample received any ART. Nearly 80% of ART users received a recommended combination for at least half the year; half had a recommended combination for 90% of the year. Lacking evaluation and management visits, or seeing only providers with low HIV patient volume lowered the odds of receiving ART. Controlling for other factors, African Americans remained less likely to receive ART at all, or to be covered for 90% of the year with a recommended regimen. The observed racial treatment differentials may lead to important health disparities.

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study

OBJECTIVES

To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics.

METHODS

Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS.

RESULTS

Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior.

CONCLUSIONS

Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.

Clinical outcomes of HIV care delivery models in the US: a systematic review

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.

Brazilian infectious diseases specialists: who and where are they?

Background

The infectious diseases specialist is a medical doctor dedicated to the management of infectious diseases in their individual and collective dimensions.

Objectives

The aim of this paper was to evaluate the current profile and distribution of infectious diseases specialists in Brazil.

Methods

This is a cross-sectional study using secondary data obtained from institutions that register medical specialists in Brazil. Variables of interest included gender, age, type of medical school (public or private) the specialist graduated from, time since finishing residency training in infectious diseases, and the interval between M.D. graduation and residency completion. Maps are used to study the geographical distribution of infectious diseases specialists.

Results

A total of 3229 infectious diseases specialist registries were counted, with 94.3% (3045) of individual counts (heads) represented by primary registries. The mean age was 43.3 years (SD 10.5), and a higher proportion of females was observed (57%; 95% CI 55.3–58.8). Most Brazilian infectious diseases specialists (58.5%) practice in the Southeastern region. However, when distribution rates were calculated, several states exhibited high concentration of infectious diseases specialists, when compared to the national rate (16.06). Interestingly, among specialists working in the Northeastern region, those trained locally had completed their residency programs more recently (8.7 yrs; 95% CI 7.9–9.5) than physicians trained elsewhere in the country (13.6 yrs: 95% CI 11.8–15.5).

Conclusion

Our study shows that Brazilian infectious diseases specialists are predominantly young and female doctors. Most have concluded a medical residency training program. The absolute majority practice in the Southeastern region. However, some states from the Northern, Northeastern and Southeastern regions exhibit specialist rates above the national average. In these areas, nonetheless, there is a strong concentration of infectious diseases specialists in state capitals and in metropolitan areas.

A population-based study evaluating family physicians' HIV experience and care of people living with HIV in Ontario

PURPOSE

Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV.

METHODS

We retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period).

RESULTS

The majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients (mean levels of adherence [95% CIs] were 0.34 [0.30-0.39] and 0.40 [0.34-0.45], respectively, vs 0.77 [0.74-0.80]). Patients' receipt of cancer screenings and health care use were unrelated to family physician HIV experience.

CONCLUSIONS

Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings.

Knowledge, Beliefs and Practices Regarding Antiretroviral Medications for HIV Prevention: Results from a Survey of Healthcare Providers in New England

Background

Antiretroviral treatment for HIV-infection before immunologic decline (early ART) and pre-exposure chemoprophylaxis (PrEP) can prevent HIV transmission, but routine adoption of these practices by clinicians has been limited.

Methods

Between September and December 2013, healthcare practitioners affiliated with a regional AIDS Education and Training Center in New England were invited to complete online surveys assessing knowledge, beliefs and practices regarding early ART and PrEP. Multivariable models were utilized to determine characteristics associated with prescribing intentions and practices.

Results

Surveys were completed by 184 practitioners. Respondent median age was 44 years, 58% were female, and 82% were white. Among ART-prescribing clinicians (61% of the entire sample), 64% were aware that HIV treatment guidelines from the Department of Health and Human Services recommended early ART, and 69% indicated they would prescribe ART to all HIV-infected patients irrespective of immunologic status. However, 77% of ART-prescribing clinicians would defer ART for patients not ready to initiate treatment. Three-fourths of all respondents were aware of guidance from the U.S. Centers for Disease Control and Prevention recommending PrEP provision, 19% had prescribed PrEP, and 58% of clinicians who had not prescribed PrEP anticipated future prescribing. Practitioners expressed theoretical concerns and perceived practical barriers to prescribing early ART and PrEP. Clinicians with higher percentages of HIV-infected patients (aOR 1.16 per 10% increase in proportion of patients with HIV-infection, 95% CI 1.01–1.34) and infectious diseases specialists (versus primary care physicians; aOR 3.32, 95% CI 0.98–11.2) were more likely to report intentions to prescribe early ART. Higher percentage of HIV-infected patients was also associated with having prescribed PrEP (aOR 1.19, 95% CI 1.06–1.34), whereas female gender (aOR 0.26, 95% CI 0.10–0.71) was associated with having not prescribed PrEP.

Conclusions

These findings suggest many clinicians have shifted towards routinely recommending early ART, but not PrEP, so interventions to facilitate PrEP provision are needed.

Health administrative data can be used to define a shared care typology for people with HIV

OBJECTIVES

Building on an existing theoretical shared primary care/specialist care framework to (1) develop a unique typology of care for people living with human immunodeficiency virus (HIV) in Ontario, (2) assess sensitivity of the typology by varying typology definitions, and (3) describe characteristics of typology categories.

STUDY DESIGN AND SETTING

Retrospective population-based observational study from April 1, 2009, to March 31, 2012. A total of 13,480 eligible patients with HIV and receiving publicly funded health care in Ontario. We derived a typology of care by linking patients to usual family physicians and to HIV specialists with five possible patterns of care. Patient and physician characteristics and outpatient visits for HIV-related and non-HIV-related care were used to assess the robustness and characteristics of the typology.

RESULTS

Five possible patterns of care were described as low engagement (8.6%), exclusively primary care (52.7%), family physician-dominated comanagement (10.0%), specialist-dominated comanagement (30.5%), and exclusively specialist care (5.2%). Sensitivity analyses demonstrated robustness of typology assignments. Visit patterns varied in ways that conform to typology assignments.

CONCLUSION

We anticipate this typology can be used to assess the impact of care patterns on the quality of primary care for people living with HIV.

Database-Supported Teleconferencing: An Additional Clinical Mentoring Tool to Assist a Multinational Company HIV/AIDS Treatment Program in Africa

BACKGROUND

The lack of human resources for health is presently recognized as a major factor limiting scale-up of antiretroviral treatment (ART) programs in resourcelimited settings. The mobilization of public and private partners, the decentralization of care, and the training of non-HIV specialist nurses and general practitioners could help increase the number of HIV-infected patients receiving ART. In addition to other forms of training, scheduled teleconferences (TCs) have been organized to support a comprehensive HIV treatment program delivered by a private company's health team.

OBJECTIVE

To describe the role of the TC as an additional tool in mentoring a company's health care workers (HCWs).

METHOD

For this study, all TC reports were retrospectively reviewed and the questions classified by topic. Participating Heineken physicians evaluated the technical quality and scientific relevance of the TCs through an anonymous survey.

RESULTS

From October 2001 to December 2003, 10 HCWs working in 14 operating companies in 5 African countries raised 268 problems during 45 TCs. A total of 79 questions (29%) were asked about antiretroviral (ARV) therapy, 53 (20%) about the diagnosis and treatment of opportunistic infection, 43 (16%) about ARV toxicity, 40 (15%) about care organization and policy, 32 (12%) about laboratory or drug supply, and 21 (8%) about biological parameters. The mean TC attendance rate was 70%. The level of satisfaction among local company physicians was 65% for logistics, 89% for scientific relevance, 84% for applicability of advice, and 85% overall. The most common complaints concerned the poor quality of the telephone connection and language problems for francophone participants.

CONCLUSION

Database-supported teleconferencing could be an additional tool to mentor company HCWs in their routine care of HIV-infected workers and family members. The role and costeffectiveness of telemedicine in improving health outcomes should be further studied.

Gender inequities in quality of care among HIV-positive individuals initiating antiretroviral treatment in British Columbia, Canada (2000-2010)

Objectives

We measured gender differences in “Quality of Care” (QOC) during the first year after initiation of antiretroviral therapy and investigated factors associated with poorer QOC among women.

Design

QOC was estimated using the Programmatic Compliance Score (PCS), a validated metric associated with all-cause mortality, among all patients (≥19 years) who initiated ART in British Columbia, Canada (2000–2010).

Methods

PCS includes six indicators of non-compliance with treatment initiation guidelines at baseline (not having drug resistance testing before treatment; starting on a non-recommended regimen; starting therapy at CD4<200 cells/mm³) and during first-year follow-up (receiving <3 CD4 tests; receiving <3 viral load tests; not achieving viral suppression within six months). Summary scores range from 0–6; higher scores indicate poorer QOC. Multivariable ordinal logistic regression was used to measure if female gender was an independent predictor of poorer QOC and factors associated with poorer QOC among women.

Results

QOC was determined for 3,642 patients (20% women). At baseline: 42% of women (34% men) did not have resistance testing before treatment; 17% of women (9% men) started on a non-recommended regimen (all p<0.001). At follow-up: 17% of women (11% men) received <3 CD4; 17% of women (11% men) received <3 VL; 50% of women (41% men) did not achieve viral suppression (all p<0.001). Overall, QOC was better among men (mean PSC = 1.54 (SD = 1.30)) compared with women (mean = 1.89 (SD = 1.37); p<0.001). In the multivariable model, female gender (AOR = 1.16 [95% CI: 0.99–1.35]; p = 0.062) remained associated with poorer QOC after covariate adjustment. Among women, those with injection drug use history, of Aboriginal ancestry, from Vancouver Island, and who initiated ART in earlier years were more likely to have poorer QOC.

Conclusions

Poorer QOC among women, especially from marginalized communities, demands that barriers undermining women's access to high-quality care be addressed to improve treatment and health for women with HIV.

The effects of health information technology on the costs and quality of medical care

Information technology has been linked to productivity growth in a wide variety of sectors, and health information technology (HIT) is a leading example of an innovation with the potential to transform industry-wide productivity. This paper analyzes the impact of health information technology (HIT) on the quality and intensity of medical care. Using Medicare claims data from 1998 to 2005, I estimate the effects of early investment in HIT by exploiting variation in hospitals' adoption statuses over time, analyzing 2.5 million inpatient admissions across 3900 hospitals. HIT is associated with a 1.3% increase in billed charges (p-value: 5.6%), and there is no evidence of cost savings even five years after adoption. Additionally, HIT adoption appears to have little impact on the quality of care, measured by patient mortality, adverse drug events, and readmission rates.

Surveillance for hepatocellular carcinoma in a Medicaid cirrhotic population

GOALS

To estimate the hepatocellular carcinoma surveillance in the Medicaid cirrhotic population.

BACKGROUND

Most studies predate 2005 American Association for the Study of Liver Diseases surveillance recommendations and do not examine the primary target population, cirrhotics.

STUDY

From 2006 to 2007, we identified adults with at least 1 cirrhosis International Classification of Disease code and 15 months of continuous enrollment in North Carolina Medicaid, recording claims for abdominal ultrasound, computed tomography, magnetic resonance imaging, and α-fetoprotein testing. We used multivariable logistic regression to identify factors independently associated with imaging.

RESULTS

A total of 5061 subjects were identified: mean age 54 years, 54% male patients, 35% African American, 56% white. Cirrhosis risk factors were alcohol (59%), hepatitis C (30%), hepatitis B (4%), others (18%), and unknown (24%). Only 26% underwent at least 1 imaging test. Just 12% of those not hospitalized or seen in an emergency department underwent any imaging test. Care in an academic facility, younger age, female sex, viral hepatitis, and Medicare coinsurance were positively associated with imaging. Twenty-one percent saw a gastroenterologist, which increased the odds of undergoing imaging (odds ratio, 2.81; 95% confidence interval, 2.32-3.41), whereas primary care visits did not (odds ratio, 0.94; 95% confidence interval, 0.76-1.16).

CONCLUSIONS

Only a quarter of North Carolina Medicaid cirrhotics underwent abdominal imaging over a 15-month period, and many tests may have been conducted without surveillance intent. Gastroenterology visits nearly tripled the odds of imaging, but primary-care visits had no effect. Efforts to improve surveillance rates in cirrhotic patients should target primary care and increased access to subspecialty care.

Teleconsultation improves primary care clinicians' confidence about caring for HIV

BACKGROUND

Telemedicine can facilitate communication between primary care clinicians and specialists. Generalists who use telemedicine for consultation (teleconsultation) may be able to practice more independently and reduce the number of formal referrals to specialists. In the United States, a federally funded human immunodeficiency virus (HIV) teleconsultation service (HIV Warmline) offers clinicians live telephone access to HIV specialists; however, its impact on clinicians' self-perceived clinical competence and referral rates has not been studied.

OBJECTIVE

To determine if primary care clinicians who used the HIV Warmline felt more capable of managing HIV in their own practices.

DESIGN

Online survey.

PARTICIPANTS

Primary care physicians and mid-level practitioners who used the HIV Warmline for teleconsultation between 1/2008 and 3/2010.

MAIN MEASURES

Participants compared the HIV Warmline to other methods of obtaining HIV clinical support, and then rated its impact on their confidence in their HIV skills and their referral patterns.

KEY RESULTS

Respondents (N = 191, 59% response rate) found the HIV Warmline to be quicker (65%), more applicable (70%), and more trustworthy (57%) than other sources of HIV information. After using the HIV Warmline, 90% had improved confidence about caring for HIV, 67% stated it changed the way they managed HIV, and 74% were able to avoid referring patients to specialists. All valued the availability of live, free consultation.

CONCLUSIONS

Primary care clinicians who called the HIV Warmline reported increased confidence in their HIV care and less need to refer patients to specialists. Teleconsultation may be a powerful tool to help consolidate HIV care in the primary care setting, and could be adapted for use with a variety of other medical conditions. The direct impact of teleconsultation on actual referral rates, quality of care and clinical outcomes needs to be studied.

Avaliação de serviços de assistência ambulatorial em aids, Brasil: estudo comparativo 2001/2007

OBJETIVO: Avaliar os serviços do Sistema Único de Saúde brasileiro de assistência ambulatorial a adultos vivendo com aids em 2007 e comparar com a avaliação de 2001. MÉTODOS: Os 636 serviços cadastrados no Ministério da Saúde em 2007 foram convidados a responder a um questionário previamente validado (Questionário Qualiaids) com 107 questões de múltipla escolha sobre a organização da assistência prestada. Analisaram-se as frequências das respostas de 2007 comparando-as com as obtidas em 2001 na forma de variação percentual (VP). RESULTADOS: Responderam o questionário 504 (79,2%) serviços. Cerca de 100,0% dos respondentes relataram ter pelo menos um médico, suprimento sem falhas de antirretrovirais e de exames CD4 e carga viral. Vários aspectos mostraram melhor desempenho em 2007 comparados a 2001: registro de número de faltas à consulta médica (de 18,3 para 27,0%, VP: 47,5%), agendamento de consulta em menos de 15 dias no início da terapia antirretroviral (de 55,3 para 66,2%, VP: 19,7%) e participação organizada do usuário (de 5,9 para 16,7%, VP: 183,1%). Houve manutenção de dificuldades: pequena variação na disponibilidade de exames especializados em até 15 dias, como endoscopia (31,9 para 34,5%, VP: 8,1%), e a piora de indicadores como tempo ideal de acesso a consultas especializadas (55,9 para 34,5% em cardiologia, VP negativa de 38,3%). O tempo médio despendido nas consultas médicas de seguimento manteve-se baixo: 15 minutos ou menos (52,5 para 49,5%, VP negativa de 5,8%). CONCLUSÕES: A avaliação de 2007 mostrou que os serviços contam com os recursos essenciais para a assistência ambulatorial. Houve melhoras em muitos aspectos em relação a 2001, mas persistem desafios. Pouco tempo dedicado à consulta médica pode estar vinculado ao número insuficiente de médicos e/ou à baixa capacidade de escuta e diálogo. A acessibilidade prejudicada a consultas especializadas mostra a dificuldade das infraestruturas locais do Sistema Único de Saúde.

Rural residence and adoption of a novel HIV therapy in a national, equal-access healthcare system

Rural persons with HIV face barriers to care that may influence adoption of advances in therapy. We performed a retrospective cohort study to determine rural-urban variation in adoption of raltegravir-the first HIV integrase inhibitor-in national Veterans Affairs (VA) healthcare. There were 1,222 veterans with clinical indication for raltegravir therapy at time of its FDA approval in October 2007, of whom 223 (19.1%) resided in rural areas. Urban persons were more likely than rural to initiate raltegravir within 180 days (17.3% vs. 11.2%, P = 0.02) and 360 days (27.5% vs. 19.7%, P = 0.02), but this gap narrowed slightly at 720 days (36.3% vs. 31.8%, P = 0.19). In multivariable analysis adjusting for patient characteristics, urban residence predicted raltegravir adoption within 180 days (odds ratio 1.72, 95% CI 1.09-2.70) and 360 days (OR 1.63, 95% CI 1.13-2.34), but not 720 days (OR 1.26, 95% CI 0.84-1.87). Efforts are needed to reduce geographic variation in adoption of advances in HIV therapy.

Influence of provider experience on antiretroviral adherence and viral suppression

BACKGROUND AND AIM

Early in the combination antiretroviral therapy (cART) era, provider experience (as measured by panel size) was associated with improved outcomes. We explored that association and other characteristics of provider experience.

METHODS

We performed a retrospective cohort analysis in Kaiser Permanente California (an integrated health care system in the United States), examining all human immunodeficiency virus seropositive (HIV+) patients initiating a first cART regimen (antiretroviral therapy [ART]-naïve, N = 7071) or initiating a second or later cART regimen (ART-experienced, N = 3730) from 1996-2006. We measured ART adherence through 12 months (pharmacy fill and refill records) and determined HIV viral load levels below limits of quantification at 12 months. Provider experience, updated annually, was measured as (1) HIV panel size (0-10 patients as reference strata), (2) years treating HIV (less than 1 year as reference), and (3) specialty ( noninfectious disease specialty, non-HIV expert as reference). We assessed associations by utilizing mixed modeling analyses (clustered by provider and medical center), controlling for patient age, sex, race/ethnicity, HIV risk behavior, hepatitis C coinfection, ART regimen class, and calendar year.

RESULTS

Among the ART-experienced, improved adherence was associated with greater years experience (mean increase 3.1% 2-5 years experience; 3.7% 5-10 years; 2.7% 11-20 years; P = 0.07, categorical). In adjusted analyses, viral suppression among ART-naïve was positively associated with panel size (odds ratio 26-50 patients: 1.31, P = 0.03, categorical), but negatively associated with years experience (18% less for greater than 100 patients; P = 0.003). No provider characteristic was significantly associated with improved adherence among ART-naïve or odds of maximal viral suppression among ART-experienced in adjusted analysis.

CONCLUSIONS

Except for panel size and years experience among ART-naïve, provider characteristics did not significantly influence ART adherence or likelihood of viral suppression.

Implementation of targeted interventions to decrease antiretroviral-related errors in hospitalized patients

PURPOSE

The implementation and effectiveness of targeted interventions aimed at decreasing the frequency of antiretroviral-related errors in hospitalized patients with human immunodeficiency virus (HIV) are described.

SUMMARY

A prospective investigation conducted at the University of North Carolina Hospitals revealed a high rate of antiretroviral-related errors occurring on admission to the hospital and throughout a patient's hospital stay. The high frequency of errors emphasized the need for targeted interventions aimed at preventing these errors and quickly identifying and resolving errors that do occur. Several interventions aimed at decreasing this error rate were instituted, including the addition of computer alerts for incorrect doses and drug interactions to the pharmacy order-entry system, distribution of an educational pocket-sized card among the staff, addition of commercially available combination antiretroviral products to the hospital formulary, updates of the computerized prescriber-order-entry (CPOE) system to include common dosage defaults, involvement of the infectious diseases consultation service to evaluate prescribed regimens of newly admitted patients with HIV, and daily review of newly initiated anti-retroviral regimens by a clinical pharmacist trained in HIV care. A follow-up analysis was conducted after these interventions were implemented to evaluate their effectiveness. Of the 78 patients identified during the postintervention analysis, 12 (15%) had at least one error in their initial drug regimen versus 49 patients (72%) in the preintervention study (p < 0.001).

CONCLUSION

Antiretroviral medication error rates decreased after the implementation of targeted interventions that included distributing an educational pocket-sized card, adding alerts to the pharmacy order- entry system, incorporating default dosages into the CPOE system, and adding combination antiretrovirals to the formulary.

Evaluation of the effectiveness of an outreach clinical mentoring programme in support of paediatric HIV care scale-up in Botswana

Clinical mentoring by providers skilled in HIV management has been identified as a cornerstone of scaling-up antiretroviral treatment in Africa, particularly in settings where expertise is limited. However, little data exist on its effectiveness and impact on improving the quality-of-care and clinical outcomes, especially for HIV-infected children. Since 2008, the Botswana-Baylor Children's Clinical Centre of Excellence (COE) has operated an outreach mentoring programme at clinical sites around Botswana. This study is a retrospective review of 374 paediatric charts at four outreach mentoring sites (Mochudi, Phutadikobo, Molepolole and Thamaga) evaluating the effectiveness of the programme as reflected in a number of clinically-relevant areas. Charts from one visit prior to initiation of mentoring and from one visit after approximately one year of mentoring were assessed for statistically-significant differences (p<0.05) in the documentation of clinically-relevant indicators. Mochudi showed notable improvements in all indicators analysed, with particular improvements in documentation of pill count, viral load (VL) results, correct laboratory monitoring and correct antiretroviral therapy (ART) dosing (p<0.0001, p<0.0001, p<0.0001 and p<0.0001, respectively). Broad and substantial improvements were also seen in Molepolole, with the most improvement in disclosure documentation of all four sites. At Thamaga, improvements were restricted to CD4 documentation (p<0.001), recent VL and documented pill count (p<0.05 and p<0.05, respectively). Phuthadikobo showed the least amount of improvement across indicators, with only VL documentation and correct ART dosing showing statistically-significant improvements (p<0.05 and p<0.0001, respectively). These findings suggest that clinical mentoring may assist improvements in a number of important areas, including ART dosing and monitoring; adherence assessment and assurance; and disclosure. Clinical mentoring may be a valuable tool in scale-up of quality paediatric HIV care-and-treatment outside specialised centres. Further study will help refine approaches to clinical mentoring, including assuring mentoring translates into improved clinical outcomes for HIV-infected children.

HIV quality of care assessment at an academic hospital: outcomes and lessons learned

Rapid changes in HIV treatment guidelines and antiretroviral therapy drug safety data add to the increasing complexity of caring for HIV-infected patients and amplify the need for continuous quality monitoring. The authors created an electronic HIV database of 642 patients who received care in the infectious disease (ID) and general medicine clinics in their academic center to monitor HIV clinical performance indicators. The main outcome measures of the study include process measures, including a description of how the database was constructed, and clinical outcomes, including HIV-specific quality improvement (QI) measures and primary care (PC) measures. Performance on HIV-specific QI measures was very high, but drug toxicity monitoring and PC-specific QI performance were deficient, particularly among ID specialists. Establishment of HIV QI data benchmarks as well as standards for how data will be measured and collected are needed and are the logical counterpart to treatment guidelines.

Essential components of effective HIV care: a policy paper of the HIV Medicine Association of the Infectious Diseases Society of America and the Ryan White Medical Providers Coalition

Human immunodeficiency virus (HIV) antiretroviral agents and effective HIV care management transformed HIV disease from a death sentence to a chronic condition for many in the United States. A comprehensive HIV care model was developed to meet the complex needs of HIV patients, with support from the Ryan White program, the Veterans Administration, and others. This paper identifies the essential components of an effective HIV care model. As access to health care expands under the National HIV/AIDS Strategy and the Patient Protection and Affordable Care Act, it will be critical to build upon the HIV care model to realize positive health outcomes for people with HIV infection.

How prepared are our future doctors for HIV/AIDS?

Three cohorts (n = 391) of final-year medical students in Hong Kong were evaluated on their preparedness to provide HIV care. Through a self-administered questionnaire, half (53%) were assessed to be better prepared and had a lower perceived risk of infection at work, though unwillingness to manage HIV patients was reported in a minority (4.6%). For a majority of medical students (72.8%), a specially-designed clinic attachment offered the only opportunity to come face-to-face with HIV patients for the first time. With continued improvement in treatment effectiveness, HIV/AIDS is evolving to become a new chronic disease in most societies. Curriculum development in HIV medicine remains a challenge in this HAART era.

The association of hospital, clinic and provider volume with HIV/AIDS care and mortality: systematic review and meta-analysis

The objective of this systematic review and meta-analysis is to examine the association between hospital, clinic and provider patient volumes on HIV/AIDS patient outcomes including mortality, antiretroviral (ARV) use and proportion of patients on indicated opportunistic infection (OI) prophylaxis. We searched MEDLINE and nine other electronic databases from 1 January 1980 through 29 May 2009. Experimental and controlled observational studies of persons with HIV/AIDS were included. Studies examined the volume or concentration of patients with HIV/AIDS in hospitals, clinics or individual providers. Outcomes included mortality, ARV use and proportion of patients on indicated OI prophylaxis. We reviewed 22,692 titles and/or abstracts. Patient characteristics, study design, volume measures, medical outcomes and study confounders were abstracted. Data were extracted independently by two reviewers. Twenty-two studies were included in the final review. High volume hospital care was associated with lower in-hospital mortality (pooled odds ratio (OR) 0.71, 95% confidence interval [CI] 0.57-0.90 p = 0.004) and lower mortality 30 days from admission (pooled OR 0.62, 95% CI 0.47-0.81 p = 0.0004). Higher volume provider care was associated with significantly higher ARV use (pooled OR 4.41, 95% CI 2.70-7.18 p<0.00001). Differences in volume definitions and controlling for confounding variables did not appreciably alter the results. Higher volume hospitals, clinics and providers were associated with significantly decreased mortality for people living with HIV/AIDS and higher volume providers and clinics had higher ARV use. Heterogeneity of volume thresholds and absence of studies from resource-limited settings are major limitations.

Provider training and experience for people living with HIV/AIDS

BACKGROUND

The complexity of HIV/AIDS raises challenges for the effective delivery of care. It is important to ensure that the expertise and experience of care providers is of high quality. Training and experience of HIV/AIDS providers may impact not only individual patient outcomes but increasingly on health care costs as well.

OBJECTIVES

The objective of this review is to assess the effects of provider training and experience on people living with HIV/AIDS on the following outcomes: immunological (ie. viral load, CD4 count), medical (ie. mortality, proportion on antiretrovirals), psychosocial (ie. quality of life measures) and economic outcomes (ie health care costs).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsycInfo, PsycLit, Social Sciences Abstracts, and Sociological Abstracts from January 1, 1980 through May 29, 2009.  Electronic searches were performed for abstracts from major international AIDS conferences. Reference lists from pertinent articles, books and review articles were retrieved and reviewed.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials, cohort, case control, cross-sectional studies and controlled before and after designs that examined the qualifications/training and patient volume of HIV/AIDS care of providers caring for persons known to be infected with HIV/AIDS were included.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed trial quality and extracted data. Study authors were contacted for further information as required. Assessment of confounding factors was undertaken independently by two reviewers.

MAIN RESULTS

A total of four studies (one randomized controlled trial, three non- randomized studies) involving 8488 people living with HIV/AIDS were included. The main findings of this review demonstrated a trend to improved outcomes when treated by a provider with more training/expertise in HIV/AIDS care in the outpatient (clinic) setting. Due to the heterogeneity of the included studies, we could not perform a meta-analysis. We present a descriptive review of the results.

AUTHORS' CONCLUSIONS

The results demonstrate improved medical outcomes when treated by a provider with more training/expertise in HIV/AIDS care in the outpatient (clinic) setting. Since all of these studies were conducted in North America, this does not address any issues regarding the level of training/expertise required by providers working in countries with more limited resources. Practitioners who do not consider themselves 'experts' in HIV/AIDS care and care for few of these patients need to seriously consider this review which demonstrates a trend towards worse patient outcomes when receiving care by those with low caseloads/training in HIV/AIDS care.

HIV-infected patients and treatment outcomes: an equivalence study of community-located, primary care-based HIV treatment vs. hospital-based specialty care in the Bronx, New York

The HIV-infected population in the USA is expanding as patients survive longer and new infections are identified. In many areas, particularly rural/medically underserved regions, there is a growing shortage of providers with sufficient HIV expertise. HIV services incorporated into community-based (CB), primary care settings may therefore improve the distribution and delivery of HIV treatment. Our objective was to describe/compare patients and treatment outcomes in two settings: a community-located, primary care-based HIV program, and a hospital-based (HB) specialty center. CB providers had on-site access to generalist HIV experts. The hospital center was staffed primarily by infectious disease physicians. This was a retrospective cohort study of 854 HIV-positive adults initiating care between 1/2005 and 12/2007 within an academic medical center network in the Bronx, NY. Treatment outcomes were virologic and immunologic response at 16-32 and 48 weeks, respectively, after combination antiretroviral therapy (cART) initiation. We found that HB subjects presented with a higher prevalence of AIDS (59% vs. 46%, p<0.01) and lower initial CD4 (385 vs. 437, p<0.05) than CB subjects. Among 178 community vs. 237 hospital subjects starting cART, 66% vs. 62% achieved virologic suppression (95% confidence interval (CI) difference -0.14-0.06) and 49% vs. 59% achieved immunologic success, defined as a 100 cell/mm³ increase in CD4 (95% CI difference 0.00-0.19). The multivariate-adjusted likelihoods of achieving viral suppression [OR=1.24 (95% CI 0.69-2.33)] and immunologic success [OR=0.76 (95% CI 0.47-1.21)] were not statistically significant for community vs. hospital subjects. Because this was an observational study, propensity scores were used to address potential selection bias when subjects presented to a particular setting. In conclusion, HIV-infected patients initiate care at CB clinics earlier and with less advanced HIV disease. Treatment outcomes are comparable to those at a HB specialty center, suggesting that HIV care can be delivered effectively in community settings.

Association between physician specialty and uptake of new medical technologies: HPV tests in Florida Medicaid

BACKGROUND

It is well established that specialists often adopt new medical technologies earlier than generalists, and that racial and ethnic minority patients are less likely than White patients to receive many procedures and prescription drugs. However, little is known about the role that specialists or generalists may play in reducing racial and ethnic disparities in uptake of new medical technologies. Human papillomavirus (HPV) DNA tests, introduced as a cervical cancer screening tool in 2000, present a rich context for exploring patterns of use across patient and provider subgroups.

OBJECTIVE

To identify patient characteristics and the provider specialty associated with overall and appropriate use of HPV DNA tests over time, and to examine the associations between clinical guidelines and adoption of the test in an underserved population.

DESIGN

Retrospective longitudinal study using Florida Medicaid administrative claims data.

PARTICIPANTS

Cervical cancer screening test claims for 415,239 female beneficiaries ages 21 to 64 from July 2001 through June 2006.

MAIN MEASURES

Overall and appropriate use of HPV DNA tests.

KEY RESULTS

Although minority women were initially less likely than White women to receive HPV DNA tests, test use grew more rapidly among Black and Hispanic women compared to White women. Obstetricians/gynecologists were significantly more likely than primary care providers to administer HPV DNA tests. Release of the first set of clinical guidelines was associated with a large increase in the use of HPV DNA tests (adjusted odds ratio: 2.46, p<0.0001); subsequent guidelines were associated with more modest increases.

CONCLUSIONS

Uptake of new cervical cancer screening protocols can occur quickly among traditionally underserved groups and may be aided by early adoption by specialists.

Physician's manual reporting underestimates mortality: evidence from a population-based HIV/AIDS treatment program

BACKGROUND

In clinical and cohort research, mortality estimates are often derived from manual reports generated by physicians or electronic reports from vital event registries. We examined the rate of underreporting of deaths by manual methods as compared with electronic reports from a vital event registry.

METHODS

The retrospective analyses included deaths among participants registered in an observational cohort who initiated highly-active antiretroviral therapy (HAART) between August 1, 1996 and June 30, 2006. Deaths were routinely reported manually by physicians and through annual electronic record linkages with a population-based vital event registry. Multivariate logistic regression was carried out to assess independent predictors of death reporting by manual methods.

RESULTS

Of the 3,116 individuals included in the analyses, 622 (20.0%) died during follow-up. Manual reporting by physicians only identified 377 (60.6%), while electronic linkages captured 598 (96.1%) of all deaths. Multivariate analysis indicated that deaths among individuals with lower CD4 cell count, higher HIV plasma viral load, a history of injection drug use, and under the care of an HIV-experienced physicians were more likely to be reported manually. Furthermore, non-accidental deaths were more likely to be reported manually, and manual reporting of deaths increased over time.

CONCLUSIONS

Relying only on manual reports to ascertain deaths significantly underestimates the total number of deaths in the population. This can generate important biases when evaluating the impact of therapeutic interventions in the populational setting.

Trends in uptake of recently approved antiretrovirals within a national healthcare system

OBJECTIVE

The aim of the study was to describe Veterans Healthcare Administration (VHA) system-wide uptake of three HIV protease inhibitors: atazanavir, darunavir and tipranavir.

METHODS

This retrospective cohort study evaluated VHA uptake of three target antiretrovirals and lopinavir/ritonavir in each complete 90-day quarter since approval to December 2007 using VHA HIV Clinical Case Registry data. We assessed uptake using number of new prescriptions, number of providers and facilities prescribing target agents, provider type, clinic type, facility size and location within four US regions.

RESULTS

Overall, 6551 HIV-infected veterans received target antiretrovirals. Uptake was generally greatest within the first year after Food and Drug Administration (FDA) approval, and then slightly declined and plateaued. Geographically, early adoption of new antiretroviral drugs tended to occur in the Western USA, as evidenced by comparison of uptake patterns of new antiretrovirals to use of all antiretroviral agents. A small percentage of prescribers of all antiretrovirals were responsible for new prescriptions for target medications, particularly for darunavir and tipranavir. Providers at almost 50% of VHA facilities were prescribing these agents within the first year.

CONCLUSIONS

Uptake of new antiretrovirals in the VHA generally reflected overall prescribing of all antiretrovirals, suggesting a lack of VHA impediments to new antiretrovirals in the healthcare system. Some regional variation in uptake among the targeted antiretrovirals occurred over time but tended to resolve after the first several months. Providers responsible for early prescribing of the target medications were limited to a fraction of providers who tended to be physicians who practised in infectious disease (ID) clinics at medium-sized facilities.

The variability and predictors of quality of AIDS care services in Brazil

BACKGROUND

Since establishing universal free access to antiretroviral therapy in 1996, the Brazilian Health System has increased the number of centers providing HIV/AIDS outpatient care from 33 to 540. There had been no formal monitoring of the quality of these services until a survey of 336 AIDS health centers across 7 Brazilian states was undertaken in 2002. Managers of the services were asked to assess their clinics according to parameters of service inputs and service delivery processes. This report analyzes the survey results and identifies predictors of the overall quality of service delivery.

METHODS

The survey involved completion of a multiple-choice questionnaire comprising 107 parameters of service inputs and processes of delivering care, with responses assessed according to their likely impact on service quality using a 3-point scale. K-means clustering was used to group these services according to their scored responses. Logistic regression analysis was performed to identify predictors of high service quality.

RESULTS

The questionnaire was completed by 95.8% (322) of the managers of the sites surveyed. Most sites scored about 50% of the benchmark expectation. K-means clustering analysis identified four quality levels within which services could be grouped: 76 services (24%) were classed as level 1 (best), 53 (16%) as level 2 (medium), 113 (35%) as level 3 (poor), and 80 (25%) as level 4 (very poor). Parameters of service delivery processes were more important than those relating to service inputs for determining the quality classification. Predictors of quality services included larger care sites, specialization for HIV/AIDS, and location within large municipalities.

CONCLUSION

The survey demonstrated highly variable levels of HIV/AIDS service quality across the sites. Many sites were found to have deficiencies in the processes of service delivery processes that could benefit from quality improvement initiatives. These findings could have implications for how HIV/AIDS services are planned in Brazil to achieve quality standards, such as for where service sites should be located, their size and staffing requirements. A set of service delivery indicators has been identified that could be used for routine monitoring of HIV/AIDS service delivery for HIV/AIDS in Brazil (and potentially in other similar settings).

Survey of physician knowledge regarding antiretroviral medications in hospitalized HIV-infected patients

Background

Antiretroviral prescribing errors are common among hospitalized patients. Inadequate medical knowledge is likely one of the factors leading to these errors. Our objective was to determine the proportion of hospital physicians with knowledge gaps about prescribing antiretroviral medications for hospitalized HIV-infected patients and to correlate knowledge with length and type of medical training and experience.

Methods

We conducted an electronic survey comprising of ten clinical scenarios based on antiretroviral-prescribing errors seen at two community teaching hospitals. It also contained demographic questions regarding length and type of medical training and antiretroviral prescribing experience. Three hundred and forty three physicians at both hospitals were asked to anonymously complete the survey between February 2007 and April 2007.

Results

One hundred and fifty-seven physicians (46%) completed at least one question. The mean percentage of correct responses was 33% for resident physicians, 37% for attending physicians, and 93% for Infectious Diseases or HIV (ID/HIV) specialist physicians. Higher scores were independently associated with ID/HIV specialty, number of outpatients seen per month and physician reported comfort level in managing HIV patients (P < .001).

Conclusion

Non-ID/HIV physicians had uniformly poor knowledge of common antiretroviral medication regimens. Involvement of ID/HIV specialists in the prescribing of antiretrovirals in hospitalized patients might mitigate prescribing errors stemming from knowledge deficits.

Do hospitalists or physicians with greater inpatient HIV experience improve HIV care in the era of highly active antiretroviral therapy? Results from a multicenter trial of academic hospitalists

BACKGROUND

Little is known about the effect of provider type and experience on outcomes, resource use, and processes of care of hospitalized patients with human immunodeficiency virus (HIV) infection. Hospitalists are caring for this population with increasing frequency.

METHODS

Data from a natural experiment in which patients were assigned to physicians on the basis of call cycle was used to study the effects of provider type-that is, hospitalist versus nonhospitalist-and HIV-specific inpatient experience on resource use, outcomes, and selected measures of processes of care at 6 academic institutions. Administrative data, inpatient interviews, 30-day follow-up interviews, and the National Death Index were used to measure outcomes.

RESULTS

A total of 1207 patients were included in the analysis. There were few differences in resource use, outcomes, and processes of care by provider type and experience with HIV-infected inpatients. Patients who received hospitalist care demonstrated a trend toward increased length of hospital stay compared with patients who did not receive hospitalist care (6.0 days vs. 5.2 days; P = .13). Inpatient providers with moderate experience with HIV-infected patients were more likely to coordinate care with outpatient providers (odds ratio, 2.40; P = .05) than were those with the least experience with HIV-infected patients, but this pattern did not extend to providers with the highest level of experience.

CONCLUSION

Provider type and attending physician experience with HIV-infected inpatients had minimal effect on the quality of care of HIV-infected inpatients. Approaches other than provider experience, such as the use of multidisciplinary inpatient teams, may be better targets for future studies of the outcomes, processes of care, and resource use of HIV-infected inpatients.

Frequency of HIV-related medication errors and associated risk factors in hospitalized patients

BACKGROUND

Retrospective studies of hospitalized HIV-infected patients have noted a high occurrence of drug-related errors, ranging from 5% to 30%.

OBJECTIVE

To prospectively evaluate errors in antiretroviral (ARV) prescribing in the inpatient setting of a hospital tertiary care center and the association of risk factors with the occurrence of errors.

METHODS

HIV-infected patients who received care and continued their ARVs for HIV infection on admission to a large academic teaching hospital between January and April 2006 were included in this study. The care and assessment of these patients was conducted on a daily basis by an infectious diseases/HIV specialized clinical pharmacist. All errors were documented and classified based on a severity scale.

RESULTS

Among the 68 patients who met the study's eligibility criteria, at least one error in the initial HIV regimen occurred in 72% of patients, and in 56% of patients, the error had the potential to cause moderate-to-severe discomfort or clinical deterioration. Patients on atazanavir-based therapy had a statistically significant increased occurrence of errors throughout their hospitalization (RR = 1.69; 95% CI 1.03 to 2.78; p = 0.02). Receiving nonformulary (combination) HIV medications increased patients' risk of having more than one error occur in their ARV regimen on admission and during hospitalization (RR = 1.95; 95% CI 1.25 to 3.04; p = 0.02). The clinical pharmacist recommendations had 100% acceptance.

CONCLUSIONS

The alarmingly high frequency of potentially harmful errors uncovered in this study necessitates further investigation using larger sample sizes. Interventions to reduce and prevent these errors must be sought to eliminate the unintended harm associated with hospitalization.

The effect of care team composition on the quality of HIV care

Compared to single-clinician care, care provided by multiple clinicians might result in higher-quality care, especially if some of them have condition-specific expertise and complementary knowledge, skills, and roles. Individual physician continuity, which has been shown to be associated with care quality, necessarily decreases when care is provided by multiple clinicians. This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. In adjusted analyses, care teams composed of three or more clinicians were associated with more consistent prescribing of pneumocystis carinii pneumonia prophylaxis when medically indicated ( p < .01). Patients with multiple physicians generally reported worse care coordination, however, and had more inappropriate use of emergency services. These findings indicate both advantages and disadvantages to having multiple clinicians. More effort should be devoted to facilitating coordination when multiple clinicians provide care.

Clinician gender is more important than gender concordance in quality of HIV care

BACKGROUND

Previous studies have examined the impact of physician gender and gender concordance on preventive care, satisfaction, and communication. Less is known about how physician gender and gender concordance affect care for chronic illnesses, including HIV.

OBJECTIVE

This study sought to determine whether patient-clinician gender concordance (patient and clinician are of the same gender) influences receipt of protease inhibitor (PI) therapy and ratings of care among HIV-infected patients.

METHODS

We reviewed data from 1860 patients and 397 clinicians in the HIV Cost and Services Utilization Study, a nationally representative the association between gender concordance and time to first PI use, and multivariable logistic regression was utilized to examine the association of gender concordance with patients' problems with care and their overall rating of care.

RESULTS

Patients who had a male clinician received PIs earlier than those who had a female clinician (adjusted time ratio = 0.69 for having a male vs having a female clinician; P <or= 0.01). Gender concordance was not a significant predictor of time to PI use. Gender discordance was associated with problems with feeling respected by clinicians. Female patients with a male clinician were most likely, and female patients with female clinicians were least likely, to report a problem with being treated with respect (P <or= 0.01 for the interaction term). Gender discordance was not associated with other problems with care or with overall ratings of care.

CONCLUSIONS

Gender discordance was associated with perceived problems of being treated with respect by clinicians, but not with time to receipt of PIs, overall ratings of care, coordination of care, or obtaining information. The perception of not being respected may represent a significant barrier to care that is particularly worse for women, in that most HIV-infected women receive their care from male clinicians.

Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors

OBJECTIVE

We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients.

DESIGN

We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region.

RESULTS

Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52).

CONCLUSIONS

Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

Testing practices and knowledge of HIV among prenatal care providers in a low seroprevalence state

As the prevalence of heterosexually transmitted HIV increases among women of childbearing age in the United States, so too does the potential for vertical transmission from mother to child. Early maternal diagnosis and appropriate management are critical to minimizing the risk of perinatal infection. We designed a study to evaluate current prenatal care provider testing practices and knowledge of HIV as it relates to pregnancy in a low seroprevalence state. A written questionnaire was mailed to 642 prenatal care providers in Kentucky. Responses were compared to a similar survey conducted in 1998 and to current federal guidelines for HIV management. Nearly all respondents reported to offer HIV testing to all prenatal patients, demonstrating a marked improvement since 1998 (p < 0.001). However, clinicians did not report adequate follow-up when testing is refused and appear to have limited knowledge of the disease as it relates to pregnancy. Only 9.3% of respondents demonstrated proficiency on two knowledge assessment questions. Those with previous experience treating prenatal patients with HIV were more likely to respond correctly (odds ratio [OR] 3.03; 95% confidence interval [CI] 1.08-8.50). Providers with little experience treating patients with HIV may not possess the basic knowledge required to manage the disease during pregnancy. Additional educational interventions are needed in low seroprevalence areas to ensure the appropriate treatment of all HIV-positive pregnant patients and to minimize the risk of preventable perinatal transmission.

Gender differences in quality of HIV care in Ryan White CARE Act-funded clinics

BACKGROUND

Women with HIV infection have lagged behind men in receipt of critical health care, but it is not known if those disparities are due in part to where women receive care. We examined differences in care received by HIV-infected women and men in a national sample of Ryan White CARE Act-funded clinics and explored the influence of clinic characteristics on care quality.

METHODS

Record review was done on a sample of 9,015 patients who received care at 69 CARE Act-funded HIV primary care clinics that participated in a quality improvement study. Outcome measures studied were highly active antiretroviral therapy (HAART) use, HIV viral suppression, Pneumocystis jiroveci pneumonia (PCP) prophylaxis, screening, and other disease prevention efforts.

RESULTS

Women were less likely than men to receive HAART (78% versus 82%, p < .001), receive PCP prophylaxis (65% versus 75%, p < .0001), or have their hepatitis C virus status known (87% versus 88%, p = .02) despite being seen more regularly (69% versus 66%, p = .04). Sites serving high percentages of women delivered similar or better care for both men and women than other sites. Although sites serving a higher percent of women had more support services such as case management and onsite obstetrician-gynecologists and provided Pap smears at higher rates, women at such sites remained less likely than men to receive important HIV care including HAART and PCP prophylaxis.

CONCLUSIONS

The gap in the quality of care provided to HIV-infected men and women in critical areas persists, and is not explained by the types of sites where men and women receive care.

Translating research findings of chronic kidney disease management to clinical practice: Challenges and opportunities

Chronic Kidney disease (CKD) has been identified as a public health epidemic, fueled in part by improved outcomes of both diabetic and cardiac patient populations, as well as by the increasing recognition that it is possible to identify CKD at earlier stages. The estimated 8 to 10 million Americans that have CKD, with its concomitant morbidity and mortality, have the potential to overwhelm the current system of specialty practice medicine and health care resources. How can clinicians, clinician scientists, and health care administrators translate research findings into clinical practice in an effective manner to improve the care of this burgeoning patient group? The challenge of translating research into clinical care requires identification of that which we do and do not know, communication of knowledge between those who do and do not know, and efficient collection of information for systematic evaluation. This article will describe the challenges of translating current research findings into clinical practice. There is a need to identify the complexity of CKD disease processes and issues associated with delivery of care and to describe the difficulties in the dissemination of new knowledge to physicians. Because of the propensity of CKD to affect identifiable groups of patients, we will discuss the potential challenges of these strategies given the racial, ethnic, and cultural diversity in North America. A potential solution to these challenges is a new paradigm of "process-based medicine" that integrates clinical and basic science research findings with multidisciplinary and shared care models of health care delivery. In this context, attention to advances in information technology, the cognitive processes that underlie physician learning, and the findings of outcome research may ensure true integration of clinical research and clinical practice.

Adult Immunization in University-Based Primary Care and Specialty Practices

The purpose of this study was to assess vaccination status of adults in primary and specialty care practices in a retrospective review of medical records from 1997 to 2000 at one university medical center. Eligible patients were aged 50 and older and had two or more visits to primary and specialty care practices (N=14,556). Outcomes were receipt of pneumococcal vaccine once, tetanus booster within 10 years, and influenza vaccine in 2 of the 3 years. Vaccination rates for patients aged 65 and older were 59% for pneumococcal, 51% for tetanus, and 32% for influenza. Asians, Latinos, and African Americans were more likely than whites to have received influenza, pneumococcal, or tetanus vaccinations. Patients seen in primary care (41%) or in both primary care and specialty practices (42%) were more likely to receive adequate vaccination than those in specialty practices (17%) (P<.001). For pneumococcal vaccinations, relative to patients receiving specialty care only, patients receiving primary care only had an adjusted odds ratios (OR) of 6.6 (95% confidence interval (CI)=5.6-7.7) and patients in both primary care and specialty care had an OR of 7.2 (95% CI=6.2-8.3). For influenza, the corresponding ORs were 3.9 and 4.8, respectively, and for tetanus, 4.6 and 5.2. Patients who received care only from specialty practices were less likely than those with some primary care to receive adequate adult vaccinations. With the exception of Russian immigrants, the study did not find that racial and ethnic minorities had lower rates of vaccination than whites.