1
|
Thomas C, Yuan X, Taussig JA, Tie Y, Dasgupta S, Riedel DJ, Weiser J. Unmet Needs for Ancillary Services by Provider Type Among People With Diagnosed Human Immunodeficiency Virus. Open Forum Infect Dis 2024; 11:ofae284. [PMID: 38966849 PMCID: PMC11222969 DOI: 10.1093/ofid/ofae284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/11/2024] [Indexed: 07/06/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Celina Thomas
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Xin Yuan
- DLH Corporation, Atlanta, Georgia, USA
| | - Jennifer A Taussig
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yunfeng Tie
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sharoda Dasgupta
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David J Riedel
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - John Weiser
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
2
|
Weiser J, Tie Y, Crim SM, Riedel DJ, Shouse RL, Dasgupta S. Do HIV Care Outcomes Differ by Provider Type? J Acquir Immune Defic Syndr 2024; 96:180-189. [PMID: 38465906 PMCID: PMC11215811 DOI: 10.1097/qai.0000000000003410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 02/26/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND We compared HIV care outcomes by HIV provider type to inform efforts to strengthen the HIV provider workforce. SETTING United States. METHODS We analyzed data from Center for Disease Control and Prevention's Medical Monitoring Project collected during June, 2019-May, 2021 from 6323 adults receiving HIV medical care. Provider types include infectious disease physicians only (ID physicians), non-ID physicians only, nurse practitioners only, physician assistants only, and ID physicians plus nurse practitioners and/or physician assistants (mixed providers). We measured patient characteristics, social determinants of health, and clinical outcomes, including retention in care; antiretroviral therapy prescription; antiretroviral therapy adherence; viral suppression; gonorrhea, chlamydia, and syphilis testing; satisfaction with HIV care; and HIV provider trust. RESULTS Compared with patients of ID physicians, higher percentages of patients of other provider types had characteristics and social determinants of health associated with poor health outcomes and received HIV care at Ryan White HIV/AIDS Program-funded facilities. After accounting for these differences, most outcomes were not meaningfully different; however, higher percentages of patients of non-ID physicians, nurse practitioners, and mixed providers were retained in care (6.5, 5.6, and 12.7 percentage points, respectively) and had sexually transmitted infection testing in the past 12 months, if sexually active (6.9, 7.4, and 13.5 percentage points, respectively). CONCLUSION Most HIV outcomes were equivalent across provider types. However, patients of non-ID physicians, nurse practitioners, and mixed providers were more likely to be retained in care and have recommended sexually transmitted infection testing. Increasing delivery of comprehensive primary care by ID physicians and including primary care providers in ID practices could improve HIV primary care outcomes.
Collapse
Affiliation(s)
- John Weiser
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA
| | - Yunfeng Tie
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA
| | - Stacy M. Crim
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA
| | - David J. Riedel
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore MD
| | - R. Luke Shouse
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA
| | - Sharoda Dasgupta
- Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention, Atlanta, GA
| |
Collapse
|
3
|
Sprague C. HIV Inequities, the Therapeutic Alliance, Moral Injury, and Burnout: A Call for Nurse Workforce Participation and Action. J Assoc Nurses AIDS Care 2024:00001782-990000000-00098. [PMID: 38563450 DOI: 10.1097/jnc.0000000000000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
ABSTRACT Health inequities for those living with HIV have persisted for key populations in the United States and globally. To address these inequities, in accordance with Goals 2 and 3 of the National HIV/AIDS Strategy for the United States, the evidence indicates that the therapeutic alliance could be effective in addressing impediments that undermine HIV outcomes. Nonetheless, the therapeutic alliance relies on health care providers, particularly nurses, reporting burnout and moral injury, further exacerbated by COVID-19. Burnout and moral injury have forced the systemic undervaluing of nurses as a social-cultural norm to the fore-in part a legacy of the economic model that underpins the health care system. Given a looming health workforce shortage and negative effects for key populations with HIV already experiencing health inequities, historic opportunities now exist to advance national institutional reforms to support nurses and other health professionals. This opportunity calls for concerted attention, multisectoral dialogue, and action, with nurses participating in and leading policy and interventions.
Collapse
Affiliation(s)
- Courtenay Sprague
- Courtenay Sprague, PhD, MA, is an Associate Professor of Global Health, Department of Conflict Resolution, Human Security & Global Governance, and Department of Nursing, University of Massachusetts Boston, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Ramirez JA, Maddali MV, Nematollahi S, Li JZ, Shah M. New Strategies in Clinical Guideline Delivery: Randomized Trial of Online, Interactive Decision Support Versus Guidelines for Human Immunodeficiency Virus Treatment Selection by Trainees. Clin Infect Dis 2021; 72:1608-1614. [PMID: 32211758 DOI: 10.1093/cid/ciaa299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 03/17/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Support for clinicians in human immunodeficiency virus (HIV) medicine is critical given national HIV-provider shortages. The US Department of Health and Human Services (DHHS) guidelines are comprehensive but complex to apply for antiretroviral therapy (ART) selection. Human immunodeficiency virus antiretroviral selection support and interactive search tool (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 trainees 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, or DHHS guidelines and HIV-ASSIST to support their decision making. ART selections were graded "appropriate" if consistent with DHHS guidelines, or concordant with regimens selected by HIV experts at 4 academic institutions. RESULTS Among 118 trainees, participants randomized to receive HIV-ASSIST had a significantly higher percentage of appropriate ART selections compared to those receiving DHHS guidelines alone (percentage of appropriate responses in DHHS vs HIV-ASSIST arms: median [Q1, Q3], 40% [30%, 50%] vs 90% [80%, 100%]; P < .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 [Q1, Q3], 0% [0%, 33%] vs 100% [66%, 100%]). CONCLUSIONS 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. CLINICAL TRIALS REGISTRATION NCT04080765.
Collapse
Affiliation(s)
- Jesus A Ramirez
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Manoj V Maddali
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Saman Nematollahi
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jonathan Z Li
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maunank Shah
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
5
|
Bono RS, Dahman B, Sabik LM, Yerkes LE, Deng Y, Belgrave FZ, Nixon DE, Rhodes AG, Kimmel AD. Human Immunodeficiency Virus-Experienced Clinician Workforce Capacity: Urban-Rural Disparities in the Southern United States. Clin Infect Dis 2021; 72:1615-1622. [PMID: 32211757 DOI: 10.1093/cid/ciaa300] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-experienced clinicians are critical for positive outcomes along the HIV care continuum. However, access to HIV-experienced clinicians may be limited, particularly in nonmetropolitan areas, where HIV is increasing. We examined HIV clinician workforce capacity, focusing on HIV experience and urban-rural differences, in the Southern United States. METHODS We used Medicaid claims and clinician characteristics (Medicaid Analytic eXtract [MAX] and MAX Provider Characteristics, 2009-2011), county-level rurality (National Center for Health Statistics, 2013), and diagnosed HIV cases (AIDSVu, 2014) to assess HIV clinician capacity in 14 states. We assumed that clinicians accepting Medicaid approximated the region's HIV workforce, since three-quarters of clinicians accept Medicaid insurance. HIV-experienced clinicians were defined as those providing care to ≥ 10 Medicaid enrollees over 3 years. We assessed HIV workforce capacity with county-level clinician-to-population ratios, using Wilcoxon-Mann-Whitney tests to compare urban-rural differences. RESULTS We identified 5012 clinicians providing routine HIV management, of whom 28% were HIV-experienced. HIV-experienced clinicians were more likely to specialize in infectious diseases (48% vs 6%, P < .001) and practice in urban areas (96% vs 83%, P < .001) compared to non-HIV-experienced clinicians. The median clinician-to-population ratio for all HIV clinicians was 13.3 (interquartile range, 38.0), with no significant urban-rural differences. When considering HIV experience, 81% of counties had no HIV-experienced clinicians, and rural counties generally had fewer HIV-experienced clinicians per 1000 diagnosed HIV cases (P < .001). CONCLUSIONS Significant urban-rural disparities exist in HIV-experienced workforce capacity for communities in the Southern United States. Policies to improve equity in access to HIV-experienced clinical care for both urban and rural communities are urgently needed.
Collapse
Affiliation(s)
- Rose S Bono
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Bassam Dahman
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren E Yerkes
- Division of Population Health Data, Virginia Department of Health, Richmond, Virginia, USA.,Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - Yangyang Deng
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Faye Z Belgrave
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Daniel E Nixon
- Department of Internal Medicine, Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anne G Rhodes
- Division of Disease Prevention, Virginia Department of Health, Richmond, Virginia, USA
| | - April D Kimmel
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia, USA
| |
Collapse
|
6
|
Weiser J, Chen G, Beer L, Boccher-Lattimore D, Armstrong W, Kurth A, Shouse RL. Sustaining the HIV care provider workforce: Medical Monitoring Project HIV Provider Survey, 2013-2014. Health Serv Res 2019; 54:1065-1074. [PMID: 31264205 DOI: 10.1111/1475-6773.13192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To describe delivery of recommended HIV care and work satisfaction among infectious disease (ID) physicians, non-ID physicians, nurse practitioners (NPs), and physician assistants (PAs). DATA SOURCES Medical Monitoring Project 2013-2014 HIV Provider Survey. STUDY DESIGN Population-based complex sample survey. DATA COLLECTION/ANALYSIS METHODS We surveyed 2208 HIV care providers at 505 US HIV care facilities and computed weighted percentages of provider characteristics, stratified by provider type. Rao-Scott chi-square tests and logistic regression used to compare characteristics of ID physicians with each other provider type. PRINCIPAL FINDINGS The adjusted provider response rate was 64 percent. Among US HIV care providers, 45 percent were ID physicians, 35 percent non-ID physicians, 15 percent NPs, and 5 percent PAs. Satisfaction with administrative burden was lowest among non-ID physicians (27 percent). Compared with ID physicians, satisfaction with remuneration was lower among non-ID physicians and higher among NPs (37, 28, and 51 percent, respectively). NPs were more likely than ID physicians to report performing four of six services that are key to providing comprehensive HIV care, but more NPs planned to leave clinical practice within 5 years (19 vs 7 percent). CONCLUSION Addressing physician dissatisfaction with remuneration and administrative burden could help prevent a provider shortage. Strengthening the role of NPs may help sustain a high-quality workforce.
Collapse
Affiliation(s)
- John Weiser
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Linda Beer
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Wendy Armstrong
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Ann Kurth
- Yale School of Nursing, Yale University, Orange, Connecticut
| | - R Luke Shouse
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|