A survey of nearly one thousand primary care providers shows a positive relationship between the quality of care HIV-infected patients receive and the experience of providers in treating HIV.
The survey was a joint project of UC San Francisco and the Community Consortium, an association of more than 200 Bay Area health care providers who care for the majority of persons with HIV/AIDS in the region.
"Physicians with more experience were more likely to recommend treatment that reflected the latest standards of care," said Thomas Mitchell, MPH, UCSF specialist and program director of the Community Consortium.
Of the 999 questionnaires mailed in 1996, 524 responses were received (52 percent response rate). Most respondents surveyed were infectious disease specialists, internists, or family practitioners located in over 20 cities across the United States. Significant differences were seen in the treatment chosen by providers with one to five HIV-infected patients compared to providers with six or more patients. Results from the survey appeared in the January 1999 issue of Clinical Infectious Diseases.
"This study was conducted just as protease inhibitors were introduced into the care regimens of people with HIV," said senior author Donald Abrams, MD, UCSF professor of medicine."The treatment situation has become even more complex now."
The self-administered questionnaire asked providers what drugs they usually prescribed for treatment and prevention of 30 HIV-related conditions. Experienced providers, as measured by the number of HIV-infected patients currently seen in their practice, were more likely to use the most effective drug therapies available, including triple combination antiretroviral therapy and multidrug combinations to fight opportunistic infections.
Although these therapies have the potential for serious adverse effects, they can significantly improve survival rates and lower cost of long-term care. "The decision of when to initiate drug therapy and what combination of drugs to use is critical, said Mitchell, and the consequences of making the wrong decisions are significant."
In the early years of the AIDS epidemic, many health care analysts favored the decentralization of HIV care among generalists, Mitchell said. But with more complex and advanced treatments, there has been a shift toward having experienced providers care for HIV patients. "We observed a consistent trend, noted Mitchell. "The higher the number of HIV-infected patients that the provider was treating, the more closely his or her reported treatment methods coincided with the latest standards of care. Now, more than ever, it is important that patients with HIV should have access to and be cared for by experienced physicians."
Fearing an influx of patients who may be high-volume users of health care, many managed health care plans do not identify or advertise physicians who are expert in the management of HIV infection, Mitchell said. Consequently, many patients may be assigned to physicians with little experience or training in this disease.
Members of the Community Consortium include health care providers in private practice and those who work at publicly-funded clinics, academic medical centers, and health maintenance organizations. The Consortium is part of the UCSF Positive Health Program.
In addition to Abrams and Mitchell, co-authors of the study include lead author Carol Brosgart, MD, director of clinical research at Gilead Sciences; Toby Dyner, MD, UCSF clinical instructor; Kathryn Stephenson, MD, UCSF assistant public administration analyst; and Rebecca Coleman, MD, associate director of clinical research, Gilead Sciences.
Journal
Clinical Infectious Diseases