Physician Specialization and Quality of HIV Care

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Physician Specialization and Quality of HIV Care

Landon BE, IB, McInnes K, et al. Physician specialization and

the quality of care for human immunodeficiency virus infection. Arch

Intern Med. 2005;165:1133-1139 .

The authors studied the association between specialty training and

HIV expertise with the care delivered to persons with HIV infection.

Methods: The evaluation involved 64 clinics funded by the White

Care Act with at least 100 patients.

At each clinic, there was a random selection of up to 75 patients to

have medical record reviews during 2000 and 2001. Clinicians

providing care for these patients were surveyed and linked to the

patients whose medical records were reviewed.

Patients receiving care from nonphysician providers were excluded.

Representative quality indicators were (1) receipt of HAART if the

CD4+ cell count was < 500 cells/mcL or if the viral load was >

10,000 copies/mL; (2) achievement of a viral load < 400 copies/mL;

(3) Pneumocystis jiroveci pneumonia (previously known as

Pneumocystis carinii pneumonia, or PCP) prophylaxis, if indicated;

and (4) access to care, defined as visits during at least 3 of 4

quarters.

Physicians were identified as specialists if trained in infectious

diseases vs general medicine, and generalists were asked whether

they considered themselves " experts " in treatment of HIV. Providers

were categorized by caseload as low (0-19 patients), medium (20-299

patients), or high (over 300 patients).

Results: The results are based on 5247 patients linked to 177

physicians who responded to the survey.

Of the 177 respondents, 58% indicated that they were trained in

general medicine and 42% were classified as infectious disease

specialists. Of the physicians considered " generalists, " 63%

considered themselves experts in HIV care.

With regard to outcome, there was no difference for the parameters

measured indicating quality of HIV care, appropriate screening, or

routine care between infectious disease trained physicians and

generalists who considered themselves HIV experts.

Nonexpert generalists were significantly less likely to have

patients appropriately given HAART and less likely to have patients

with a viral load < 400 copies/mL when compared with experts.

Similarly, all physicians with caseloads smaller than 20 patients

were less likely to have patients on HAART when indicated compared

with those with higher caseloads. These results are summarized in

Table 7 . (Sorry, the table is note presented pleasre refere to the

url Moderator. AIDS INDIA e FORUM)

The findings support previous studies that showed that quality of

care, to a great extent, is correlated with self-reported expertise.

Comment: This is one of several reports to indicate that expertise

is correlated with outcome in care of HIV-infected patients.

Nevertheless, the difference was modest. Most significant was a

viral load of < 400 copies/mL, which is rarely sought in these kinds

of analyses.

For the nonexpert generalists, this was achieved in 31% compared

with 39% among patients receiving care from an expert generalists

and 41% for ID-trained physicians (P = .01). There was also a

significant difference in the number given HAART, but the

indications at the time of the study were different; the CD4+

threshold was 500 cells/mcL and the viral load threshold used in the

study is not in anyone's guidelines.

The study supports previous reports indicating that generalists can

develop expertise in HIV infection as previously reported by Stone

and coworkers.[14] Of interest is the observation, once again, that

panel size correlated with favorable outcome, but those with a heavy

patient load did no better than those with a panel size of 20-300

patients. It might be mentioned that the current DHHS guidelines

recommend a panel size of at least 25 patients.

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