General medical physicians in the United States with appropriate expertise and experience can provide high quality HIV care, according to a study published in the May 23rd edition of the Archives of Internal Medicine. The investigators established that appropriately experienced generalists were able to offer a standard of HIV care equal to that of infectious diseases specialists. However, general medical doctors without specialist knowledge of HIV provided an inferior standard of care.
There is debate in the United States about the types of physician who should provide care to HIV-positive individuals. Although the treatment of HIV requires specialist knowledge, the high rate of coinfections, such as hepatitis C virus, seen in HIV-positive patients; the metabolic side-effects of HAART; and the wide range of medical and social services needed by HIV-infected individuals may mean that general medical doctors are in the best position to ensure that accessible, comprehensive and coordinated services are being provided.
A study conducted soon after the introduction of HAART found that general medical physicians with HIV expertise prescribed anti-HIV therapy at a similar rate to infectious diseases specialists. General medical physicians who lacked HIV expertise, however, used HAART less frequently.
Investigators wished to establish if these differences in quality of care still persisted.
HIV-positive patients receiving care at 64 Ryan White CARE (Comprehensive AIDS Resources Emergency) Act-funded clinics and their principal treating physicians were randomly selected.
Quality of care was assessed by measuring physicians' adherence to consensus guidelines for HIV treatment, including the appropriate provision of HAART, the proportion of patients achieving an undetectable viral load, screening for infections, the use of prophylaxis and access to care.
Physicians' specialisation was assessed by determining their experience of treating HIV-positive patients, current HIV caseload, and self assessed HIV-related expertise.
Doctors were also asked six questions about viral load and the use of antiretroviral therapy to determine knowledge about HIV and its treatment.
Over 5200 patients and 177 linked physicians were included in the investigators’ analysis. The majority of doctors (58%) defined themselves as general medical physicians, the remaining 42% saying they were infectious diseases specialists.
Of the general medical physicians, 63% said that they considered themselves to be experts in HIV care. Mean HIV knowledge score was 5.1 (on a six point scale). Non-specialist general medical physicians had significantly lower mean scores (4.3) than either infectious diseases specialists (mean, 5.3), or general medical doctors specialising in HIV (mean, 5.2; p
Non-expert general medical physicians had lower quality scores than infectious diseases specialists or generalists specialising in HIV. For example, over 80% of the patients of infectious diseases doctors were taking HAART, compared to only 73% of patients cared for by non-expert general medical physicians (p
Caseload was also related to quality of care, with patients seeing fewer than twenty patients providing fewer appropriate patients with HAART (p = 0.04) and seeing their patients less often.
Physicians' knowledge of HIV was found to be related to the outcome of patient care. For every point increase in a doctor’s understanding of HIV therapy the odds of their patients having controlled viral load increased by 1.14.
When speciality training, caseload and knowledge were examined simultaneously, the investigators found that the difference in the standard of care offered by non-specialist general medical doctors continued to be inferior (p = 0.02).
The investigators write “our results suggest that generalists with appropriate experience and expertise in a particular area can provide high-quality care to patients with complex illnesses.” However, the standard of care provided by generalist doctors without specialist knowledge of HIV was “suboptimal.”
The investigators stress, “measures related to the adequacy of antiretroviral therapy showed the strongest and most consistent differences between physicians with and without expertise.”
Limitations with the study are acknowledged by the investigators, not least that they were unable to determine patient satisfaction with the standard of care received.
“Guidelines and strategies to improve care for HIV should…promote the use of expert generalists as well as infectious diseases physicians”, conclude the investigators.
Landon BE et al. Physician specialization and the quality of care for human immunodeficiency virus infection. Arch Intern Med 165: 1133 – 1139, 2005.