HIV hospital inpatient care unaffected by physician type or experience, US study finds

The quality of care for HIV-positive hospital inpatients is essentially unaffected by the type of physician or their degree of experience with HIV care, according to a US study. These surprising results, based on a survey of 1207 patients at six large US hospitals, were published in the April 1^st issue of Clinical Infectious Diseases.

Hospitalists – specialist physicians who primarily care for hospital inpatients – are a rapidly-growing, relatively new type of medical specialist. Under the hospitalist model of care, the hospitalist assumes primary responsibility for a patient admitted to hospital, co-managing their care with the patient's primary care physician. On discharge, the patient's care is returned to the primary care (family) physician, or GP.

Hospitalists are, increasingly, assuming care for HIV-positive inpatients; however, the resulting effect on patient care has not been well studied. Here, researchers examined the effects of physician type (hospitalist or not) and level of HIV-specific experience on patient outcomes, quality of care, and resource use at six major US hospitals/academic institutions. (Preliminary results were reported at the 44^th annual meeting of the Infectious Diseases Society of America in 2006.)

The study included 1207 HIV-positive patients admitted to six academic medical centres across the United States between July 2001 and June 2003 (a mean of 201 patients from each study site). Patients were racially diverse (39% black, 41% white, 8% Hispanic, and 4% Asian); the mean age was 43 years, and 28% were female. The patients were cared for by 214 physicians: 43 hospitalists and 171 non-hospitalists. (For this analysis, 'hospitalists' were defined as physicians who spent 25% or more of their time on inpatient care. Non-hospitalists included physicians in 17 different areas of specialisation; 11% were infectious disease specialists.)

The analysis examined the effect of physician type (hospitalist vs. non-hospitalist) and experience in HIV care on the length of patient hospital stay, the cost and use of resources, and patient health outcomes (as assessed by self-reported patient satisfaction, readmission rates, and mortality rates after discharge).

Experience was defined as 'high' if they had cared for more than four patients with HIV, 'medium' for two to four patients, and 'low' for one or none, during the study period: crucially, however, this scale was limited to inpatient experience within the two-year study period and did not include any outpatient experience or experience before the study period.

The analysis found no significant difference in any of the outcomes regardless of physician type or experience. There was a small, statistically non-significant, trend toward slightly longer stays with hospitalist care (mean, 6.0 vs. 5.2 days; p=0.13). There were no significant differences in any other outcomes – self-reported patient satisfaction, 30-day post-discharge self-reported health status, in-hospital and 6-month post-discharge mortality rate, 30-day readmission rate, and overall dollar cost of care –by physician type or experience.

This study, believed by the researchers to be "the first … to examine the effects of hospitalists and HIV-specific inpatient experience on the overall care of hospitalized patients infected with HIV," found no significant differences in patient outcomes or processes of care on the basis of physician type or experience. The authors speculated that hospitalists' growing trend in overall patient experience "may be offset by fewer hospital admissions of HIV-infected patients over time and less lifetime experience with HIV infection."

This explanation, however, runs counter to the finding that experience did not affect outcomes – a result that was itself not explained, except possibly by the study definition of "experience" (as described above). While the authors believed that the categories used in their analysis were similar to those used in other published studies and provided "an adequate indicator of recent … experience", greater lifetime experience with HIV patient care may have led to considerably greater differences than those reflected here.