A Population-Based Study Evaluating Family Physicians' HIV Experience and Care of People Living With HIV in Ontario

Abstract

PURPOSE Greater physician experience managing human immunodeficiency virus (HIV) infection has been associated with better HIV-specific outcomes. The objective of this study was to evaluate whether the HIV experience of a family physician modifies the association between the model of care delivery and the quality of care for people living with HIV. METHODSWe retrospectively analyzed data from a population-based observational study conducted between April 1, 2009, and March 31, 2012. A total of 13,417 patients with HIV in Ontario were stratified into 5 possible patterns or models of care. We used multivariable hierarchical logistic regression analyses, adjusted for patient characteristics and pairwise comparisons, to evaluate the modification of the association between care model and indicators of quality of care (receipt of antiretroviral therapy, cancer screening, and health care use) by level of physician HIV experience (≤5, 6-49, ≥50 patients during study period). RESULTSThe majority of HIV-positive patients (52.8%) saw family physicians exclusively for their care. Among these patients, receipt of antiretroviral therapy was significantly lower for those receiving care from family physicians with 5 or fewer patients and 6-49 patients compared with those with 50 or more patients CONCLUSIONS Family physician HIV experience was strongly associated with receipt of antiretroviral therapy by HIV-positive patients, especially among those seeing only family physicians for their care. Future work must determine the best models for integrating and delivering comprehensive HIV care among diverse populations and settings. Ann Fam Med 2015;13:436-445. doi: 10.1370/afm.1822. INTRODUCTIONA ntiretroviral therapy (ART) has substantially reduced the mortality and morbidity arising from human immunodeficiency virus (HIV) infection, thus shifting the care needs of people living with longstanding HIV. Evidence suggests that clinicians with more HIV training, HIV experience, or both provide higher quality of care as measured by disease-specific indicators, including ART prescribing. [1][2][3][4][5][6] Many of these studies, however, were performed early in the ART era, when both disease and treatments were novel and complex. Recent work has found similar quality of HIV-specific care between generalist and specialist physicians, even though the HIV experience of these physicians varied. 7,8 In addition, multidisciplinary care teams with nonexpert family physicians may improve patients' ART adherence more than HIV specialist care alone. 9 Another important consideration is that specialist HIV physicians are less adept than generalists at preventing and managing the common comorbidities emerging with increased HIV longevity. [10][11][12][13][14][15][16][17][18] increasing recognition that the management of HIV requires a primary care presence, but we have a poor understanding of how to integrate HIV-specific expertise within a primary care context. 7,10,[14][15][16][17][18][19][20][21] Overall, it has been difficult to distin...

A cross-sectional population-based study of breast cancer screening among women with HIV in Ontario, Canada

“…Physiciandirected interventions may be required, as physicians may emphasize the provision of HIV-specific primary care services to the detriment of routine, non-HIV-specific health screening, such as mammography. 12,31,32 This phenomenon may be related in part to the time constraints associated with the management of HIV and associated comorbidities. 33,34 These findings have implications for HIV care practice and policy, which must increasingly encompass the prevention and management of comorbidities across the lifespan and requires communication and integration across primary and specialist care.…”

“…1, 2011, to Mar. 31,2013. Ontario has single-payer, universal coverage for physician services, including screening mammography.…”

Non-Communicable Disease Preventive Screening by HIV Care Model

“…Increased experience caring for PLWHA or HIV patient volume has been shown to affect the rate of incorporating new literature into practice[42–46], HIV outcomes[47, 48], and mortality[49, 50]. Yet relatively few studies have assessed the optimal HIV care model—whether comprised of ID, generalist, or both—in terms of NCD screening in the current era of HIV care[24–26], when prevention and management of chronic disease complications are key clinical priorities.…”

In This Issue: Generalist Care Around the World

“…4 Their study also shows that family doctors who take care of more HIV-positive patients in the context of their regular practice are more likely to adhere to ART protocols than those who care for fewer, which likely has parallels in managing other complex conditions.…”