Sustaining the HIV care provider workforce: Medical Monitoring Project HIV Provider Survey, 2013‐2014

Abstract

Objective To describe delivery of recommended HIV care and work satisfaction among infectious disease (ID) physicians, non‐ID physicians, nurse practitioners (NPs), and physician assistants (PAs). Data Sources Medical Monitoring Project 2013‐2014 HIV Provider Survey. Study Design Population‐based complex sample survey. Data Collection/Analysis Methods We surveyed 2208 HIV care providers at 505 US HIV care facilities and computed weighted percentages of provider characteristics, stratified by provider type. Rao‐Scott chi‐square tests and logistic regression used to compare characteristics of ID physicians with each other provider type. Principal Findings The adjusted provider response rate was 64 percent. Among US HIV care providers, 45 percent were ID physicians, 35 percent non‐ID physicians, 15 percent NPs, and 5 percent PAs. Satisfaction with administrative burden was lowest among non‐ID physicians (27 percent). Compared with ID physicians, satisfaction with remuneration was lower among non‐ID physicians and higher among NPs (37, 28, and 51 percent, respectively). NPs were more likely than ID physicians to report performing four of six services that are key to providing comprehensive HIV care, but more NPs planned to leave clinical practice within 5 years (19 vs 7 percent). Conclusion Addressing physician dissatisfaction with remuneration and administrative burden could help prevent a provider shortage. Strengthening the role of NPs may help sustain a high‐quality workforce.

Do HIV Care Outcomes Differ by Provider Type?

“…22 In addition to this finding, a previous MMP analysis found that NPs were twice as likely as ID physicians to report providing comprehensive sexual behavior-related risk-reduction services. 8 There are several potential explanations for our finding that patients of ID physicians were less likely than others to be retained in care. It is possible that patients of ID physicians on average require less frequent visits than patients of other provider types because of lower medical complexity due to having fewer comorbidities or differing social determinants of health for which we did not control.…”

“…8 Another analysis of MMP data found that among patients who needed HIV case management, those who received care from ID physicians were more likely than patients of NPs to have that need remain unmet, even after accounting for patient differences and the availability of onsite HIV case management services at the HIV care facility (publication pending), suggesting that coordination of care may more often be lacking among some patients of ID physicians with complex needs. In addition, a 2014 MMP survey of HIV care providers found that NPs are more likely than ID physicians to provide care for .50 HIV patients and are 5 times as likely to be full-time HIV care providers, 8 which aligns with previous findings that experience, rather than provider profession, is associated with favorable outcomes. [18][19][20] Retention in care and recommended STI testing are dependent on the coordination of care and prevention elements of primary care.…”

“…24 ART prescription and viral suppression, which did not differ by provider type, are more reflective of HIV disease-specific care than of primary care. Although 80% of ID physicians report having sufficient time with patients to provide necessary HIV information, only approximately 40% spend .20 minutes with HIV patients during follow-up visits, compared with two-thirds of NPs and PAs (8). A focused approach to HIV care and treatment by some ID physicians may exclude an emphasis on prevention and coordination of care that primary care physicians, NPs, and PAs routinely address.…”

“…However, a potential barrier to broadening the HIV provider workforce is high levels of dissatisfaction with administrative burden, time available to provide necessary care, and remuneration among non-ID physician HIV care providers. 8 Also of concern, the percentage of NPs planning to leave HIV practice within 5 years is triple that of ID physicians, 8 which could have implications for meeting the National HIV/AIDS Strategy for the United States/Ending the HIV Epidemic goals 1,5 and goals of the STI National Strategic Plan. 26 Other strategies for ensuring that patients of ID physicians receive comprehensive primary care include ongoing training in primary care delivery, multidisciplinary case conferences, and use of decision support to nudge ID physicians to routinely provide recommended preventive care and assess their patients' psychosocial needs.…”

“…6,7 This will require increases in formal training opportunities and incentives to choose a career in HIV medicine, such as higher compensation for HIV care, reduced administrative burden, and assurance of safe and sustainable caseload. 8 However, it is unclear how various provider types should be prioritized in these rebuilding efforts. A previous survey found that selfreported delivery of recommended HIV care was equivalent across provider types and that NPs were more likely than ID physicians to provide certain services considered key to providing comprehensive HIV care.…”