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Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy

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Abstract

BACKGROUND: Controversy exists regarding who should provide care for those with HIV/AIDS. While previous studies have found an association between physician HIV experience and patient outcomes, less is known about the relationship of physician specialty to HIV/AIDS outcomes or quality of care.

OBJECTIVE: To examine the relationship between choice of appropriate antiretroviral therapy (ART) to physician specialty and HIV/AIDS experience.

DESIGN: Self-administered physician survey.

PARTICIPANTS: Random sample of 2,478 internal medicine (IM) and infectious disease (ID) physicians.

MEASUREMENTS: Choice of guideline-recommended ART.

RESULTS: Two patients with HIV disease, differing only by CD4+ count and HIV RNA load, were presented. Respondents were asked whether ART was indicated, and if so, what ART regimen they would choose. Respondents’ ART choices were categorized as “recommended” or not by Department of Health and Human Services guidelines. Respondents’ HIV/AIDS experience was categorized as moderate to high (MOD/HI) or none to low (NO/LO). For Case 1, 72.9% of responding physicians chose recommended ART. Recommended ART was more likely (P<.01) to be chosen by ID physicians (88.2%) than by IM physicians (57.1%). Physicians with MOD/HI experience were also more likely (P<.01) to choose recommended ART than those with NO/LO experience. Finally, choice of ART was examined using logistic regression: specialty and HIV experience were found to be independent predictors of choosing recommended ART (for ID physicians, odds ratio [OR], 4.66; 95% confidence interval [95% CI], 3.15 to 6.90; and for MOD/HI experience, OR, 2.05; 95% CI, 1.33 to 3.16). Results for Case 2 were similar. When the analysis was repeated excluding physicians who indicated they would refer the HIV “patient,” specialty and HIV experience were not significant predictors of choosing recommended ART.

CONCLUSIONS: Guideline-recommended ART appears to be less likely to be chosen by generalists and physicians with less HIV/AIDS experience, although many of these physicians report they would refer these patients in clinical practice. These results lend support to current recommendations for routine expert consultant input in the management of those with HIV/AIDS.

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References

  1. Palella FJ, Delaney, Moorman AC, et al. Declining morbidity and mortality among patients with advanced HIV infection. HIV Outpatient Study Investigators. N Engl J Med. 1998;338:853–60.

    Article  PubMed  Google Scholar 

  2. Carpenter CC, Fischl MA, Hammer SM, et al. Antiretroviral therapy for HIV infection in 1998: Updated recommendations of the International AIDS Society-USA Panel. JAMA. 1998;280:78–86.

    Article  PubMed  CAS  Google Scholar 

  3. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. Department of Health and Human Services and Henry J. Kaiser Family Foundation. MMWR Morb Mortal Wkly Rep. 1998;47:43–82.

    Google Scholar 

  4. Hammer SM, Squires KE, Hughes MD, et al. A controlled trial of two nucleoside analogues plus indinavir in persons with human immunodeficiency virus infection and CD4 cell counts of 200 per cubic millimeter or less. AIDS Clinical Trials Group 320 Study Team. N Engl J Med. 1997;337:725–33.

    Article  PubMed  CAS  Google Scholar 

  5. Cameron B, Heath-Chiozzi M, Kravcik S, Mills R, Potoff A, Henry D. Prolongation of life and prevention of AIDS in advanced HIV immunodeficiency with ritonavir. In: Program and Abstracts of the 3rd Conference on Retroviruses and Opportunistic Infections. Washington, DC: Foundation for Retrovirology and Human Health; 1996.

    Google Scholar 

  6. Montaner JS, Riess P, Cooper D, et al. A randomized, doubleblind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIV-infected patients: the INCAS trial. Italy, The Netherlands, Canada and Australia Study. JAMA. 1998;279:930–7.

    Article  PubMed  CAS  Google Scholar 

  7. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report 1998: U.S. HIV and AIDS Cases Reported through December 1999. 2000;9:5–44.

    Google Scholar 

  8. Fauci AS, Bartlett JG, and the Panel on Clinical Practices for Treatment of HIV Infection. Panel on Clinical Practices for Treatment of HIV Infection. Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adolescents. Department of Health and Human Services. Office of Public Health and Science 1997. Federal Register Doc 97-16228.

  9. Carpenter CCJ, Fischl MA, Hammer SM, et al. Antiretroviral therapy for HIV infection in 1997. Updated Recommendations of the International AIDS Society-USA Panel. JAMA. 1997;277:1962–9.

    Article  PubMed  CAS  Google Scholar 

  10. Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians’ experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med. 1996;334:701–6.

    Article  PubMed  CAS  Google Scholar 

  11. Stone VE, Seage GR, Hertz T, Epstein AM. The relation between hospital experience and mortality for patients with AIDS. JAMA. 1992;268:2655–61.

    Article  PubMed  CAS  Google Scholar 

  12. Shapiro MF, Greenfield S. Experience and outcomes in AIDS. JAMA. 1992;268:2698–9.

    Article  PubMed  CAS  Google Scholar 

  13. Cotton DJ. Improving survival in acquired immunodeficiency syndrome: is experience everything? JAMA. 1989;261:3016–7.

    Article  PubMed  CAS  Google Scholar 

  14. Markson LE, Houchens R, Fanning TR, Turner BJ. Repeated emergency department use by HIV-infected persons: effect of clinic accessibility and expertise in HIV care. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17:35–41.

    PubMed  CAS  Google Scholar 

  15. Brosgart CL, Mitchell TF, Coleman RL, Dyner T, Stephenson KE, Abrams DI. Clinical experience and choice of drug therapy for human immunodeficiency viral disease. Clin Infect Dis. 1999;28:14–22.

    PubMed  CAS  Google Scholar 

  16. Bach PB, Calhoun EA, Bennett CL. The relation between physician experience and patterns of care for patients with AIDS-related Pneumocystis carinii pneumonia: results from a survey of 1,500 physicians in the United States. Chest. 1999;115:1563–9.

    Article  PubMed  CAS  Google Scholar 

  17. Hecht FM, Wilson IB, Wu AW, Cook RL, Turner BJ. Optimizing care for persons with HIV infection. Society of General Internal Medicine AIDS Task Force. Ann Intern Med. 1999;131:136–43.

    PubMed  CAS  Google Scholar 

  18. Mansourati FF, Stone VE, Mayer KH, Duefield CA, Poses RM. The relation of HIV/AIDS practice variations to physicians’ judgements regarding antiretroviral therapy. J Gen Intern Med. 1999;14(suppl 2):108.

    Google Scholar 

  19. SAS/STAT User’s Guide: Version 7. Fifth Edition. Cary, NC: SAS Institute; 1997.

    Google Scholar 

  20. Bureau of Health Professions. Seventh Report to the President and Congress on the Status of Health Personnel in the United States. Washington, DC: National Academy Press; 1996.

    Google Scholar 

  21. Kitahata MM, Van Rompaey SE, Shields AW. Physician experience in the care of HIV-infected persons is associated with earlier adoption of new antiretroviral therapy. J Acquir Immune Defic Syndr. 2000;24:106–14.

    PubMed  CAS  Google Scholar 

  22. Markson LE, Cosler LE, Turner BJ. Implications of generalists’ slow adoption of zidovudine in clinical practice. Arch Intern Med. 1994;154:1497–504.

    Article  PubMed  CAS  Google Scholar 

  23. Ayanian JZ, Hauptman PJ, Guadagnoli E, Antman EM, Pashos CL, McNeil BJ. Knowledge and practices of generalist and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med. 1994;331:1136–42.

    Article  PubMed  CAS  Google Scholar 

  24. Chin MH, Friedmann PD, Cassel CK, Lang RM. Differences in generalist and specialist physicians’ knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure. J Gen Intern Med. 1997;12:523–30.

    Article  PubMed  CAS  Google Scholar 

  25. Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary PD. Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med. 1997;157:2570–6.

    Article  PubMed  CAS  Google Scholar 

  26. Chin MH, Wang JC, Zhang JX, Lang RM. Differences among geriatricians, general internists, and cardiologists in the care of patients with heart failure: a cautionary tale of quality assessment. J Am Geriatr Soc. 1998;46:1349–54.

    PubMed  CAS  Google Scholar 

  27. Goldstein LB, Bonito AJ, Matchar DB, Duncan PW, Samsa GP. US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke. Medical therapy in patients with carotid artery stenosis. Stroke. 1996;27:1473–8.

    PubMed  CAS  Google Scholar 

  28. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and different specialities. Results from the Medical Outcomes Study. JAMA. 1995;274:1436–44.

    Article  PubMed  CAS  Google Scholar 

  29. Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med. 1996;335:1880–7.

    Article  PubMed  CAS  Google Scholar 

  30. Mitchell JB, Ballard DJ, Whisnant JP, Ammering CJ, Samsa GP, Matchar DB. What role do neurologists play in determining the costs and outcomes of stroke patients? Stroke. 1996;27:1937–43.

    PubMed  CAS  Google Scholar 

  31. Paauw DS, Wenrich MD, Curtis JR, Carline JD, Ramsey PG. Ability of primary care physicians to recognize physical findings associated with HIV infection. JAMA. 1995;274:1380–2.

    Article  PubMed  CAS  Google Scholar 

  32. Turner BJ, McKee L, Fanning T, Markson LE. AIDS specialist versus generalist ambulatory care for advanced HIV infection and impact on hospital use. Med Care. 1994;32:902–16.

    Article  PubMed  CAS  Google Scholar 

  33. Curtis JR, Paauw DS, Wenrich MD, Carline JD, Ramsey PG. Ability of primary care physicians to diagnose and manage Pneumocystis carinii pneumonia. J Gen Intern Med. 1995;10: 395–9.

    Article  PubMed  CAS  Google Scholar 

  34. Northfelt DW, Hayward RA, Shapiro MF. The acquired immunodeficiency syndrome is a primary care disease. Ann Intern Med. 1988;109:773–5.

    PubMed  CAS  Google Scholar 

  35. Centers for Disease Control and Prevention. HIV prevention practices of primary-care physicians-United States, 1992. JAMA. 1994;271:261–2.

    Article  Google Scholar 

  36. Wenrich MD, Curtis JR, Carline JD, Paauw DS, Ramsey PG. HIV risk screening in the primary care setting: Assessment of physician skills. J Gen Intern Med. 1997;12:107–13.

    PubMed  CAS  Google Scholar 

  37. Robbins GK. Time for a new paradigm—optimal management of patients with human immunodeficiency virus infection and AIDS. Clin Infect Dis. 1999;28:23–5.

    PubMed  CAS  Google Scholar 

  38. Stone VE. Generalists providing antiretroviral therapy for patients with HIV/AIDS: Have the rules changed? SGIM Forum. 1998;21:1,6–8.

    Google Scholar 

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Correspondence to Valerie E. Stone MD, MPH.

Additional information

This work was supported by a Generalist Physician Faculty Scholar Award from the Robert Wood Johnson Foundation and a grant from Agouron Pharmaceuticals, Inc.

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Stone, V.E., Mansourati, F.F., Poses, R.M. et al. Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy. J GEN INTERN MED 16, 360–368 (2001). https://doi.org/10.1046/j.1525-1497.2001.016006360.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.2001.016006360.x

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