How many HIV patients receive appropriate treatment and achieve outcomes indicating high-quality care?

Among HIV-infected adult patients at 68 federally funded clinics, four of five received antiretroviral treatment when indicated, but less than two of five were able to control their infection. Three of four received medicine to prevent lung infections when needed, and two of three had routine clinic visits.

Why is this important?

More than 1 million Americans are currently infected with human immunodeficiency virus (HIV). About 40,000 new infections are diagnosed each year (CDC 2006). Recent advances in treatment have made the disease a manageable, chronic illness.

HIV patients should receive regular care from a health professional who can monitor their status and adjust treatment to include the most up-to-date therapies (Carpenter et al. 2000). Appropriate treatment can prevent complications such as pneumonia, slow the progression to AIDS, and prolong life.

Findings

Among HIV-infected adult patients treated at one of 68 federally funded HIV clinics between 1999 and 2001:

• Roughly one of five (16–25%) did not receive highly active antiretroviral therapy (HAART) despite the need for such treatment.
• More than three of five (60–70%) individuals eligible for or receiving HAART did not have their HIV infection under control.
• Roughly one of four (22–27%) did not receive medicine to help prevent opportunistic lung infections (prophylaxis for Pneumocystis carinii pneumonia or PCP).
• Roughly one of three (30–43%) did not visit their clinician in at least three of four quarters during the measurement year (Wilson et al.).

Among clinicians responsible for the care of these HIV patients, nurse practitioners and physician assistants provided equal or better care compared with infectious disease physicians and expert generalist physicians. Nonexpert generalist physicians provided somewhat lower quality of care (Landon et al. 2005).

Implications

Receipt of HAART and PCP prophylaxis had not changed substantially in these clinics during 1999–2001 compared with national rates of 85 percent and 74 percent, respectively, achieved in 1998 (Shapiro et al. 1999). Achieving control of HIV requires that patients adhere to a complex medication regimen that may be difficult without good psychosocial support.Although initial evaluation and preventive care of HIV-infected patients is well within the scope of generalist physicians, referral to HIV specialists may be warranted when generalist physicians have not acquired expertise in HIV care (Khalsa 2006). With adequate training and support, nurse practitioners and physician assistants may serve as a vital resource for the treatment of HIV-infected individuals, especially in rural, underserved, or resource-limited sites of care (Wilson et al. 2005).

Improvement Ideas and Resources

Based on recommendations of the Institute of Medicine (IOM 2003), the federal HIV/AIDS Bureau has developed technical assistance resources, software, and other tools to help federally funded HIV clinics implement quality improvement programs. The Bureau required that all newly funded clinics participate in a quality collaboration during 2000–2001 (from which data shown in the chart are drawn). Intervention clinics did not achieve significantly greater improvement than a control group of clinics, however, suggesting that more effective improvement methods are needed (Landon et al. 2004).

• Other research shows that the quality of the physician–patient relationship is a strong independent predictor of whether patients receive HAART, adhere to treatment, and achieve control of HIV infection (Beach et al. 2006; Schneider et al. 2004).
• A national study found that HIV patients who had contact with a case manager were less likely to have unmet needs for supportive services and more likely to be using antiretroviral therapy (Katz et al. 2001).

Measure:

The chart is based on a study of 6651 HIV-infected adults (ages 18 and older) randomly selected from patients who had a least one visit to a participating clinic during the review period and who were treated by one of 243 surveyed clinicians. The review period was June 1999 through May 2000 and January through December 2001. The surveyed clinicians, who had primary responsibility for caring for HIV patients, were categorized by their self-reported level of training and expertise in treating HIV (Wilson et al. 2005). Appropriate HIV care was defined based on recommendations of the International AIDS Society—USA Panel in effect at the time of the study (Carpenter et al. 2000). HAART use and HIV control were measured at the last visit during the review period. Patients were considered eligible for HAART if their CD4 cell counts were less than 500 cells/µL or their viral loads were greater than 20,000 copies/mL), and if they were already receiving HAART. Viral load was considered to be controlled if undetectable or if less than 400 copies/mL. (Results for other recommended screening and preventive care are not shown.)Adjusted rates shown in the chart controlled for differences in patient age, sex, number of HIV-related diagnoses, number of comorbid conditions, presence of a psychiatric disorder, current injection drug use, lowest CD4 cell counts, and interview periods; whether the site was in the intervention or control group; and to account for clustering of patients within providers and providers within sites (Wilson et al. 2005).

Limitations:

Although participating clinics were representative of federally funded clinics, the results may not be representative of care for all HIV patients. The study did not report results by time period and did not measure mortality outcome, hospitalization rates, medication adherence, or patient ratings of care (Wilson et al. 2005).

Source:

Researchers from Tufts–New England Medical Center, Harvard Medical School, and Harvard University analyzed linked medical record and clinician survey data from 68 clinics (including community-health centers, hospital-based clinics, and local government services), located in 30 states, that participated or served as controls in a quality improvement study (Landon et al. 2004). Because there was no difference in quality of care between the intervention and control sites, results for all clinics were combined for this analysis. All clinics had at least 100 HIV patients and received funding from the federal Ryan White CARE Act, which funds 200 sites nationwide that serve a large proportion of patients with low incomes and complex social problems (Wilson et al. 2005).

References:

* Indicates source of data used in the chart(s).Beach, M. C., J. Keruly, and R. D. Moore. 2006. Is the Quality of the Patient-Provider Relationship Associated with Better Adherence and Health Outcomes for Patients with HIV? Journal of General Internal Medicine 21 (6): 661–665. Carpenter, C. C., D. A. Cooper, M. A. Fischl et al. 2000. Antiretroviral Therapy in Adults: Updated Recommendations of the International AIDS Society-USA Panel. Journal of the American Medical Association 283 (3): 381–90. CDC (Centers for Disease Control and Prevention). 2006. Epidemiology of HIV/AIDS—United States, 1981–2005. IOM (Institute of Medicine). 2003. Measuring What Matters: Allocation, Planning, and Quality Assessment for the Ryan White CARE Act. Washington, D.C.: National Academy Press. Katz, M. H., W. E. Cunningham, J. A. Fleishman et al. 2001. Effect of Case Management on Unmet Needs and Utilization of Medical Care and Medications Among HIV-Infected Persons. Annals of Internal Medicine 135 (8 Pt 1): 557–65. Landon, B. E., I. B. Wilson, K. McInnes et al. 2004. Effects of a Quality Improvement Collaborative on the Outcome of Care of Patients with HIV infection: The EQHIV Study. Annals of Internal Medicine 140 (11): 887–96. Landon, B. E., I. B. Wilson, K. McInnes et al. 2005. Physician Specialization and the Quality of Care for Human Immunodeficiency Virus Infection. Archives of Internal Medicine 165 (10): 1133–9. Schneider, J., S. H. Kaplan, S. Greenfield et al. 2004. Better Physician-Patient Relationships Are Associated with Higher Reported Adherence to Antiretroviral Therapy in Patients with HIV Infection. Journal of General Internal Medicine 19 (11): 1096–103. Shapiro, M. F., S. C. Morton, D. F. McCaffrey et al. 1999. Variations in the Care of HIV-Infected Adults in the United States: Results from the HIV Cost and Services Utilization Study. Journal of the American Medical Association 281 (24): 2305–15. * Wilson, I. B., B. E. Landon, L. R. Hirschhorn et al. 2005. Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians. Annals of Internal Medicine 143 (10): 729–36.