By Christopher J. Hoffmann, MD, MPH

Clinician experience, which is often defined by the number of patients with a specific condition seen over a defined period of time, is associated with better outcomes in surgery, oncology, pediatric specialties, and adult medicine specialties. HIV care is provided by specialists certified in infectious diseases, by HIV clinicians who are not infectious disease specialists, and by generalists who provide care for a varying number of people living with HIV. Whether high- and low-volume providers achieve similar quality of care has long been a question in the field of HIV care. Several single center or medical system studies have reported associations between greater provider experience and patient medication adherence, higher rates of antiretroviral therapy (ART) prescribing, and lower patient mortality. Nonetheless, there are arguments to support both specialist HIV care (depth of knowledge) and generalist HIV care (increased accessibility and/or acceptability of services).  

 

To further explore the relationship between provider experience and clinical outcomes in the current era of ART, the New York State AIDS Institute compared clinical indicators results between low- and not-low-volume care providers of patients receiving either Medicaid or AIDS Drug Assistance Program benefits (ADAP) [O'Neil, et al. CID 2015]. Using Medicaid and ADAP databases, these researchers identified care providers prescribing ART to fewer than 20 adult patients in federal fiscal year 2009. Of these, 270 were eventually confirmed as low-volume providers; 73% practiced in New York City. The median annual volume of HIV patients was 4.3, with 75% of care providers prescribing for 5 or fewer patients. Of the 270 low-volume providers, 84 supplied charts for review. HIV RNA suppression, frequency of visits, and laboratory monitoring were compared between charts from the low-volume providers and a sample of charts from higher-volume providers. Most notably, HIV RNA suppression was observed among just 56% of patients cared for by low-volume providers, compared to 77% of patients cared for by higher-volume providers. Rates of syphilis screening, office visits, HIV RNA assays, and CD4 count testing were all lower for patients seen by low volume providers. 

 

This study raises several important questions: (1) Were the patients seen by the low-volume providers different in a way that could contribute to lower rates of adherence and laboratory testing? (2) What is the best definition of a low-volume provider-i.e., is the correct measure 20 patients or should it be closer to 5 given the median of 4.3 in the study? (3) If the provider's care can explain the outcomes, how can guidelines and quality improvement efforts better reach these individuals to achieve meaningful changes in the care setting? It may be possible to address some of these questions through a follow-on study. In the interim, improving dissemination and implementation of best practice guidance to busy clinicians remains an ongoing challenge for the AIDS Institute and all other similar organizations striving to improve the quality of HIV care. Read study abstract (PubMed).