A shift in referral patterns for HIV/AIDS patients

In June 2008, it will be 27 years since the first reported clusters of Pneumocystis pneumonia cases, which were the earliest published reports of the HIV epidemic.¹ There are now more than a million individuals infected with HIV in the United States.²

Since the first antiretroviral drug, azidothymidine (AZT), was approved in 1987, more than a dozen medications have been introduced to treat this illness.² Care for patients with HIV/AIDS is rapidly evolving—so much so that the International AIDS Society publishes revised treatment guidelines every 2 years.³ The US Department of Health and Human Services also issues frequent guidelines for HIV care.⁴

Methods

Asking FPs about their HIV/AIDS management practices

This cross-sectional survey was designed as an 11-year follow-up to a previous research study, described in greater detail elsewhere.¹²

In June 2005, we obtained a membership listing from the Massachusetts Academy of Family Physicians (MAFP). Using the total design methodology described by Dillman,¹³ a cover letter and survey instrument were mailed to current MAFP members (N=777). Nonresponders were sent a reminder postcard 2 weeks later, and a second survey 2 weeks after that. A final reminder and survey were mailed to the remaining nonrespondents a month later. No incentives were offered for the completion of the survey.

The survey instrument was developed using the original data collection tool from 1994, supplemented by questions assessing any changes in patient management over the previous 11 years. The 31-item survey included questions about the sociodemographic and practice characteristics of the respondents, their patient mix, their education, and their management of patients with HIV/AIDS, as well as a series of Likert-type attitudinal questions assessing their knowledge, access to specialists, and safety concerns regarding HIV.

Outcomes measured: Changes in care and referral patterns

The main outcomes of the survey were changes in the management of patients with HIV/AIDS, particularly regarding referral patterns compared with the previous decade. Univariate and bivariate statistics, frequency and percentile distributions, as well as means and medians, were used to characterize the physician cohort, their practice characteristics, referral patterns, and attitudes. We also examined a variety of relationships (eg, differences by gender, years of practice, and involvement in teaching), including changes from the data we collected in 1994 (using a repeated cross-sectional design approach).

Data were analyzed using SPSS for Windows, version 14 (SPSS, Inc, Chicago, Ill). Depending on the categorical or continuous nature of the data, chi-square and t-tests were used to assess significance at the .05 level. These bivariate analyses were subsequently used to select which independent variables we would include in the stepwise logistic regression analyses.

This study was reviewed by the University of Massachusetts’ Institutional Review Board for the conduct of human subject research and received an exemption from formal review.

Results

Who were the respondents?

In all, 369 completed surveys were returned, along with 44 uncompleted surveys (returned as undeliverable or with an indication that the respondent was no longer practicing), for a response rate of 53.2% (413/777) and a completion rate of 47.4% (369/777).

The respondents included an equal representation of male and female physicians. The majority practiced in non- urban settings (62.6%), and nearly one half (44.8%) had finished their residency since the first survey was sent. Half (54.9%) participated in a solo or single-specialty practice. FPs more often reported teaching medical students regularly (52.9%) than being involved in residency education (30.9%). More than a third (34.2%) reported that ≥15% of their patients participated in “high-risk” behaviors for HIV. (The definition of high-risk was left to the individual respondent.)

Compared with our earlier survey, respondents are now more likely to be female, more likely to be practicing in an urban setting, and slightly more likely to teach medical students. Current respondents also reported that they had fewer patients involved in high-risk behaviors.

The majority (63.8%) indicated that they had at least one HIV+ patient in their practice, with 39.0% also reporting at least one AIDS patient. Compared with the previous cohort studied, HIV+ patient numbers remained about the same; however, the number of practices caring for at least 1 AIDS patient was significantly lower (TABLE 1).

TABLE 1
Demographics of FPs responding (1994 vs 2005)

HIV/AIDS care and changing referral patterns

When asked how referral patterns had changed over the past decade, the overwhelming majority (94.4%) reported being far less likely to manage HIV/AIDS patients alone. Just over half (56.2%) of the physicians in the current survey indicated being more likely to co-manage patients, and an impressive 85.3% noted that they were more likely to refer patients immediately compared with their own practice patterns a decade ago.

Changing care patterns for asymptomatic HIV+ patients. A total of 39.0% of current respondents referred patients immediately, 57.0% co-managed patients, while only 4.1% managed these patients alone (the data for the 1994 cohort was 7.0%, 45.8%, and 47.2%, respectively; P<.0001).

AIDS patients have similar patterns. Similar changes were seen in regard to care patterns for AIDS patients. Among the current cohort, 61.7% reported that they referred these patients immediately, compared with only 18.3% in 1994; 36.8% noted that they co-managed these patients (vs 74.3% in 1994); and only 1.5% reported that they managed these patients alone (vs 7.4% in 1994; P<.0001).

Use of resources. When they were asked which resources they used to help provide care for HIV patients, 39.9% indicated an HIV clinic at the closest teaching hospital (vs 28.4% in 1994); 41.4% noted a specialist at the community hospital where they practiced (vs 52.6% in 1994); and the remainder were fairly equally distributed (in both cohort years) between a local community health center that treats HIV+ patients, a consultant requested by the patient, or an FP colleague (P=.0003).

Which FPs are likely to refer? Given the small number of respondents who manage asymptomatic HIV+ and AIDS patients alone, we focused our analyses between those who refer immediately and those who co-manage care.

Those who reported referring asymptomatic HIV+ patients immediately were less likely to have ≥3 HIV+ or ≥3 AIDS patients in their current practice. They were significantly more likely to be in a group practice and significantly less likely to work at a community health center. They also reported being less likely to teach medical students and residents (TABLE 2).

Similar findings in referral patterns were also seen in the management of symptomatic HIV+/AIDS patients (TABLE 3). In addition, those physicians who immediately refer AIDS patients were also less likely to report that >15% of their patients were involved in high-risk behaviors.

TABLE 2
Care of asymptomatic HIV+ patients—which FPs refer, which co-manage?

Who is caring for HIV/AIDS patients? Those FPs who reported an increase over 11 years in the number of patients with HIV/AIDS in their practices were more likely to practice in a community health center (P<.001), and were more likely to teach medical students (P=.002) and residents (P<.001). Additionally, these FPs reported a higher percentage of patients with high-risk behaviors (P=.008). These FPs were less likely to report that they didn’t have time to care for HIV/AIDS patients (P=.037). They felt more knowledgeable about HIV (P=.005) and AIDS care (P<.001), and were more likely to learn about HIV/AIDS care through formal CME (P=.001).

In contrast, those FPs with <10 HIV/AIDS patients in their practice were more likely to be in rural practices (P=.006), to have been in practice longer (mean, 14.75 vs 12.35 years; P=.042), and to teach medical students (P=.045). There were no differences noted between gender, practice arrangement, or residency education.

TABLE 3
Care of symptomatic HIV+/AIDS patients—which FPs refer, which co-manage?

Multivariate analyses

To identify factors that contributed the most to the immediate referral of asymptomatic HIV+ patients, we employed a stepwise logistic regression analysis based on the results of our bivariate analyses.

FPs were less likely to refer immediately if they were female, practiced in a community health center, had a higher number of HIV patients in their practice, learned about HIV/AIDS care during residency as well as through formal CME programs, taught medical students regularly, and felt more knowledgeable about HIV/AIDS care. They were more likely to refer these patients if they reported having no time to care for HIV/AIDS patients. A similar model was observed for the referral of symptomatic AIDS patients (TABLE 4).

TABLE 4
Multivariate analyses of factors related to referring patients immediately vs co-managing

Discussion

Referral patterns change with demographics and new treatments

In comparing data with our survey from 1994, we found significant differences in care and referral patterns for HIV/AIDS patients.

FPs are more likely to refer, and right away. FPs are more likely to refer HIV patients immediately, compared with a decade ago; this likely results from many factors. The complexity of this disease and the rapid rate of change in management have been well documented.³

Keeping up-to-date with current practice guidelines and managing complications of treatment protocols can be time-consuming. Also, more physicians in our current survey reported having no AIDS patients in their practices compared with 1994.

The emergence of community health centers. Another interesting finding, based on the results of both our bivariate and multivariate analyses, was to see the community health center emerge as a resource for patients with HIV/AIDS. This may reflect the more urban location of community health centers and the higher prevalence of HIV/AIDS patients in those locales, an increased involvement with teaching, and an increased volume of patients with HIV/AIDS—all resulting in an increased knowledge of HIV/AIDS care. Additionally, community health centers are capable of providing a more comprehensive range of services than a traditional practice, through the support of the Federal Ryan White CARE Act. This likely plays a role in the increasing numbers of such patients being cared for in this setting.

Implications for future training of FPs. Optimal care of HIV patients requires a combination of disease-specific expertise and primary care skills and organization.¹⁴ Recent literature demonstrates that generalist physicians are able to develop condition-specific knowledge similar to those with specialty training—if they have a substantial caseload, and if they make an effort to stay current in a particular area.¹⁵ Residency training sites, particularly community health centers, will likely emerge as leaders in the training of primary care physicians to care for this disease. The ongoing expertise of faculty in these sites will be a vital aspect of this training.

Limitations of this study Our survey was limited to members of the MAFP, and may not be generalizable to other primary care providers. It also may not be generalizable to other states, given the demographics of Massachusetts and the availability of health care in a more urban environment. The availability of HIV resources and referral centers may vary from state to state.

The survey relied upon self-report and may be prone to either over- or under-reporting of current practice and recall of changes over the past decade.

Also, a higher response rate among male FPs, with females being less likely to refer patients, may have understated the relationship between gender and referral patterns for these patients.

Quality of care? it’s still a question. The quality of care provided by the subset of family physicians that are caring for their HIV/AIDS patients was not studied in this article. As this group continues to train new physicians and provide ongoing care for these patients, it will be important to measure the quality of care being provided.^9,16

Conclusion

Will the role of the FP in HIV/AIDS care expand?

Our study demonstrates a significant shift amongst FPs with regard to their referral patterns for patients with HIV/AIDS over the last decade. This overall shift likely reflects the complexity of caring for these patients.

However, as these patients have longer survival rates, primary care offices will likely be seeing more individuals with HIV disease. While these patients may be followed by specialists, the role of the primary care physician in providing care may well expand. Funding for specific training programs on HIV/AIDS care should be targeted to community health centers where there is sufficient volume of HIV patients and an already demonstrated expertise amongst clinical faculty.

Acknowledgments

We gratefully acknowledge the survey implementation and data entry efforts of Denise West and the expert review by Jeff Baxter, MD.

Correspondence
Philip O. Fournier, MD, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655; FournieP@ummhc.org

In June 2008, it will be 27 years since the first reported clusters of Pneumocystis pneumonia cases, which were the earliest published reports of the HIV epidemic.¹ There are now more than a million individuals infected with HIV in the United States.²

Since the first antiretroviral drug, azidothymidine (AZT), was approved in 1987, more than a dozen medications have been introduced to treat this illness.² Care for patients with HIV/AIDS is rapidly evolving—so much so that the International AIDS Society publishes revised treatment guidelines every 2 years.³ The US Department of Health and Human Services also issues frequent guidelines for HIV care.⁴

Methods

Asking FPs about their HIV/AIDS management practices

This cross-sectional survey was designed as an 11-year follow-up to a previous research study, described in greater detail elsewhere.¹²

In June 2005, we obtained a membership listing from the Massachusetts Academy of Family Physicians (MAFP). Using the total design methodology described by Dillman,¹³ a cover letter and survey instrument were mailed to current MAFP members (N=777). Nonresponders were sent a reminder postcard 2 weeks later, and a second survey 2 weeks after that. A final reminder and survey were mailed to the remaining nonrespondents a month later. No incentives were offered for the completion of the survey.

The survey instrument was developed using the original data collection tool from 1994, supplemented by questions assessing any changes in patient management over the previous 11 years. The 31-item survey included questions about the sociodemographic and practice characteristics of the respondents, their patient mix, their education, and their management of patients with HIV/AIDS, as well as a series of Likert-type attitudinal questions assessing their knowledge, access to specialists, and safety concerns regarding HIV.

Outcomes measured: Changes in care and referral patterns

The main outcomes of the survey were changes in the management of patients with HIV/AIDS, particularly regarding referral patterns compared with the previous decade. Univariate and bivariate statistics, frequency and percentile distributions, as well as means and medians, were used to characterize the physician cohort, their practice characteristics, referral patterns, and attitudes. We also examined a variety of relationships (eg, differences by gender, years of practice, and involvement in teaching), including changes from the data we collected in 1994 (using a repeated cross-sectional design approach).

Data were analyzed using SPSS for Windows, version 14 (SPSS, Inc, Chicago, Ill). Depending on the categorical or continuous nature of the data, chi-square and t-tests were used to assess significance at the .05 level. These bivariate analyses were subsequently used to select which independent variables we would include in the stepwise logistic regression analyses.

This study was reviewed by the University of Massachusetts’ Institutional Review Board for the conduct of human subject research and received an exemption from formal review.

Results

Who were the respondents?

In all, 369 completed surveys were returned, along with 44 uncompleted surveys (returned as undeliverable or with an indication that the respondent was no longer practicing), for a response rate of 53.2% (413/777) and a completion rate of 47.4% (369/777).

The respondents included an equal representation of male and female physicians. The majority practiced in non- urban settings (62.6%), and nearly one half (44.8%) had finished their residency since the first survey was sent. Half (54.9%) participated in a solo or single-specialty practice. FPs more often reported teaching medical students regularly (52.9%) than being involved in residency education (30.9%). More than a third (34.2%) reported that ≥15% of their patients participated in “high-risk” behaviors for HIV. (The definition of high-risk was left to the individual respondent.)

Compared with our earlier survey, respondents are now more likely to be female, more likely to be practicing in an urban setting, and slightly more likely to teach medical students. Current respondents also reported that they had fewer patients involved in high-risk behaviors.

The majority (63.8%) indicated that they had at least one HIV+ patient in their practice, with 39.0% also reporting at least one AIDS patient. Compared with the previous cohort studied, HIV+ patient numbers remained about the same; however, the number of practices caring for at least 1 AIDS patient was significantly lower (TABLE 1).

TABLE 1
Demographics of FPs responding (1994 vs 2005)

HIV/AIDS care and changing referral patterns

When asked how referral patterns had changed over the past decade, the overwhelming majority (94.4%) reported being far less likely to manage HIV/AIDS patients alone. Just over half (56.2%) of the physicians in the current survey indicated being more likely to co-manage patients, and an impressive 85.3% noted that they were more likely to refer patients immediately compared with their own practice patterns a decade ago.

Changing care patterns for asymptomatic HIV+ patients. A total of 39.0% of current respondents referred patients immediately, 57.0% co-managed patients, while only 4.1% managed these patients alone (the data for the 1994 cohort was 7.0%, 45.8%, and 47.2%, respectively; P<.0001).

AIDS patients have similar patterns. Similar changes were seen in regard to care patterns for AIDS patients. Among the current cohort, 61.7% reported that they referred these patients immediately, compared with only 18.3% in 1994; 36.8% noted that they co-managed these patients (vs 74.3% in 1994); and only 1.5% reported that they managed these patients alone (vs 7.4% in 1994; P<.0001).

Use of resources. When they were asked which resources they used to help provide care for HIV patients, 39.9% indicated an HIV clinic at the closest teaching hospital (vs 28.4% in 1994); 41.4% noted a specialist at the community hospital where they practiced (vs 52.6% in 1994); and the remainder were fairly equally distributed (in both cohort years) between a local community health center that treats HIV+ patients, a consultant requested by the patient, or an FP colleague (P=.0003).

Which FPs are likely to refer? Given the small number of respondents who manage asymptomatic HIV+ and AIDS patients alone, we focused our analyses between those who refer immediately and those who co-manage care.

Those who reported referring asymptomatic HIV+ patients immediately were less likely to have ≥3 HIV+ or ≥3 AIDS patients in their current practice. They were significantly more likely to be in a group practice and significantly less likely to work at a community health center. They also reported being less likely to teach medical students and residents (TABLE 2).

Similar findings in referral patterns were also seen in the management of symptomatic HIV+/AIDS patients (TABLE 3). In addition, those physicians who immediately refer AIDS patients were also less likely to report that >15% of their patients were involved in high-risk behaviors.

TABLE 2
Care of asymptomatic HIV+ patients—which FPs refer, which co-manage?

Who is caring for HIV/AIDS patients? Those FPs who reported an increase over 11 years in the number of patients with HIV/AIDS in their practices were more likely to practice in a community health center (P<.001), and were more likely to teach medical students (P=.002) and residents (P<.001). Additionally, these FPs reported a higher percentage of patients with high-risk behaviors (P=.008). These FPs were less likely to report that they didn’t have time to care for HIV/AIDS patients (P=.037). They felt more knowledgeable about HIV (P=.005) and AIDS care (P<.001), and were more likely to learn about HIV/AIDS care through formal CME (P=.001).

In contrast, those FPs with <10 HIV/AIDS patients in their practice were more likely to be in rural practices (P=.006), to have been in practice longer (mean, 14.75 vs 12.35 years; P=.042), and to teach medical students (P=.045). There were no differences noted between gender, practice arrangement, or residency education.

TABLE 3
Care of symptomatic HIV+/AIDS patients—which FPs refer, which co-manage?

Multivariate analyses

To identify factors that contributed the most to the immediate referral of asymptomatic HIV+ patients, we employed a stepwise logistic regression analysis based on the results of our bivariate analyses.

FPs were less likely to refer immediately if they were female, practiced in a community health center, had a higher number of HIV patients in their practice, learned about HIV/AIDS care during residency as well as through formal CME programs, taught medical students regularly, and felt more knowledgeable about HIV/AIDS care. They were more likely to refer these patients if they reported having no time to care for HIV/AIDS patients. A similar model was observed for the referral of symptomatic AIDS patients (TABLE 4).

TABLE 4
Multivariate analyses of factors related to referring patients immediately vs co-managing

Discussion

Referral patterns change with demographics and new treatments

In comparing data with our survey from 1994, we found significant differences in care and referral patterns for HIV/AIDS patients.

FPs are more likely to refer, and right away. FPs are more likely to refer HIV patients immediately, compared with a decade ago; this likely results from many factors. The complexity of this disease and the rapid rate of change in management have been well documented.³

Keeping up-to-date with current practice guidelines and managing complications of treatment protocols can be time-consuming. Also, more physicians in our current survey reported having no AIDS patients in their practices compared with 1994.

The emergence of community health centers. Another interesting finding, based on the results of both our bivariate and multivariate analyses, was to see the community health center emerge as a resource for patients with HIV/AIDS. This may reflect the more urban location of community health centers and the higher prevalence of HIV/AIDS patients in those locales, an increased involvement with teaching, and an increased volume of patients with HIV/AIDS—all resulting in an increased knowledge of HIV/AIDS care. Additionally, community health centers are capable of providing a more comprehensive range of services than a traditional practice, through the support of the Federal Ryan White CARE Act. This likely plays a role in the increasing numbers of such patients being cared for in this setting.

Implications for future training of FPs. Optimal care of HIV patients requires a combination of disease-specific expertise and primary care skills and organization.¹⁴ Recent literature demonstrates that generalist physicians are able to develop condition-specific knowledge similar to those with specialty training—if they have a substantial caseload, and if they make an effort to stay current in a particular area.¹⁵ Residency training sites, particularly community health centers, will likely emerge as leaders in the training of primary care physicians to care for this disease. The ongoing expertise of faculty in these sites will be a vital aspect of this training.

Limitations of this study Our survey was limited to members of the MAFP, and may not be generalizable to other primary care providers. It also may not be generalizable to other states, given the demographics of Massachusetts and the availability of health care in a more urban environment. The availability of HIV resources and referral centers may vary from state to state.

The survey relied upon self-report and may be prone to either over- or under-reporting of current practice and recall of changes over the past decade.

Also, a higher response rate among male FPs, with females being less likely to refer patients, may have understated the relationship between gender and referral patterns for these patients.

Quality of care? it’s still a question. The quality of care provided by the subset of family physicians that are caring for their HIV/AIDS patients was not studied in this article. As this group continues to train new physicians and provide ongoing care for these patients, it will be important to measure the quality of care being provided.^9,16

Conclusion

Will the role of the FP in HIV/AIDS care expand?

Our study demonstrates a significant shift amongst FPs with regard to their referral patterns for patients with HIV/AIDS over the last decade. This overall shift likely reflects the complexity of caring for these patients.

However, as these patients have longer survival rates, primary care offices will likely be seeing more individuals with HIV disease. While these patients may be followed by specialists, the role of the primary care physician in providing care may well expand. Funding for specific training programs on HIV/AIDS care should be targeted to community health centers where there is sufficient volume of HIV patients and an already demonstrated expertise amongst clinical faculty.

Acknowledgments

We gratefully acknowledge the survey implementation and data entry efforts of Denise West and the expert review by Jeff Baxter, MD.

Correspondence
Philip O. Fournier, MD, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655; FournieP@ummhc.org

In June 2008, it will be 27 years since the first reported clusters of Pneumocystis pneumonia cases, which were the earliest published reports of the HIV epidemic.¹ There are now more than a million individuals infected with HIV in the United States.²

Since the first antiretroviral drug, azidothymidine (AZT), was approved in 1987, more than a dozen medications have been introduced to treat this illness.² Care for patients with HIV/AIDS is rapidly evolving—so much so that the International AIDS Society publishes revised treatment guidelines every 2 years.³ The US Department of Health and Human Services also issues frequent guidelines for HIV care.⁴

Methods

Asking FPs about their HIV/AIDS management practices

This cross-sectional survey was designed as an 11-year follow-up to a previous research study, described in greater detail elsewhere.¹²

In June 2005, we obtained a membership listing from the Massachusetts Academy of Family Physicians (MAFP). Using the total design methodology described by Dillman,¹³ a cover letter and survey instrument were mailed to current MAFP members (N=777). Nonresponders were sent a reminder postcard 2 weeks later, and a second survey 2 weeks after that. A final reminder and survey were mailed to the remaining nonrespondents a month later. No incentives were offered for the completion of the survey.

The survey instrument was developed using the original data collection tool from 1994, supplemented by questions assessing any changes in patient management over the previous 11 years. The 31-item survey included questions about the sociodemographic and practice characteristics of the respondents, their patient mix, their education, and their management of patients with HIV/AIDS, as well as a series of Likert-type attitudinal questions assessing their knowledge, access to specialists, and safety concerns regarding HIV.

Outcomes measured: Changes in care and referral patterns

The main outcomes of the survey were changes in the management of patients with HIV/AIDS, particularly regarding referral patterns compared with the previous decade. Univariate and bivariate statistics, frequency and percentile distributions, as well as means and medians, were used to characterize the physician cohort, their practice characteristics, referral patterns, and attitudes. We also examined a variety of relationships (eg, differences by gender, years of practice, and involvement in teaching), including changes from the data we collected in 1994 (using a repeated cross-sectional design approach).

Data were analyzed using SPSS for Windows, version 14 (SPSS, Inc, Chicago, Ill). Depending on the categorical or continuous nature of the data, chi-square and t-tests were used to assess significance at the .05 level. These bivariate analyses were subsequently used to select which independent variables we would include in the stepwise logistic regression analyses.

This study was reviewed by the University of Massachusetts’ Institutional Review Board for the conduct of human subject research and received an exemption from formal review.

Results

Who were the respondents?

In all, 369 completed surveys were returned, along with 44 uncompleted surveys (returned as undeliverable or with an indication that the respondent was no longer practicing), for a response rate of 53.2% (413/777) and a completion rate of 47.4% (369/777).

The respondents included an equal representation of male and female physicians. The majority practiced in non- urban settings (62.6%), and nearly one half (44.8%) had finished their residency since the first survey was sent. Half (54.9%) participated in a solo or single-specialty practice. FPs more often reported teaching medical students regularly (52.9%) than being involved in residency education (30.9%). More than a third (34.2%) reported that ≥15% of their patients participated in “high-risk” behaviors for HIV. (The definition of high-risk was left to the individual respondent.)

Compared with our earlier survey, respondents are now more likely to be female, more likely to be practicing in an urban setting, and slightly more likely to teach medical students. Current respondents also reported that they had fewer patients involved in high-risk behaviors.

The majority (63.8%) indicated that they had at least one HIV+ patient in their practice, with 39.0% also reporting at least one AIDS patient. Compared with the previous cohort studied, HIV+ patient numbers remained about the same; however, the number of practices caring for at least 1 AIDS patient was significantly lower (TABLE 1).

TABLE 1
Demographics of FPs responding (1994 vs 2005)

HIV/AIDS care and changing referral patterns

When asked how referral patterns had changed over the past decade, the overwhelming majority (94.4%) reported being far less likely to manage HIV/AIDS patients alone. Just over half (56.2%) of the physicians in the current survey indicated being more likely to co-manage patients, and an impressive 85.3% noted that they were more likely to refer patients immediately compared with their own practice patterns a decade ago.

Changing care patterns for asymptomatic HIV+ patients. A total of 39.0% of current respondents referred patients immediately, 57.0% co-managed patients, while only 4.1% managed these patients alone (the data for the 1994 cohort was 7.0%, 45.8%, and 47.2%, respectively; P<.0001).

AIDS patients have similar patterns. Similar changes were seen in regard to care patterns for AIDS patients. Among the current cohort, 61.7% reported that they referred these patients immediately, compared with only 18.3% in 1994; 36.8% noted that they co-managed these patients (vs 74.3% in 1994); and only 1.5% reported that they managed these patients alone (vs 7.4% in 1994; P<.0001).

Use of resources. When they were asked which resources they used to help provide care for HIV patients, 39.9% indicated an HIV clinic at the closest teaching hospital (vs 28.4% in 1994); 41.4% noted a specialist at the community hospital where they practiced (vs 52.6% in 1994); and the remainder were fairly equally distributed (in both cohort years) between a local community health center that treats HIV+ patients, a consultant requested by the patient, or an FP colleague (P=.0003).

Which FPs are likely to refer? Given the small number of respondents who manage asymptomatic HIV+ and AIDS patients alone, we focused our analyses between those who refer immediately and those who co-manage care.

Those who reported referring asymptomatic HIV+ patients immediately were less likely to have ≥3 HIV+ or ≥3 AIDS patients in their current practice. They were significantly more likely to be in a group practice and significantly less likely to work at a community health center. They also reported being less likely to teach medical students and residents (TABLE 2).

Similar findings in referral patterns were also seen in the management of symptomatic HIV+/AIDS patients (TABLE 3). In addition, those physicians who immediately refer AIDS patients were also less likely to report that >15% of their patients were involved in high-risk behaviors.

TABLE 2
Care of asymptomatic HIV+ patients—which FPs refer, which co-manage?

Who is caring for HIV/AIDS patients? Those FPs who reported an increase over 11 years in the number of patients with HIV/AIDS in their practices were more likely to practice in a community health center (P<.001), and were more likely to teach medical students (P=.002) and residents (P<.001). Additionally, these FPs reported a higher percentage of patients with high-risk behaviors (P=.008). These FPs were less likely to report that they didn’t have time to care for HIV/AIDS patients (P=.037). They felt more knowledgeable about HIV (P=.005) and AIDS care (P<.001), and were more likely to learn about HIV/AIDS care through formal CME (P=.001).

In contrast, those FPs with <10 HIV/AIDS patients in their practice were more likely to be in rural practices (P=.006), to have been in practice longer (mean, 14.75 vs 12.35 years; P=.042), and to teach medical students (P=.045). There were no differences noted between gender, practice arrangement, or residency education.

TABLE 3
Care of symptomatic HIV+/AIDS patients—which FPs refer, which co-manage?

Multivariate analyses

To identify factors that contributed the most to the immediate referral of asymptomatic HIV+ patients, we employed a stepwise logistic regression analysis based on the results of our bivariate analyses.

FPs were less likely to refer immediately if they were female, practiced in a community health center, had a higher number of HIV patients in their practice, learned about HIV/AIDS care during residency as well as through formal CME programs, taught medical students regularly, and felt more knowledgeable about HIV/AIDS care. They were more likely to refer these patients if they reported having no time to care for HIV/AIDS patients. A similar model was observed for the referral of symptomatic AIDS patients (TABLE 4).

TABLE 4
Multivariate analyses of factors related to referring patients immediately vs co-managing

Discussion

Referral patterns change with demographics and new treatments

In comparing data with our survey from 1994, we found significant differences in care and referral patterns for HIV/AIDS patients.

FPs are more likely to refer, and right away. FPs are more likely to refer HIV patients immediately, compared with a decade ago; this likely results from many factors. The complexity of this disease and the rapid rate of change in management have been well documented.³

Keeping up-to-date with current practice guidelines and managing complications of treatment protocols can be time-consuming. Also, more physicians in our current survey reported having no AIDS patients in their practices compared with 1994.

The emergence of community health centers. Another interesting finding, based on the results of both our bivariate and multivariate analyses, was to see the community health center emerge as a resource for patients with HIV/AIDS. This may reflect the more urban location of community health centers and the higher prevalence of HIV/AIDS patients in those locales, an increased involvement with teaching, and an increased volume of patients with HIV/AIDS—all resulting in an increased knowledge of HIV/AIDS care. Additionally, community health centers are capable of providing a more comprehensive range of services than a traditional practice, through the support of the Federal Ryan White CARE Act. This likely plays a role in the increasing numbers of such patients being cared for in this setting.

Implications for future training of FPs. Optimal care of HIV patients requires a combination of disease-specific expertise and primary care skills and organization.¹⁴ Recent literature demonstrates that generalist physicians are able to develop condition-specific knowledge similar to those with specialty training—if they have a substantial caseload, and if they make an effort to stay current in a particular area.¹⁵ Residency training sites, particularly community health centers, will likely emerge as leaders in the training of primary care physicians to care for this disease. The ongoing expertise of faculty in these sites will be a vital aspect of this training.

Limitations of this study Our survey was limited to members of the MAFP, and may not be generalizable to other primary care providers. It also may not be generalizable to other states, given the demographics of Massachusetts and the availability of health care in a more urban environment. The availability of HIV resources and referral centers may vary from state to state.

The survey relied upon self-report and may be prone to either over- or under-reporting of current practice and recall of changes over the past decade.

Also, a higher response rate among male FPs, with females being less likely to refer patients, may have understated the relationship between gender and referral patterns for these patients.

Quality of care? it’s still a question. The quality of care provided by the subset of family physicians that are caring for their HIV/AIDS patients was not studied in this article. As this group continues to train new physicians and provide ongoing care for these patients, it will be important to measure the quality of care being provided.^9,16

Conclusion

Will the role of the FP in HIV/AIDS care expand?

Our study demonstrates a significant shift amongst FPs with regard to their referral patterns for patients with HIV/AIDS over the last decade. This overall shift likely reflects the complexity of caring for these patients.

However, as these patients have longer survival rates, primary care offices will likely be seeing more individuals with HIV disease. While these patients may be followed by specialists, the role of the primary care physician in providing care may well expand. Funding for specific training programs on HIV/AIDS care should be targeted to community health centers where there is sufficient volume of HIV patients and an already demonstrated expertise amongst clinical faculty.

Acknowledgments

We gratefully acknowledge the survey implementation and data entry efforts of Denise West and the expert review by Jeff Baxter, MD.

Correspondence
Philip O. Fournier, MD, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655; FournieP@ummhc.org