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Multiple HIV care models effective for disease management
Using multiple care models to treat patients with HIV may be slightly more effective than using a single model, study data show.
Researchers also reported that differences among all care delivery models in the study were small, and equaled or outperformed previous quality indicator rates.
“The HIV/AIDS epidemic has transitioned over the past two decades, from a focus on treatment of opportunistic infections and management of complex ART regimens to a chronic disease model for care of patients with near-normal life expectancy and an increased focus on noncommunicable disease prevention and management while maintaining high quality HIV care,” Corinne M. Rhodes, MD, MPH, of the division of general internal medicine at the University of Pennsylvania, Philadelphia, and colleagues wrote. “There are multiple approaches to provide HIV care that include HIV and primary care provided by infectious disease specialist alone, by generalist alone or by a combination model where HIV care is provided by ID specialist and primary care is provided by a generalist. There are no formal recommendations for preferred HIV care model.”
The researchers organized 1,565 patients with HIV into three care groups: generalist, ID provider and ID provider plus generalist. Rhodes and colleagues then created four categories of quality-of-care indicators: HIV management, immunization, screening and process.
Most patients fell under the ID group (n = 875), with 90 in the generalist group and 675 in the combined group. Researchers noted different racial, ethnic and socioeconomic demographic makeups among each group. The ID group had a higher proportion of white, male English-speaking patients, while the ID plus generalist group had larger proportions of black patients, a higher number of clinic visits in 2012 and a higher proportion of patients with high Charlson scores. The generalist group contained a higher proportion of patients earning below the statewide median income and more Hispanic and non-English speaking patients.
The ID group had a retention rate of 96%, compared with 99.3% in the ID plus generalist group and 100% in the generalist group. Multivariable adjusted analysis showed the ID plus generalist group outperformed the ID group in HIV management (94.4% vs. 91.7%; P = .03), and had higher quality measures than the generalist group for immunization (87.8% vs. 80.6%; P = .03), Rhodes and colleagues reported. The absolute differences between individual groups ranged from 2% to 7%, prompting the researchers to suggest that the results should be taken in the context of physician or patient preference as well as cost and use.
“In conclusion, we found minimal differences in HIV quality metrics between HIV care models, with performance across groups surpassing previous results reported in the literature,” Rhodes and colleagues wrote. “Whether these differences translate into improved morbidity or mortality remains unknown. Our results suggest many models of HIV care are effective for HIV-related screening and management and that health care system, feasibility and patient and physician preference may guide HIV care model selections.” – by Andy Polhamus
Disclosure: Rhodes reports no relevant financial disclosures. Please see the full study for a complete list of all other authors’ relevant financial disclosures.
Perspective
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Michael A. Horberg
This is a very good study emphasizing a lot of what doctors in HIV medicine know — that HIV is chronic condition now, requiring both HIV specialty care and aggressive primary care. As a result, patients that are cared for by both ID and generalists, or ID doctors who do extensive primary care for their HIV–infected patients, do better.
Many prior studies have shown this, including ones from my own research group and health system — Kaiser Permanente — but now from a consortium of a large academic health system we see similar results. This is encouraging and moves the field along as we see the value of collaboration. A single practitioner or specialist working in isolation just will not get as good results as multidisciplinary and integrated care can achieve.
This study also moves the field forward by combining process and outcome quality performance measures into larger composite measures. This actually reflects necessary medical care even better. An HIV–infected patient needs not only retention or lab measurement, but likely both. Measuring these independent of each other really does not tell the whole story, nor does it reflect how good care should be delivered. The same applies to screening and immunizations. Here, real performance (as seen in Table 3 of the study) shows the results when all individual process or outcome measures for a particular area (like screenings or immunizations) are combined.
Finally, I would note that the performance of these clinics was very good. These doctors and clinics knew what they were doing. I am also proud that they referenced the HIVMA and IDSA HIV Primary Care Guidelines. Basing performance on recommended care from those guidelines and combining these metrics will really improve care in the future.
Disclosure: Horberg reports being an employee with Kaiser Permanente.