A shift in referral patterns for HIV/AIDS patients

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).