A shift in referral patterns for HIV/AIDS patients
This follow-up study shows that FPs are more likely to make quick referrals of HIV/AIDS patients than a decade ago.
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?
| REFER IMMEDIATELY (N=134)* | CO-MANAGE (N=196*) | P VALUE | |
|---|---|---|---|
| Practice type | |||
| Solo practice | 24 (17.9%) | 30 (15.6%) | .001 |
| Single specialty | 58 (43.3%) | 70 (36.5%) | |
| HMO | 3 (2.2%) | 0 (0.0%) | |
| Multispecialty | 22 (16.4%) | 20 (10.4%) | |
| CHC | 14 (10.4%) | 57 (29.7%) | |
| Hospital-based clinic | 13 (9.7%) | 15 (7.8%) | |
| Teach medical students regularly | |||
| Yes | 51 (38.1%) | 118 (61.5%) | <.001 |
| No | 83 (61.9%) | 74 (38.5%) | |
| Teach residents regularly | |||
| Yes | 20 (15.0%) | 78 (40.8%) | <.001 |
| No | 113 (85.0%) | 113 (59.2%) | |
| Number of HIV+ patients in practice | |||
| <3 patients | 121 (91.0%) | 132 (68.0%) | <.001 |
| ≥3 patients | 12 (9.0%) | 62 (32.0%) | |
| Number of AIDS patients in practice | |||
| <3 patients | 128 (96.2%) | 165 (85.1%) | .001 |
| ≥3 patients | 5 (3.8%) | 29 (14.9%) | |
| % of patients who engage in high-risk behavior | |||
| 0%—5% | 44 (33.1%) | 44 (23.0%) | .133 |
| 6%—15% | 46 (34.6%) | 78 (40.8%) | |
| >15% | 43 (32.3%) | 69 (36.1%) | |
| HMO, health maintenance organization; CHC, community health center. | |||
| * Total N=369. We removed those physicians who noted “manage alone” because of the small sample size. Each item’s total may not be the total number of respondents due to unanswered questions. Percentages are based on the total number of responders to each question, not the total number of respondents. | |||
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?
| Refer IMMEDIATELY (N=134)* | CO-MANAGE (n=196)* | P VALUE | |
|---|---|---|---|
| Practice type | |||
| Solo practice | 37 (17.7%) | 17 (13.7%) | <.001 |
| Single specialty | 91 (43.5%) | 42 (33.9%) | |
| HMO | 3 (1.4%) | 0 (0.0%) | |
| Multispecialty | 34 (16.3%) | 10 (8.1%) | |
| CHC | 25 (12.0%) | 46 (37.1%) | |
| Hospital-based clinic | 19 (9.1%) | 9 (7.2%) | |
| Teach medical students regularly | |||
| Yes | 92 (43.6%) | 82 (67.2%) | |
| No | 119 (56.4%) | 40 (32.8%) | <.001 |
| Teach residents regularly | |||
| Yes | 40 (19.1%) | 60 (49.2%) | |
| No | 169 (80.9%) | 62 (50.8%) | <.001 |
| Number of HIV+ patients in practice | |||
| <3 patients | 180 (86.1%) | 77 (61.6%) | |
| ≥3 patients | 29 (13.9%) | 48 (38.4%) | <.001 |
| Number of AIDS patients in practice | |||
| <3 patients | 203 (97.1%) | 93 (74.4%) | |
| ≥3 patients | 6 (2.9%) | 32 (25.6%) | <.001 |
| % of patients who engage in high-risk behavior | |||
| 0%—5% | 67 (32.1%) | 21 (17.2%) | |
| 6%—15% | 83 (39.7%) | 49 (40.2%) | |
| >15% | 59 (28.2%) | 52 (42.6%) | .004 |
| HMO, health maintenance organization; CHC, community health center. | |||
| * Total N=369. We removed those physicians who noted “manage alone” because of small sample size. Each item’s total may not be the total number of respondents due to unanswered questions. Percentages are based on the total number of responders to each question, not the total number of respondents. | |||
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
| INDEPENDENT FACTORS | IMEDIATE REFERRALS FOR ASYMPT OMATIC HIV+ PATIENTS (N=297) OR * (95% CI ) | IMEDIATE REFERRALS FOR SYMPT OMATIC HIV+/AIDS PATIENTS (N=302) OR* (95% CI ) |
|---|---|---|
| Gender | ||
| Male | 1.0 | 1.0 |
| Female | 0.505 (0.283–0.901) | 0.311 (0.168–0.576) |
| Practice location: Community health center | ||
| No | 1.0 | ns† |
| Yes | 0.402 (0.178–0.910) | |
| Number of HIV+ patients in practice | ||
| 4-level ordinal variable: | ||
| 1=None; 2=1-2; 3=3-10; 4≥10 | 0.637 (0.440–0.923) | not in model |
| Number of AIDS patients in practice | ||
| 4-level ordinal variable: | ns† | 0.514 (0.343–0.769) |
| 1=None; 2=1-2; 3=3-10; 4≥10 | ||
| Learned about HIV/AIDS care during residency | ||
| No | 1.0 | ns† |
| Yes | 0.476 (0.243–0.930) | |
| Learned about HIV/AIDS care from formal CME programs | ||
| No | 1.0 | 1.0 |
| Yes | 0.468 (0.257–0.851) | 0.375 (0.204–0.691) |
| Participate in teaching medical students regularly | ||
| No | 1.0 | 1.0 |
| Yes | 0.417 (0.238–0.732) | 0.531 (0.281–1.003) |
| Participate in teaching residents regularly | ||
| No | ns† | 1.0 |
| Yes | 0.537 (0.279–1.035) | |
| Feel knowledgeable about HIV care | ||
| No | 1.0 | 1.0 |
| Yes | 0.345 (0.187–0.638) | 0.357 (0.176–0.728) |
| Have no time in my practice to care for HIV/AIDS patients | ||
| No | 1.0 | 1.0 |
| Yes | 2.076 (1.155–3.729) | 4.306 (2.098–8.838) |
| * An OR of 1.0 reflects the referent category within each of the independent factors. | ||
| † ns = not significant in the stepwise regression model. | ||
| OR, odds ratio; CI, confidence interval; CME, continuing medical education. | ||
