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.
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
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
