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Is Experience With Human Immunodeficiency Virus Disease Related to Clinical Practice?
A Survey of Rural Primary Care Physicians
Cynthia L. Willard, MD;
Petra Liljestrand, PhD;
Ronald H. Goldschmidt, MD;
Kevin Grumbach, MD
Arch Fam Med. 1999;8:502-508.
ABSTRACT
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Background Human immunodeficiency virus (HIV) disease is spreading to the rural United States, and medical care is increasingly provided by local primary care physicians. A volume-outcome relationship might exist in HIV care. However, little is known about the HIV experience and practices of rural primary care physicians.
Objectives To estimate the HIV experience of rural primary care physicians, and to determine whether experience is associated with use of newer management strategies, confidence in care, and consultation needs.
Design Telephone survey of a random sample of primary care physicians.
Setting Primary care sites in nonmetropolitan California.
Participants One hundred twenty eligible primary care physicians in nonmetropolitan California, with 102 respondents (85.0%).
Main Outcome Measures Physicians' HIV experience, use of protease inhibitors and viral load tests, familiarity with vertical HIV transmission prophylaxis, confidence in HIV care, and consultation needs.
Results Most physicians were low-volume providers of HIV care and had limited knowledge of newer management strategies. Experience with protease inhibitors and viral load tests was significantly related to number of recent patients with HIV; 25.0% of those with 1 to 3 patients but 75.0% of those with 4 or more patients had prescribed protease inhibitors (P = .01), whereas 20.8% of those with 1 to 3 patients but 83.3% of those with 4 or more patients had used a viral load test (P = .001). Only 59.8% of all respondents, but 100.0% of those with 4 or more patients, were familiar with vertical HIV transmission prophylaxis (P = .001). After adjustment for other characteristics, HIV experience remained significantly associated with use of newer management strategies (P = .01) and familiarity with vertical HIV transmission prophylaxis (P = .007). Physicians' confidence in HIV care increased with experience (P = .006), and consultation needs decreased (P = .006).
Conclusions Primary care physicians in rural California lacked in-depth experience with HIV disease. Experience was significantly associated with use of newer HIV management strategies, confidence, and consultation needs. Treating 4 or more patients with HIV or acquired immunodeficiency syndrome may be the threshold above which primary care physicians rapidly adopt new strategies and have confidence in their care.
INTRODUCTION
THE INCIDENCES of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are steadily increasing in rural America.1-3 The magnitude of this increase may be underestimated because, in some rural settings, cases of HIV infection or AIDS have been underreported,4-5 and the migration of HIV-infected persons has not been included in considerations of seroprevalence.6-8 Increasingly, medical care for patients is provided by local primary care physicians,9-10 but limited information exists on the nature of these services. A recent study of primary care physicians in rural California reported that two thirds of respondents had treated an HIV-infected patient by 1995.11 However, the depth of rural physicians' experience with HIV disease remains unknown, raising concern about the quality of care received by patients in rural areas.
This issue is particularly relevant in light of several studies examining the competency of primary care physicians in treatment of HIV disease and the relationship between provider experience and patient outcome. Some reports suggest that primary care physicians have deficiencies in their ability to recognize certain HIV-related conditions (such as oral hairy leukoplakia and Kaposi sarcoma)12 and to diagnose and treat Pneumocystis carinii pneumonia (PCP) properly.13 Since the emergence of HIV, debate has continued over who should treat infected persons. Recently, the focus has shifted away from specialty qualifications and toward provider experience as the key factor.14-16 Several studies have shown a relationship of volume to outcome in the treatment of persons with HIV or AIDS, and this may be particularly relevant in rural areas if patients are treated by physicians with low-volume HIV practices. Inpatient mortality rates for patients with AIDS were lower at hospitals with more AIDS experience17-18; women with advanced AIDS survived longer if they received care at clinics with more HIV experience19; and a study showed that patients with AIDS being treated by more experienced primary care physicians lived longer.20 (In this study, patients of the most experienced generalists had median survival times similar to the longest reported in other clinical studies.21-22) The relationship between provider HIV experience and outcome may be the result of differing management strategies among more experienced physicians. In some reports, physicians with HIV experience began antiretroviral (ARV) therapy earlier in disease23 and used PCP prophylaxis, ARV therapy, and laboratory tests more frequently.20 However, little is known about other aspects of the volume-outcome relationship in HIV disease.
Although some studies have estimated rural providers' contact with patients with HIV, specific information regarding the provision of HIV-related health services in rural areas remains sparse.24 There are no assessments on the depth of HIV experience among rural physicians. In addition, there are no data on differences in self-assessment and practice patterns between low-volume and higher-volume HIV providers. Specifically, it is not known whether there is an association between physicians' experience with HIV and their self-confidence, their consultation needs, and the degree to which they used certain HIV management strategies. Better understanding of these issues is necessary for the development of strategies to enhance the quality of HIV care, particularly in rural areas where providers with low-volume HIV practices may be the only option.
We conducted a study to investigate the depth of HIV experience and approaches to HIV care in a sample of rural primary care physicians. In addition, we sought to determine how physicians' management, confidence, and consultation needs in HIV care are associated with their volume of patients with HIV.
SUBJECTS AND METHODS
We conducted a telephone survey of adult primary care physicians practicing in rural California. A random sample of general internists, family physicians, and general practitioners in office-based practice in nonmetropolitan counties of California was obtained from the American Medical Association Masterfile. The Masterfile includes physicians who are not members of the American Medical Association. The study protocol was approved by the University of California–San Francisco Human Subjects Committee.
Participants initially were mailed a letter describing the telephone survey in the fall of 1996. All interviews were conducted by one of us (C.L.W.) from November 2, 1996, to February 23, 1997. We attempted to contact nonresponders by telephone up to 6 times. Physicians were excluded from the survey if they were not in primary care practice in a nonmetropolitan county of California or if they were retired, on leave, or relocated.
MEASURES
The survey instrument contained 33 items covering 8 domains. This report focuses on the following 5 domains: (1) demographics, (2) HIV experience, (3) HIV practices and knowledge, (4) self-confidence in ability to provide HIV care, and (5) consultation needs.
Respondents reported the total number of patients with HIV treated since completing residency training and in the previous 6 months. They rated their confidence levels on a 4-point scale for several HIV-related areas, including use of ARV therapy and treatment of asymptomatic patients, symptomatic patients, and patients with AIDS. They were asked to rate their consultation needs on a 4-point scale for several HIV-related areas, including basic knowledge of the disease, treatment of HIV patients and HIV management recommendations, differential diagnosis, and interpretation of laboratory tests in patients with HIV.
To learn more about rural physicians' adoption of recent developments in HIV care, we asked respondents about their familiarity with and use of selected management strategies, including prescribing protease inhibitor drugs, use of plasma HIV RNA levels (viral load tests), and knowledge of prophylaxis for vertical (maternal-child) HIV transmission. Respondents who had treated patients with HIV in the past 6 months were asked whether they had used a viral load test or prescribed a protease inhibitor in their practice. These strategies were recommended in a consensus statement by an international panel of clinical investigators in July 1996,25 although viral load tests and protease inhibitors were used increasingly before this time. At the time of our survey, it was unknown whether the reductions in HIV viral load achieved with combination ARV therapy would translate into clinical benefits. Nonetheless, we considered reported use of protease inhibitors and viral load tests by our respondents to be useful indicators of their adoption of newer management strategies in HIV care. Clinical trials subsequently have demonstrated a significant decrease in morbidity and mortality in patients receiving protease inhibitors.26-27 Reduction of vertical HIV transmission with zidovudine was reported in 1994 as a result of the AIDS Clinical Trials Group 076 Study.28 Respondents were asked if they were familiar with the practice of giving zidovudine to HIV-infected pregnant women to prevent transmission. They were not asked for specific information regarding their use of this strategy, as we sought to determine only their awareness of the existence of this protocol.
DATA ANALYSIS
The analysis consisted of descriptive statistics, including proportions, means, and variance. For a portion of the analysis, the primary variables of interest were the cumulative number of patients with HIV cared for since training and in the previous 6 months. The sample was divided into 5 groups by the number of patients with HIV treated since completion of training, ie, 0, 1 to 3, 4 to 10, 11 to 25, and 26 or more. For experience in the previous 6 months, the sample was divided into the following 3 groups: 0, 1 to 3, and 4 or more patients. Pearson  2 and Fisher exact tests were used to examine whether physicians with different experience levels varied in several domains, including use of protease inhibitors and viral load tests and knowledge of vertical transmission prophylaxis. Analysis of variance was used to determine the significance of the differences noted in mean number of patients with HIV treated according to different physician characteristics and in the mean confidence and consultation ratings for physicians according to experience levels. Univariate and multivariate logistic regression analyses were performed to identify the physician characteristics associated with reported use of protease inhibitors and viral load tests and familiarity with vertical transmission prophylaxis. A 2-sided P value of less than .05 was considered statistically significant. All analyses were performed using commercially available computer software (SPSS; SPSS Inc, Chicago, Ill).
RESULTS
PHYSICIAN CHARACTERISTICS
One hundred seventy-eight physicians constituted the initial sample. Of these, 58 were ineligible because they had retired (n = 8) or relocated (n = 5), were not listed in the telephone directory (n = 29), were on leave (n = 6), or were not in primary care practice (n = 10). Interviews were conducted with 102 of the remaining 120 eligible physicians (85.0% response rate). Twenty-three nonmetropolitan counties in California were represented.
Respondents were predominantly male, white, and in private, solo practice (Table 1). Most were in family practice (52.9%), with the remainder in general internal medicine (29.4%) and general practice (17.6%). Physicians provided a wide range of services, including inpatient care, prenatal care, birthing services, outpatient gynecology, care of children, and assisting in surgery. Approximately 60% had been in practice 17 or more years.
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Table 1. Characteristics of 102 Study Physicians
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HIV CARE EXPERIENCE
The following tabulation shows the respondents' reports of HIV training in residency and their estimates of the number of HIV-infected persons cared for since completing residency training and in the previous 6 months:
Of the 35.3% who had treated a patient with HIV in the previous 6 months, one third had treated 4 or more patients, suggesting a concentration of HIV primary care among these higher-volume providers. Conversations with respondents reinforced this finding. One physician from Northern California remarked:
There is a primary care group that has become focused on HIV . . . I'm not prejudiced, I just feel they [the patients] need the best care and I'm not up-to-date. There is better service across town. A few years ago a group of primary care docs got together and decided to get up-to-date. They went to conferences, read journals, had meetings with specialists. Now they see all the AIDS patients in the area.
Another physician reiterated this concentration of care: "[We] are all like HIV referral doctors. We sort of unofficially started seeing a lot of HIV, now people refer to us."
Those who received HIV training in residency had cared for greater numbers of patients with HIV in the previous 6 months (mean, 2.4 vs 0.9 patients) and since residency training (mean, 11.7 vs 8.1 patients), but these differences were not statistically significant.
Although most physicians reported experience managing common conditions in HIV disease (ie, fever [88.6%], weight loss [85.2%], rash [76.1%], diarrhea [73.9%], and PCP [73.9%]), fewer had managed the more complicated conditions associated with AIDS, ie, cytomegalovirus disease (31.8%), Mycobacterium avium complex disease (31.8%), and cryptococcal disease (22.7%). As would be expected, physicians who had cared for greater numbers of patients with HIV had managed significantly more complicated AIDS-related illnesses (P = .006; data not shown).
EXPERIENCE WITH AND KNOWLEDGE OF RECENT HIV DEVELOPMENTS
Physicians with more HIV experience were more likely to report use of protease inhibitors and viral load tests and familiarity with vertical transmission prophylaxis. As shown in Table 2, use of protease inhibitors and viral load tests was significantly related to the number of patients with HIV recently treated; 75.0% of those with 4 or more patients in the past 6 months, but only 25.0% of those with 1 to 3 patients, reported prescribing a protease inhibitor (P = .01). Respondents prescribing protease inhibitors had cared for a greater number of patients with HIV in the previous 6 months (mean, 6.1 vs 2.2 patients; P = .02) and since residency (mean, 31.1 vs 14.1 patients; P = .07). Of those with 4 or more patients, 83.3% compared with 20.8% of those with 1 to 3 patients reported using a viral load test (P = .001). Those respondents who had used viral load tests had cared for a greater number of patients with HIV in the previous 6 months (mean, 6.5 vs 2.1 patients; P = .01) and since residency (mean, 28.2 vs 13.8 patients; P = .02). Of all respondents, 59.8% reported familiarity with vertical transmission prophylaxis; 76.5% of those respondents who provide prenatal care and 88.5% of those who provide birthing services were familiar with the protocol. Among all respondents, knowledge of this strategy was significantly related to their volume of recent patients with HIV (Table 2).
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Table 2. Management Strategies, Knowledge, and Training of 102 Physicians According to Their HIV Experience*
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On both crude and adjusted analysis, the number of patients with HIV recently treated was the physician characteristic most strongly associated with familiarity with newer management strategies in HIV treatment. On crude analysis, only 2 physician characteristics were significantly associated with use of protease inhibitors and viral load tests, treatment of 4 or more patients with HIV in the previous 6 months (P = .01 and P = .002, respectively) and being in solo practice (P = .05 and P = .05, respectively). Other characteristics, including sex, specialty, HIV training in residency, provision of birthing services, and being in practice less than 17 years, were not significantly associated with use of protease inhibitors or viral load tests (data not shown). In logistic regression models that included experience and practice size predictor variables, the number of patients with HIV treated was the only significant predictor of use of protease inhibitors (odds ratio [OR], 21; 95% confidence interval [CI], 1.9-227.9; P = .01) and viral load tests (OR, 36.6; 95% CI, 2.4-552.4; P = .009).
Familiarity with vertical transmission prophylaxis was significantly associated with several physician characteristics on crude analysis, including HIV training in residency (P = .008), providing birthing services (P = .003), being in practice less than 17 years (P<.001), HIV experience in the previous 6 months (P = .001), and being in general practice (P = .009) (with those in general practice less likely to be familiar with the strategy than those in family practice or internal medicine). Sex and being in solo practice were not significantly associated with familiarity with the strategy (data not shown). In multivariate analysis, familiarity with vertical transmission prophylaxis was significantly associated with provision of birthing services (OR, 8.5; 95% CI, 1.8-36; P = .004) and HIV experience in the previous 6 months (OR, 8.0; 95% CI, 1.5-15.2; P = .007).
CONFIDENCE
Respondents were asked to rate their confidence with HIV treatment on a 4-point scale (1 indicates not at all confident; 4, very confident). Few respondents were very confident in the following areas of HIV care: ARV use (5.0%), asymptomatic care (18.8%), symptomatic care (8.9%), and AIDS care (4.0%). Mean level of confidence was significantly related to numbers of patients with HIV treated in the previous 6 months (P = .001) (Figure 1) and cumulatively (P = .001), and was higher for all stages of disease among respondents with more experience.
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Figure 1. Respondents' confidence in human immunodeficiency virus (HIV) care in relation to the number of patients with HIV treated in the previous 6 months. AIDS indicates acquired immunodeficiency virus; ARV, antiretroviral therapy. Confidence was rated on a scale of 1 (not at all confident) to 4 (very confident). For all analyses, P<.01, analysis of variance.
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CONSULTATION NEEDS
Respondents were asked to rate their consultation needs on a 4-point scale (1 indicates no need; 4, very high need) in several HIV-related areas of care. Consultation need was inversely related to the numbers of patients with HIV treated in the previous 6 months (P<.001) (Figure 2) and cumulatively (P<.001). Mean consultation scores were significantly higher for those physicians caring for fewer patients with HIV in the previous 6 months and cumulatively (P = .006). However, even physicians with the most HIV experience reported a moderate need for consultation in all areas of HIV care.
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Figure 2. Reported consultation needs in relation to the number of patients with human immunodeficiency virus (HIV) treated in the previous 6 months. Consultation need was rated on a scale of 1 (no need) to 4 (very high need). For all analyses, P<.01, analysis of variance.
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COMMENT
Our study provides important information on rural HIV practice and further evidence that the number of patients with HIV or AIDS treated by a physician is a key factor in HIV care. We show for the first time that the volume of patients treated is associated with physicians' self-reported confidence and consultation needs.
Although most (82.4%) respondents had provided HIV care, most lacked in-depth experience. Those who had treated 4 or more patients with HIV in the previous 6 months reported a significantly greater use of newer management strategies as well as greater confidence in their HIV care than those who had treated 3 or fewer patients with HIV. Only a quarter of those with 3 or fewer patients with HIV in the previous 6 months had prescribed protease inhibitors or used viral load tests, compared with three quarters of those with 4 or more patients in the previous 6 months. Although this study was begun when these advances in care were relatively new, the differences between the groups were striking. Moreover, levels of self-confidence parallel these findings. Those physicians caring for 3 or fewer patients with HIV in the previous 6 months showed little confidence in their HIV skills, whereas those with 4 or more patients reported a reasonable level of confidence.
Physicians' experience with HIV was also the factor most closely associated with knowledge of prophylaxis to prevent vertical HIV transmission. Although this strategy has been recommended widely since 1994, only 59.8% of all respondents were familiar with it. It is reassuring that most physicians (88.5%) providing birthing services and 100.0% of those with 4 or more patients with HIV in the previous 6 months were familiar with the protocol.
Consultation needs were high for both groups. Although low-volume providers of HIV care were less confident in their HIV skills and reported higher consultation needs, even higher-volume providers expressed moderate consultation needs. Low-volume providers readily acknowledged their limitations, which may make them amenable to seeking consultation and continuing education in the care of patients with HIV. It is unclear how accessible these resources are in rural areas,29-30 and we did not evaluate referral pattern differences between high- and low-volume providers.
Several physicians described an informal movement to concentrate HIV care among those primary care physicians with more experience. Our data confirmed this pattern, as there were 7 respondents (6.9%) who had cared for more than 25 patients with HIV each. This concentration could ensure quality HIV care in areas without HIV specialists. More information is needed on how adopting the identity of "AIDS physician" may have an impact on rural practices with regard to stigmatization, confidentiality, and other issues.
This study has several strengths. Through the telephone survey format, we obtained qualitative and quantitative data, and the response rate of 85.0% was better than those of other telephone surveys of physicians in clinical practice.11, 31 Since the interviewer was a primary care physician, we believe we were able to obtain frank and insightful information from respondents. This method allowed us to estimate, to our knowledge for the first time, the association between volume of patients with HIV and physicians' perceptions of their skills.
Several limitations of this study should be noted. The findings depend on the veracity of physicians' reports. We did not measure physicians' actual practice patterns, referral patterns, or patient outcomes. Although we found an association between HIV provider experience and reported competency, a causal relationship cannot be determined from this study. Respondents with more patients with HIV may have reported a higher use of protease inhibitors because a larger pool of patients would increase the opportunity to prescribe protease inhibitors. However, a similar pattern was found for use of viral load tests, which are recommended in the management of all patients with HIV disease. In addition, a portion of the initial sample was excluded because we were unable to reach them (unlisted numbers or disconnected telephone service). Reasons for this could be retirement or relocation. A subset of the latter group may have been eligible if they had remained in practice in a nonmetropolitan county. If these physicians differed from the sample with regard to HIV experience and care, this may have biased our study.
We did not compare the rural physician sample to an urban counterpart and cannot say if the relationship of HIV provider experience to self-confidence and consultation needs would be similar in an urban sample. The association of experience with clinical practice has been described in another study of urban primary care physicians.20 This relationship may be specific to HIV disease. Research in other areas of medicine has shown that hospitals treating a higher volume of patients have better outcomes for some surgical procedures and medical conditions.32-34 Selective referral, or patients seeking care from high-quality hospitals or providers, might account for this association, or greater familiarity with a particular disease may lead to more effective treatment and better outcomes, ie, practice makes perfect.35 However, other studies have not demonstrated a relationship between physician experience and diagnostic performance.36-37
THESE FINDINGS have several implications for the organization of HIV care in rural areas. Although many primary care physicians in rural California have treated patients with HIV, most are low-volume providers of HIV care. Should low-volume providers treat HIV-infected patients, and if so, how can their educational and consultation needs be met? A recent Health and Human Services panel on treatment guidelines for HIV infection acknowledged the growing complexity of treatment, and advised that treatment of patients with HIV should be directed by a physician with extensive HIV experience when possible.38 Our study indicates this might not be occurring regularly. Although it is not known what minimal level of experience is acceptable, these data suggest that caring for 4 or more patients with HIV during the previous 6 months is associated with greater confidence in HIV skills, lower reported consultation needs, and greater familiarity with newer management strategies. However, the opportunity for physicians to gain a critical level of experience may not exist in rural areas, and patients may not have the option to seek care from an expert unless they are able to travel great distances. A recent survey of patients with HIV in rural Kentucky showed that many traveled an average of 2 hours to urban areas for health care, in part because of concerns about the HIV competency of local physicians.39 The concentration of HIV care among a subgroup of rural primary care physicians with an interest in HIV and AIDS already occurs to some degree in California, and represents a way of creating higher-volume providers of HIV treatment in these areas.
It is essential that all providers of HIV treatment have effective educational support and consultation, especially those with low loads of patients with HIV. With fewer than 4 patients, there are indications that care might be suboptimal. Physicians in this category acknowledge a lack of confidence and should be amenable to seeking assistance from others more experienced in HIV care. This support can be through the usual consultation routes, universities, managed care groups, and from the Health Resources and Services Administration AIDS Education and Training Centers. In addition, telephone consultation is available through the Health Resources and Services Administration AIDS Education and Training Centers National HIV telephone consultation service (also known as the Warmline, at [800] 933-3413). Internet information and consultation can be helpful, but have yet to reach their clinical potential.
Primary care physicians in rural areas are to be commended for their willingness to care for patients with a complex and evolving disease such as HIV. Most rural primary care physicians in California have cared for patients with HIV or AIDS, but there are few experienced providers of HIV care among them. Although HIV experience was significantly related to use of newer management strategies among our respondents, the critical experience level appears to be relatively low. Recent treatment of 4 or more patients with HIV or AIDS may be the threshold above which primary care physicians rapidly adopt new strategies and have confidence in their care. Our study is consistent with other research findings20 demonstrating this relation of experience to clinical practice. Future efforts should focus on how best to meet the education and consultation needs of low-volume providers of HIV care in rural areas. In addition, more information is needed on referral patterns and possible barriers to consultation.
AUTHOR INFORMATION
Accepted for publication October 22, 1998.
This work was supported in part by grant PE00118-04 from the Pacific AIDS Education and Training Center, San Francisco, Calif, with the Bureau of Health Professions, Health Resources and Services Administration, US Department of Health and Human Services, Rockville, Md; and by the University of California–San Francisco Family Practice Residency Program at San Francisco General Hospital, San Francisco.
Presented in part at the American Public Health Association Annual Meeting, Indianapolis, Ind, November 13, 1997.
Reprints: Cynthia L. Willard, MD, 168 North L St, Salt Lake City, UT 84103 (e-mail: cynthiawillard{at}hotmail.com).
From the Department of Family and Community Medicine, San Francisco General Hospital Family Practice Residency Program (Drs Willard, Goldschmidt, and Grumbach) and the Community Provider AIDS Training Project (Drs Liljestrand and Goldschmidt), and the Primary Care Research Center (Dr Grumbach), University of California–San Francisco. Dr Willard is now with the Community Health Foundation of East Los Angeles, Los Angeles, Calif.
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