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Primary care physicians often fail to recognize important
signs of HIV infection
Practicing primary care physicians may miss important signs of
infection with the human immunodeficiency virus (HIV) during
patient examinations, according to a study supported by the
Agency for Health Care Policy and Research (HS06454). Even when
directed by the patient to sites of symptoms typical of HIV
disease, only about 25 percent of primary care physicians both
detected the abnormality and correctly diagnosed the condition.
Prior studies have documented inadequate skills associated with
assessment of risk for HIV infection. This is the first published
study of physicians' ability to identify physical findings
associated with HIV infection.
In this study, only about 26 percent of physicians evaluating a
patient with Kaposi's sarcoma (KS)—with classic raised,
reddish-purple KS lesions and associated pain—were able to
detect and correctly diagnose the KS. KS is a rare tumor in
individuals not infected with HIV and the most common tumor in
patients who are HIV-positive. Less than 23 percent of physicians
evaluating a patient with oral hairy leukoplakia (OHL), with sore
throat and white spots on the tongue, detected the spots and
correctly diagnosed the OHL, which is strongly associated with
HIV infection. Finally, only 17 percent of physicians detected
diffuse lymph-adenopathy in a patient complaining of fatigue,
fever, and joint pain. Although associated with many diseases,
diffuse lymphadenopathy is a common finding in HIV-positive
Physician deficiencies in HIV-related physical diagnosis skills
did not appear to be associated with year of graduation from
medical school or type of residency training, suggesting the need
for additional educational interventions to improve these skills.
Such oversights are a concern, especially when one considers that
preventable serious infections and premature deaths occur in
individuals with undiagnosed HIV infection, according to
researchers at the University of Washington School of Medicine,
The investigators assessed the ability of 134 primary care
physicians (general internists and family practitioners) to
identify these three symptoms of HIV infection during examination
of a standardized patient (SP). SPs are individuals with
prominent physical findings who are trained to enact a specific
case presentation and to evaluate physicians' performance.
Details are in "Ability of primary care physicians to recognize
physical findings associated with HIV infection," by Douglas S.
Paauw, M.D., Marjorie D. Wenrich, M.P.H., J. Randall Curtis,
M.D., M.P.H., and others, in the November 1, 1995 Journal of
the American Medical Association 274(17), pp. 1380-1382.
Even when health status is very poor, most AIDS patients
want to be revived if their hearts stop
For persons with acquired immunodeficiency syndrome (AIDS),
current health status does not necessarily affect their desire to
be revived if their hearts stop, according to a study supported
by the Agency for Health Care Policy and Research (HS06239).
About 65 percent of terminally ill AIDS patients in this study,
mostly young homosexual and bisexual men, wanted to be revived if
their hearts stopped. Overall, those who considered themselves to
be in the best health were more likely to want to be revived.
However, over half of those who considered their health to be the
very worst (the lowest quartile) also wanted to be resuscitated.
A key finding was that the relationship between health status and
desire for resuscitation does not hold up for all patients. For
the third of patients who expressed the most reluctance to give
up life, by saying they wanted life extension even if it meant
living in some undesirable state (such as being blind or fed by a
tube), current health status was unrelated to desire for
These results suggest limits to the validity of assessing how a
patient values his or her current health status by asking
questions that involve loss or risk of life, such as "standard
gambles" (for example, what risk the patient is willing to take
of dying in surgery to cure a health problem) and time trade-off
questions (for example, how many years of later life a person is
willing to give up for better life now). A general reluctance to
give up life may confound how patients answer such questions,
notes Arnold Epstein, M.D., of Harvard Medical School. These
findings are based on interviews of 291 patients with AIDS, who
participated in the Boston Health Study during 1990 and 1991.
For more information, see "The role of reluctance to give up life
in the measurement of the values of health states," by Floyd J.
Fowler, Jr., Ph.D., Paul D. Cleary, Ph.D., Michael P. Massagli,
Ph.D., and others, in Medical Decision Making 15(3), pp. 195-200,
Hospitalization costs rise sharply for AIDS patients in the
months prior to death
A high proportion of the total cost for treating acquired
immunodeficiency syndrome (AIDS) is concentrated in the last few
months before patient death. Hospitalization costs rise sharply
during that time, while outpatient costs drop slightly, according
to a recent study. If costly inpatient episodes prior to death
are typical, any cost savings achieved by growing efforts to
expand community-based AIDS care may be minimized, notes John A.
Fleishman, Ph.D., of the Center for Cost and Financing, Agency
for Health Care Policy and Research.
He and Brown University researchers analyzed hospital medical and
billing records for 914 people with AIDS who were receiving
health services in nine cities across the United States in
1990-1991 and whose usual source of care was a hospital clinic.
During the 18-month study period, the number of inpatient
admissions was four times as high for AIDS patients who died, and
the number of inpatient nights was more than six times higher
than those of AIDS patients who did not die, regardless of
patient race, exposure group, community, insurance status, or
As a result, annualized inpatient costs for AIDS patients who
died were seven times greater than costs for patients who did not
die. For example, among 69 decedents for whom four quarters of
billing data were available, quarterly inpatient costs during the
year prior to death were $3,109 (at 1 year prior to death),
$3,511 (at 9 months prior to death), $5,362 (at 6 months prior to
death), and $17,940 (during the last 3 months of life) compared
with the respective costs for 69 nondecedents of $775, $853,
$988, and $1,039. In contrast, mean outpatient costs displayed no
systematic trend over time. Although total terminal AIDS care
costs for whites did not differ from blacks, whites had higher
outpatient use and lower inpatient use than minority patients.
Further details are in "Longitudinal patterns of medical service
use and costs among people with AIDS," by Dr. Fleishman, Vincent
Mor, Ph.D., and Linda L. Laliberte, M.S., J.D., in HSR: Health
Services Research 30(3), pp. 403-424, 1995.
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