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HCSUS studies examine the impact of rural location, insurance, and physician expertise on HIV/AIDS care

Rural location, insurance status, and physician experience all influence the quality of care for people infected with the human immunodeficiency virus (HIV) that causes AIDS, according to three new studies that analyzed data from the 1996 HIV Cost and Services Utilization Study (HCSUS), a nationally representative sample of adults receiving HIV care in the United States. HCSUS studies are led by RAND researchers, Martin F. Shapiro, M.D., Ph.D., and Samuel A. Bozzette M.D., Ph.D., and supported by a cooperative agreement between RAND and the Agency for Healthcare Research and Quality (HS08578).

The first study found ongoing disparities between rural and urban areas in access to high-quality HIV care. The second study demonstrated that HIV-infected people with health maintenance organization (HMO) or public insurance are less likely than those with private non-HMO insurance to get care for HIV symptoms. The third study concluded that doctors' expertise in HIV/AIDS care is more strongly associated with HIV caseload (experience) than formal HIV/AIDS specialty training. The studies are summarized here.

Cohn, S.E., Berk, M.L., Berry, S.H., and others. (2001, December). "The care of HIV-infected adults in rural areas of the United States." Journal of Acquired Immune Deficiency Syndromes 28, pp. 385-392.

The growing number of rural people infected with HIV is challenging already overburdened rural health care systems that have too few doctors, underdeveloped social and home care support systems, and long travel distances to care. In fact, there are ongoing disparities between urban and rural areas in access to high-quality HIV care, concludes this study. For example, about 6 percent of all AIDS cases were from rural counties by the end of 1997, but only 1.4 percent of adults—or less than one-fourth of HIV patients living in rural counties—received HIV care in rural areas during the first 6 months of 1996.

Rural care patients were more likely than urban care patients to be seen by providers with little experience caring for HIV-infected patients (38 vs. 3 percent saw providers who had cared for fewer than 10 HIV-infected patients during the 6-month sampling period). Also, only 22 percent of rural care patients saw providers who had cared for 50 or more HIV-infected patients in the prior 6 months versus 85 percent of urban care patients who saw doctors who had cared for 50 or more patients in the prior 2 months.

Furthermore, rural care patients were less likely than urban care patients to have taken highly active antiretroviral therapy (HAART, 57 vs. 73 percent), which has been proven to prolong life, or medication to prevent a potentially fatal infection that often strikes HIV patients with advanced HIV disease, Pneumocystis carinii pneumonia (60 vs. 75 percent). After controlling for disease severity and other factors, urban care patients had three times the odds of receiving HAART of rural care patients. These findings are based on interviews with 367 HIV-infected adults receiving health care in rural areas and 2,806 HIV-infected adults receiving health care in urban areas of the United States in 1996, shortly after introduction of HAART.

Kilbourne, A.M., Andersen, R.M., Asch, S., and others. (2002, March). "Response to symptoms among a U.S. national probability sample of adults infected with human immunodeficiency virus." Medical Care Research and Review 59(1), pp. 36-58.

Studies have shown that vulnerable groups of HIV-infected patients—such as minorities, women, and those with low education—typically receive less HIV care than others. However, these studies did not take into account the individual's specific clinical need for health care, such as care for serious HIV-related symptoms. This study found that 68 percent of HIV-infected patients received care for their most troublesome HIV-related symptom. Surprisingly, women, minorities, and the less educated were no more likely to go without HIV symptom care than other groups.

However, the insurance status of these vulnerable patients did affect their HIV symptom care. Those without health insurance were half as likely as those with private-non-health maintenance organization (HMO) insurance to obtain symptom care. Those with private HMO, Medicare, or Medicaid insurance also were far less likely to receive symptom care than those with non-HMO private insurance.

HIV-related symptoms often signal disease progression, and lack of treatment for them can lead to subsequent medical complications and costly emergency room or hospital care, note the researchers. They used HCSUS data to determine the likelihood of receiving care for a person's most bothersome HIV-related symptom (headache, cough, weight loss, or diarrhea) within the past 6 months. They examined the impact of sociodemographics, insurance status, coexisting psychiatric problems (mood disorder and drug dependence), and symptom severity on HIV symptom care.

Landon, B.E., Wilson, I.B., Wenger, N.S., and others. (2002, January). "Specialty training and specialization among physicians who treat HIV/AIDS in the United States." Journal of General Internal Medicine 17, pp. 12-22.

Doctors' expertise in HIV/AIDS care is more strongly associated with their HIV caseload than with formal HIV/AIDS specialty training, according to these researchers. They found that primary care doctors were able to develop HIV expertise similar to that of doctors with infectious disease (ID) specialty training if they had a substantial case load and made an effort to stay current on the topic by attending conferences, reading medical journals, and the like. The researchers analyzed HCSUS data on physicians' specialty training and HIV caseload, scores on an HIV-specific knowledge test, referral patterns, and attendance rates at HIV-related educational activities.

Of the 379 doctors caring for HIV patients who completed the survey, 40 percent had ID training, and 56 percent were generalists; 4 percent of ID-trained and 37 percent of generalist physicians did not consider themselves HIV experts. ID experts had a median current HIV caseload of 150 patients, and generalist experts had a median caseload of 200 patients, compared with 5 for non-expert generalists. Mean scores on the knowledge scale were similar for ID and generalist experts (9 vs. 8.5 items correct out of 11) and lower for generalist non-experts (6.5 items correct). In models that included specialty training and caseload, doctors with caseloads of 20 to 49 patients were nearly three times as likely and those with more than 50 patients were nearly six times as likely to have a high knowledge score (80 percent or more correct) as those who saw fewer patients, and the effect of specialty on knowledge was substantially weakened.

Experts had attended more local and national HIV meetings than non-experts (9.3 vs. 2.7 and 4.0 vs. 2.3, respectively) in the past year. Fewer ID experts ever referred HIV patients to other doctors than generalist experts (13 vs. 27 percent). Similarly, general medicine experts were more likely than ID experts to refer patients for evaluating possible changes in antiretroviral therapy (22 vs. 11 percent) and choosing alternative prophylactic regimens for AIDS-related infections (16 vs. 8 percent).

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