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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 individuals.

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, Seattle.

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 resuscitation.

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, 1995.

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 disease stage.

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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