AIDS mortality rates lower at sites with HIV experience
What can society, clinicians do to change this?
Not all AIDS patients are treated equally. That fact is a focal point of two recent studies that compared hospitals and other providers in treating HIV-infected populations. The studies underscore the disturbing finding that HIV/AIDS patients are more likely to receive antiretroviral treatment and even survive if they are treated by providers who have more experience with the disease.
"This shines a spotlight on the disparity in the U.S. health care delivery system," says Daniel Zingale, executive director of AIDS Action in Washington, DC.
After examining data on more than 7,000 AIDS patients admitted to one of 333 hospitals in California, California researchers concluded that AIDS mortality at hospitals with more experience was 30% less than mortality at the least experienced hospitals. This amounts to four more deaths per 100 patients with AIDS admitted. The study defined experience according to the hospital’s rate of AIDS discharges per 10,000 total discharges.1
In a separate study, published in the Annals of Internal Medicine in June, researchers found that pregnant, HIV-infected women were more likely to receive antiretroviral treatment when they were being treated at a medical center that performed HIV clinical trials or at a state-funded site with HIV services for people on Medicaid.
"If a care site has more experience in HIV care, it’s likely to mean patients will get access to advances in care more rapidly, like the latest antiretroviral therapy or AZT treatment for pregnant women," says Barbara Turner, MD, a professor of medicine at Thomas Jefferson Uni versity and director of health care research at the Center for Research in Medical Education and Health Care in Philadelphia. Thomas led the study of HIV-infected pregnant women.
"We found that women with HIV lived longer if they had providers who treated more HIV patients," Turner says. "Specialists pick up on these advances quicker, and that has something to do with the better survival rate in our study."
Zingale and other AIDS advocates recently have pointed out the disparity in treatment and survival between poor minority HIV patients and middle-class white patients. And while some HIV research has found worse long-term outcomes for the poor and minorities, the California study eliminated these as causal factors.
Public hospitals had higher mortality
The California study, which adjusted data for severity of illness and comorbidity, did not find a higher death rate among women or blacks. Age and insurance status also were not associated with mortality. However, the study did find that public hospitals had significantly higher mortality than did for-profit and nonprofit hospitals.1
Policy-makers need to act on these types of studies and provide more consistent provider education and routine AIDS mortality outcome assessments, and establish mechanisms for regionalization and selective referrals, the California researchers argue.
The California study and similar research focused on the care of AIDS patients in hospitals, because until recent years, that’s where most of these patients were treated, Turner points out. "But now that HIV is a chronic disease with a change in the morbidity and mortality of the infected, we have to conceptualize long-term models of care and think about the payment system," she says.
Turner says state Medicaid programs and private health care insurers need to make changes that address the true time and cost of treating HIV patients.
For instance, physicians who work under capitation arrangements, where they are paid a certain amount each month per patient, cannot afford to care for more than a few HIV-infected patients, Turner says.
"It’s very demanding work," she explains. "I mean, I love, love, love my HIV population because it’s a very close doctor-patient relationship, so the rewards are enormous." But any doctor would be unwise to take on more than a few HIV patients when Medicaid or other payers are giving them a small set fee per month for each patient, she adds.
HIV patients might receive a better continuum of care from a clinic where both primary care physicians and specialists will see them. Also, clinics have greater financial resources to care for an expensive ambulatory care disease like HIV, Turner says.
However, problems arise when patients are forced to limit their treatment options because their insurance or Medicaid coverage will only cover certain providers. Some models may limit HIV patients to specialists, and others may make them see a family practitioner, who acts as an HMO "gatekeeper," before they can receive help from specialists. Neither type of system works unless the patient’s care is coordinated and part of a continuum, Turner says.
Plus, private practice physicians rarely can find time to keep up with all of the medical advances related to HIV. Even HIV researchers like Turner no longer solely handle this population.
"I’ve given up on keeping up with HIV in my primary care practice, where I have more than your average number of HIV patients," Turner says. "I share every single HIV patient with a specialist."
However, she notes that it’s important for specialists to keep primary care physicians in the treatment loop because HIV patients have such a wide array of health issues that a collaborative effort is necessary to provide adequate treatment.
Specialists might focus exclusively on suppressing the virus, while a primary care physician also will treat the patient’s drug side effects, such as high cholesterol and neuropathic pain.
"I have patients who already were diabetic before HIV, and some patients have developed glucose intolerance on the treatments," Turner says. "Diabetes is like bread and butter to me because I see diabetes all the time, but I don’t think infectious disease doctors do."
Reference
1. Cunningham WE, Tisnado DM, Lui HH, et al. The effect of hospital experience on mortality among patients hospitalized with acquired immunodeficiency syndrome in California. Am J Med 1999; 107:143.
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