Primary care for patients infected with human immunodeficiency virus: a randomized controlled trial

Abstract

Objective: To measure the impact of a teaching intervention and to compare process and outcomes of care for HIV-infected patients randomly assigned to a general medicine clinic (GMC) or an infectious disease clinic (IDC) for primary care.

Design: Prospective, randomized, controlled trial.

Setting: University hospital in Durham, NC.

Patients: Two hundred fourteen consecutive HIV-infected patients presenting for primary care.

Intervention: Physicians at the GMC received HIV-related training and evidence-based practice guidelines.

Measurements: Utilization of services, health-related quality of life, preventive and screening measures, and antiretroviral use for one year.

Results: At baseline GMC patients were more likely to be African American (85% vs 71%; P =.03) and had lower baseline CD4+ cell counts than IDC patients (262 +/- 269 vs 329 +/- 275; P =.05). A similar and high proportion of patients in both groups received appropriate preventive care services including Pneumocystis carinii pneumonia (PCP) prophylaxis, pneumococcal vaccination, and antiretroviral therapy. Screening for TB was more frequent in GMC (89% vs 68%; P =.001). In the year following randomization, GMC patients made more visits to the emergency department than IDC patients (1.6 +/- 3.0 vs 0.7 +/- 1.5; P =.05). Hospital use was higher for GMC patients with average length of stay 7.8 +/- 6.3 days compared to 5.7 +/- 3.8 days for IDC patients (P =.01). In analyses, which adjust for potential baseline imbalances, these differences remained.

Conclusions: Targeted education in GMC achieved similar provision of primary care for GMC patients, yet use of health care services was higher for this group. The delivery of adequate primary care is necessary but not sufficient to produce changes in health care utilization.

Figure 1

Randomization and patient follow-up.

Figure 2

Number of patients followed per physician during the study period. Bars show the percentage of physicians who followed 1 study patient, 2–5 study patients, or >5 study patients. The color indicates level of training. The first 3 bars represent within-study experience of the physicians in GMC and the final 3 bars represent within-study experience of the physicians in IDC.

Figure 3

Antiretroviral use. The time periods represent 4 nonoverlapping time periods approximately representing the 4 years of the study. Because we completed follow-up in February of 1998, the fourth time period is less than 1 year. The average number of antiretrovirals is reported for any patient followed during that time; therefore, patients may be included in more than 1 time period. The proportion of patients on at least 1 antiretroviral during each of the study years is also reported.