The HIV Workforce in New York State: Does Patient Volume Correlate with Quality?

BACKGROUND: Knowledge of care practices among clinicians who annually treat <20 human immunodeficiency virus (HIV)-positive patients with antiretroviral therapy (ART) is insufficient, despite their number, which is likely to increase given shifting healthcare policies. We analyze the practices, distribution and quality of care provided by low-volume prescribers (LVPs) based on available data sources in New York State. METHODS: We communicated with 1278 (66%) of the LVPs identified through a statewide claims database to determine the circumstances under which they prescribed ART in federal fiscal year 2009. We reviewed patient records from 84 LVPs who prescribed ART routinely and compared their performance with that of experienced clinicians practicing in established HIV programs. RESULTS: Of the surveyed LVPs, 368 (29%) provided routine ambulatory care for 2323 persons living with HIV/AIDS, and 910 LVPs cited other reasons for prescribing ART. Although the majority of LVPs (73%) practiced in New York City, patients living upstate were more likely to be cared for by a LVP (odds ratio, 1.7; 95% confidence interval, 1.4-1.9). Scores for basic HIV performance measures, including viral suppression, were significantly higher in established HIV programs than for providers who wrote prescriptions for <20 persons living with HIV/AIDS (P < .01). We estimate that 33% of New York State clinicians who provide ambulatory HIV care are LVPs. CONCLUSIONS: Our findings suggest that the quality of care associated with providers who prescribe ART for <20 patients is lower than that provided by more experienced providers. Access to experienced providers as defined by patient volume is an important determinant of delivering high-quality care and should guide HIV workforce policy decisions.

Social marketing self-esteem: a socio-medical approach to high-risk and skin tone alteration activities.

This paper proposes social marketing as a tool to build individual self-esteem and thus prevent the uptake of activities that pose risk to health. Evidence supporting this approach can be drawn from pioneer social marketing campaigns of the last 30 years that successfully addressed the prevention, treatment and stigmatization of skin cancer and leprosy with a fraction of the communication and media tools available today. Focusing primarily on the practices of skin tanning and lightening, this paper builds on studies that validate the ties between self-esteem and behavior, and addresses popular conceptions of skin color as drivers for individual behavior.