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.

Choice of spirometric reference values for compensation assessment.

BACKGROUND AND OBJECTIVE: Two sets of local reference values are available for spirometry in Hong Kong, but it is uncertain how well they work in the assessment of occupational lung diseases. This study examined their relative performance in the compensational assessment of silicosis. METHODS: Local reference values published in 1982 and 2006 were compared in two different populations comprising normal construction/quarry workers and silicosis patients. Only men aged 20-74 years were included. RESULTS: The FVC results of 93 normal workers were significantly higher than those predicted by either the 1982 or the 2006 reference values. Compared with the 1982 reference values, the mean FEV(1)% or FVC% was age-dependent and 5.2% higher in the normal workers. Smoking decreased the forced expiratory ratio, but did not show a major effect on FEV(1) or FVC among asymptomatic subjects. Despite their derivation largely from never-smokers, the 2006 reference values better predicted FEV(1) and FVC among all smoking categories. Among the 357 silicosis patients, the 1982 reference values also gave 8.8% higher FEV(1)% and 7.4% higher FVC%. These spirometric values differed by more than 10% in patients aged 60 years or more. Despite the presence of disease, the mean FVC% was still significantly above 100%. CONCLUSIONS: Both the 1982 and 2006 local reference values underestimated the FVC of normal construction and quarry workers, reflecting possible occupational selection factors. The 2006 reference values outperformed the 1982 ones, especially among older subjects. Careful calibration with similar occupational groups in the same laboratory is highly desirable in the choice of spirometric reference values for compensation assessment. Smoking does not appear to affect this choice.

Integrating multiple programme and policy approaches to hepatitis C prevention and care for injection drug users: a comprehensive approach.

BACKGROUND: New York State is home to an estimated 230,000 individuals chronically infected with hepatitis C virus (HCV) and roughly 171,500 active injection drug users (IDUs). HCV/HIV co-infection is common and models of service delivery that effectively meet IDUs' needs are required. A HCV strategic plan has stressed integration. METHODS: HCV prevention and care are integrated within health and human service settings, including HIV/AIDS organisations and drug treatment programmes. Other measures that support comprehensive HCV services for IDUs include reimbursement, clinical guidelines, training and HCV prevention education. Community and provider collaborations inform programme and policy development. RESULTS: IDUs access 5 million syringes annually through harm reduction/syringe exchange programmes (SEPs) and a statewide syringe access programme. Declines in HCV prevalence amongst IDUs in New York City coincided with improved syringe availability. New models of care successfully link IDUs at SEPs and in drug treatment to health care. Over 7000 Medicaid recipients with HCV/HIV co-infection had health care encounters related to their HCV in a 12-month period and 10,547 claims for HCV-related medications were paid. The success rate of transitional case management referrals to drug treatment is over 90%. Training and clinical guidelines promote provider knowledge about HCV and contribute to quality HCV care for IDUs. Chart reviews of 2570 patients with HIV in 2004 documented HCV status 97.4% of the time, overall, in various settings. New HCV surveillance systems are operational. Despite this progress, significant challenges remain. DISCUSSION: A comprehensive, public health approach, using multiple strategies across systems and mobilizing multiple sectors, can enhance IDUs access to HCV prevention and care. A holisitic approach with integrated services, including for HCV-HIV co-infected IDUs is needed. Leadership, collaboration and resources are essential.