PROCAARE: Epidemiology--Physician experience--Seattle USA

[Albert Shaw <ashaw@usa.healthnet.org>]

EPIDEMIOLOGY--PHYSICIAN EXPERIENCE--SEATTLE USA
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Reference: Kitahata, M.M., Koepsell, T.D., Devo, R.A., Maxwell, C.L., 
Dodge, W.T., Wagner, E.H. (1996).  Physicians' experience with the 
acquired immunodeficiency syndrome as a factor in patients' survival.  
New Engl. J. Med. 334: 701-6.

This retrospective study examined over 400 HIV-infected men followed over 
a 10-year period through a staff-model health maintenance organization in 
Seattle, Washington.  Over 100 physicians serving as the patients' 
primary care providers were classified on the basis of their experience 
with the treatment of AIDS.  The physicians were classified as having low 
or high levels of experience during medical school and residency based 
upon the time of their training (e.g. lower experience would be 
associated with training before 1984)  and the cities in which they 
trained (those cities with an incidence of AIDS greater than 15 per 
100,000 were associated with a high amount of experience).  In addition, 
practice-based estimates of AIDS experience were derived depending on the 
total number of patients with AIDS a physician had cared for; low 
experience was defined as one patient, moderate experience 2-5 patients, 
and high experience greater than 5 patients.

During the ten years of the study, 39% of the physicians followed only 
one patient with AIDS, 42% were in the moderate experience group, and 19% 
had the highest experience.  Patient survival correlated with physician 
experience, with median survivals of 14 months for the least experienced 
group, 21 months for the moderate experience group, and 26 months for 
providers with the greatest experience (p<0.001).  These differences 
persisted when controlled for CD4 count, year of AIDS diagnosis, and 
severity of illness.  Experienced physicians were significantly more 
likely to begin P. carinii prophylaxis and to regularly follow CD4 
counts, and showed a trend toward greater use of antiretroviral agents.  
These results indicate that optimal care of patients with AIDS in regions 
with variable levels of physician experience may be achieved through a 
combination of generalist and specialist providers.