Ira B. Wilson, MD, MSc; Bruce E. Landon, MD, MBA; Lisa R. Hirschhorn, MD, MPH; Keith McInnes, MS; Lin Ding, PhD; Peter V. Marsden, PhD; Paul D. Cleary, PhD
Acknowledgments: The authors thank Carol Cosenza, MSW, and Patricia Gallagher, PhD, of the Center for Survey Research who assisted with instrument development and survey administration; colleagues at the Health Resources and Services Administration and at the Institute for Healthcare Improvement who participated in and facilitated the Evaluation of Quality Improvement for HIV Care (EQHIV) study; and Joan Lederman, RNC, MSN, and Lois Eldred, DrPH, MPH, for reading and commenting on an earlier draft of this manuscript.
Grant Support: By the Agency for Healthcare Research and Quality (grant R-01HS10227) and Lifespan/Tufts/Brown Center for AIDS Research (grant P30A142853).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Ira B. Wilson, MD, MSc, Tufts-New England Medical Center, #345, 750 Washington Street, Boston, MA 02111; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Wilson: Tufts-New England Medical Center, #345, 750 Washington Street, Boston, MA 02111.
Drs. Landon, Ding, and Cleary and Mr. McInnes: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115-5899.
Dr. Hirschhorn: Harvard Medical School, 401 Path Drive, Boston, MA 02110.
Dr. Marsden: Harvard University, 33 Kirkland Street, Cambridge, MA 02138.
Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide.
To compare the quality of care provided by NPs and PAs with that provided by physicians.
68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states.
The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS.
8 quality-of-care measures assessed by medical record review.
After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P < 0.001] and 0.62 [P = 0.025], respectively). Nurse practitioners and PAs had statistically significantly higher performance scores than generalist non–HIV experts on 6 of the 8 quality measures.
These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes.
For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non–HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.
Nurse practitioners (NPs) and physician assistants (PAs) or physicians often deliver primary care to patients with HIV.
Researchers reviewed records of 6651 patients at 68 HIV clinics to compare NPs' and PAs' and physicians' quality of care. Nurse practitioners and PAs and physicians with HIV expertise performed similarly on 6 of 8 guideline-related quality measures, while NPs' and PAs' patients had higher rates of purified protein derivatives and Papanicolaou smears than expert physicians' patients. Nurse practitioners and PAs performed better on 6 of 8 quality measures than generalist physicians without HIV expertise.
Experienced NPs and PAs might provide basic guideline-related care similar to that of physician experts and better than that of physicians without HIV-related expertise.
Diagram of study design.
Table 1. Characteristics of Clinicians Identified as Primary Care HIV Providers
Table 2. Patient Characteristics
Table 3. Site Characteristics
Distribution of visits by primary HIV provider type.PNPPA
Table 4. Adjusted Rates of Performance of Different Quality Measures by Clinician Type
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P Dileep Kumar
Port Huron Hospital
November 18, 2005
Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians.
Wilson and colleagues did not make any distinction between nurse practitioners and physician assistants in their report (1) about the quality of HIV care provided by nurse practitioners, physician assistants and physicians. Both groups can have different backgrounds, training experiences and emphasis on practice style that can confound the results of their study. The authors also did not precisely define "˜expertise' in the field of HIV treatment among various physicians. The answers to the questions posed by the authors may simply indicate the physicians' level of confidence rather than true competency.
1. Wilson IB, Landon BE, Hirschhorn LR, et al. Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians. Ann Intern Med. 2005;143:729-736.
Wilson IB, Landon BE, Hirschhorn LR, McInnes K, Ding L, Marsden PV, et al. Quality of HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians. Ann Intern Med. 2005;143:729–736. doi: 10.7326/0003-4819-143-10-200511150-00010
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Published: Ann Intern Med. 2005;143(10):729-736.
HIV, Infectious Disease.
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