A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario

Abstract

Objectives: Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided. Design: Retrospective population-based observational study from 1 April 2009 to 31 March 2012. Participants: 13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care. Outcome measures: Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses. Results: Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physiciandominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIVspecific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients' HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)). Conclusions: How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures.