International Journal for Quality in Health Care 16:41-50 (2004)
© International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved
Symptom-based framework for assessing quality of HIV care
1 VA Greater Los Angeles Health System and the University of California, Los Angeles, CA,
2 RAND Health, Santa Monica, CA,
3 Division of General Medicine, University of Pennsylvania, Philadelphia, PA,
4 Health Services Research and Development Program, VA San Diego Healthcare System, San Diego, CA,
5 Division of Infectious Diseases, Department of Medicine,
6 UCSD School of Medicine, La Jolla, CA,
7 Division of General Internal Medicine and Health Services Research, School of Medicine, University of California, Los Angeles, CA, USA
Objective. To evaluate HIV quality of care using a symptom-based, patient-centered framework.
Methods. An expert panel developed 13 quality indicators for three common symptoms: cough with fever and/or shortness of breath; severe or persistent diarrhea; and significant weight loss. A nationally representative probability sample of HIV-infected adults was interviewed between 1996 and 1997. Participants were asked about the presence and severity of HIV symptoms during the preceding 6 months, and care received. Variation in adherence to the indicators was assessed by symptom type and patient characteristics.
Results. In all, 2864 (71%) patients completed interviews and 920 reported being at least moderately bothered with one of the three symptoms. Of these, 41, 74, and 65% of patients with a symptom of cough, weight loss, or diarrhea, respectively, reported receiving all indicated care. Performance was better for patients with more severe HIV, measured as a CD4 cell count <50 cells/microliter, compared with those with less severe HIV, measured as CD4 cell count >500 cells/microliter (43% versus 60%; P = 0.02). Uninsured patients had worse performance than Medicare patients (45% versus 62%; P = 0.04), but care did not differ by patient’s age, gender, ethnicity, HIV risk factor, providers’ HIV patient load, or region. Only CD4 count remained significantly associated with performance in the multivariate analyses.
Conclusions. Symptom-based quality indicators may provide a useful supplement to conventional measures. Patients with HIV reported substantial underuse of services for common, burdensome symptoms. Although adherence to quality indicators was better for patients with more advanced HIV disease, many still received suboptimal care. Vulnerable patient groups generally did not receive worse quality of care, suggesting that symptom-based measures of quality may measure domains that are distinct from those captured by conventional indicators.
Keywords: HIV, patient-centered care, quality indicators, quality of care, symptoms
Accepted for publication September 24, 2003.
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