Minority providers jordan

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  • Statistical tests used to assess the significance of differences between groups varied according to data structure:For comparisons of percentages, a z-test of proportions was usedFor comparisons of means, a t-test was used All tests were based on 95% confidence unless otherwise noted (90% confidence)
  • METHODOLOGY:The data were divided up so that approximately one third of respondents fell into each of 3 categories.  Itwasn’t completelyarbitrary. These cut-offs made sense when it came to other variables as well (such as age, % AfAm patients, specialty, etc.).  In addition, it seemed to make sense in light of the univariate distribution of % patients tested due to doc recommendation. The “high” testers are testing an above average (median/mean) % of patients, but the majority of physicians have testing levels below the mean. It madesense to break up the below average testers furtherinto two groups.  More than half of the docs in the “low” group test zero % of their patients - so it makes sense to separate out the low group from the medium. There is tremendous variance in the % of patients tested due to physician recommendation; some doctors test no patients, some test all. The % of patients tested due to physician recommendation ranges from 0 to 100%. A third of physicians test less than 8% of their patients and a third test a quarter or more.
  • Minority providers jordan

    1. 1. HIV Testing Among African-American Frontline Providers in the US Dr. Wilbert Jordan1Valerie Stone, MD, MPH2; Lori DeLaitsch, MPH3; TiffanySurles, PharmD3; Eric Y. Wong, PhD3; Bryan Baugh, MD3 1Oasis Clinic, Los Angeles, CA; 2Massachusetts General Hospital, Boston, MA; 3Tibotec Therapeutics, Titusville, NJ
    2. 2. DISCLOSURES• This presentation and the HIV Testing Survey were supported by Tibotec Therapeutics• Dr. Wilbert Jordan has received consulting fees from Tibotec Therapeutics
    3. 3. Background• To date, no study has evaluated perceptions and practices of African-American health care providers (HCPs) related to HIV testing – Previous studies suggest that HIV testing rates could be increased by increasing number of recommendations made by physicians to patients1-3• African-Americans bear a disproportionate burden of HIV in the US1, 4-6 – African-Americans account for 13% of US population, but accounted for nearly half (45%) of new infections in 20067• African-American HCPs primarily care for African-American patients8 – African Americans account for 13% of US population but only 3% of physicians (2002)9
    4. 4. Background• In 2006, CDC issued recommendations for universal, opt-out testing regardless of sexual activity or risk factors – All patients ages 13-64 in areas where prevalence of undiagnosed HIV infection is >0.1% – Test all high risk patients at least annually – Test all pregnant women – Routine screening for patients initiating TB and STD treatment
    5. 5. Background• Additional testing may lead to greater burden on HCPs and medication assistance programs, which are already strained – 65 million people live in areas designated as having a shortage of primary care physicians1 – 16,600 additional providers needed to fill the gaps; number expected to grow10 – Currently, 6972 patients are on ADAP waiting lists across 11 states11• Increased testing leading to earlier diagnosis would enable patients to seek medical treatment sooner and has obvious benefits for public health
    6. 6. Objectives for Today’s Workshop• Review results of a recent survey given to African- American physicians regarding HIV testing in the African- American community• Define the scope of the problem: – Current attitudes and practices – Desired attitudes and practices• Identify existing barriers and resource gaps• Discuss interventions for physicians and patients that would improve testing rates by the NMA• Consider implications for public policy
    7. 7. Survey Objectives• To understand perceived attitudes and behaviors surrounding HIV testing in the African-American community• To identify drivers of testing and key barriers• To understand what contributes to successful communication between physicians and patients to increase HIV testing• To take a look at physicians’ understanding of HIV testing and treatment
    8. 8. Methods• Survey-based research to understand barriers to and drivers of testing among African-American primary care physicians – Survey designed after in-depth interviews with African-American physician advisors• Respondent criteria: – African-American practicing physician (≥1 yr) working with adults – Primary care (general practitioner, family practitioner, internal medicine) or other front line physicians (OB/GYN, emergency care) – At least 20% of patients must be African-American
    9. 9. Methods• 502 surveys completed online at NMA annual convention and via email – 36 questions plus demographic and screening questions – Average completion time: 15 minutes• Survey developed and funded by Tibotec Therapeutics
    10. 10. Survey Findings
    11. 11. Physician Demographics % RespondentsParameter (N=502) ER/ UrgentGender Care, 13 Male 47 % IM/GP, 3 2%Age (years) <40 27 40-49 34 Family >50 39 Practice, 25%Region OB/GYN Northeast 16 26% South 59 Midwest 17 West 9 36% 64%Years in Practice <5 15 NMA 6-10 22 member 11-15 18 Non- 16-20 15 member 21-30 24 31+ 6
    12. 12. Physician Demographics: Practice Setting Office- 50% based… PracticeHOSPITA Percentage L… 32% Type Private/ 18% 67 Hospita… For-profit 17% Non-profit 30 Hospita…Academi 21% Government- c-… 10 affiliatedCommuni 19% ty-…Respondents were allowed to check multiple responses.
    13. 13. Patient Base Insurance/Payer Type 30%* Private insurance 26% • 87% of patients are 18 Medicare 25% * years of age or older 28% 24% * Medicaid 29% • 56% of patients are Payers e.g.: 4% African American Kaiser/ Other staff models 4% 3% Department of Defense 3% • Approximately two- 3% VA 3% thirds of patients are 5% * female Other insurance 5% Uninsured 13% 16% All patients African-American Patients* Statistically significant between groups
    14. 14. Testing Results: Overall
    15. 15. Physician Recommendation to Test is Extremely Influential on PatientPhysicians estimate that one-third of patients have beentested within past year, and majority of patients (70%) gottested due to physician’s recommendation Of these, 70% tested due to physician’s 24% of all patients recommendation are tested due to Not Tested physician’s tested 34% recommendation 66%
    16. 16. Overall Testing Trends Q: In the past year, what percentage of your patients in your practice have been tested for HIV? Q: What % of patients actually tested within past year tested due to physician recommendation. Even among the most routine testers (OB/GYN), only about half of all patients are tested ER/Urgent Care Family Practice Internal Med/GP OB/GYN 52% * 24% 29% 27% ER/Urgent Care Family Practice Internal Med/GP OB/GYN NOTE: OB and GYN results combined; may* Significantly higher than ER, FP and IM overestimate testing in non-pregnancy setting
    17. 17. Current CDC Recommendations• All patients ages 13-64 (regardless of sexual activity or risk factors) if prevalence of undiagnosed infection >0.1%• Test all high risk patients at least annually• Routine screening for patients initiating TB treatment• Routine screening for all patients seeking STD screening/treatment• HIV screening included in routine panel of prenatal screening tests for all pregnant women• Patients should be informed and be able to opt out – Separate written consent is not required
    18. 18. Routine Testing is Not the Most Common Approach Q: For which of the following patients would you typically recommend HIV testing? Select all that apply. Patients in “high-risk” groups 92% Patients seeking treatment for STDs 91% Pregnant/trying to become pregnant 81% Patients incarcerated in past 5 years 79% All patients who are sexually active 74% Patients initiating treatment for Tuberculosis 67% Patients aged 13-64 in areas where HIV 65%prevalence of undocumented infection is >0.1% Still, only 34% of patients are being tested
    19. 19. Risk-based Testing Is Most CommonQ: What are the primary reasons you would recommend HIV testing to a patient? Select all that apply. Multiple sex partners 89% Injection drug use 85% Sexual assault 83% Suspected prostitution 77% Homosexuality 77% Previous incarceration 70% Routine test 55% Other 13% • Risk-based approach requires discussion of sensitive or difficult subjects
    20. 20. Top 5 Barriers to Recommending TestingQ: What are the key factors that limit African-American physicians from recommendingHIV testing? Select top five. Percent listing in Top 5 Patient may perceive the recommendation as accusatory or judgmental 57% Patient wouldn’t want to be identified as HIV+/worried that people will find out 48% Competing priorities/other needs more urgent 45% Insufficient time with the patient 45%There’s such a stigma associated with HIV, doctors don’t want to offend anyone 43% • Three of the top barriers are associated with stigma, patient disclosure and value judgments • Two of the top barriers reflect competing priorities on physicians’ time • Constraints such as shortage of resources or financial considerations (for physicians or patients) were not in Top 5
    21. 21. African-American Physicians Feel that African American Patients Are More Comfortable Talking to African-American Physicians African-American patients are less 8% comfortable talking to African-American physicians 57% 35%African-Americanpatients are more Race unrelated tocomfortable talking to comfort levelAfrican-Americanphysicians
    22. 22. Physicians More Comfortable Discussing Testing with African-American and At-risk PatientsQ: How comfortable would you say you are with raising the issue of HIV testing with each of the following patient types? (1 = Not at all; 7 = Extremely); Bars represent percentage of physicians assigning “6” or “7”. Patients you perceive to be at risk for HIV 86% African-American women 82% African-American men 77% Non- African-American women 76% Non- African-American men 74% Patients you DO NOT perceive to be at risk for HIV 66% • Comfort level increases with perceived risk • African-American patients perceived to be at greater risk • Majority of physicians appear to be “very” or “extremely” comfortable • Why are they not asking more patients to get tested?
    23. 23. Specialties Other Than OB/GYN: No Difference in Comfort Level Based on GenderQ: How comfortable would you say you are with raising the issue of HIV testing with each of the following patient types? (1 = Not at all; 7 = Extremely); Bars represent percentage of physicians assigning “6” or “7”. Patients you perceive to be at risk for HIV 83% African-American women 79% African-American men 78% Non- African-American women 73% Non- African-American men 73% Patients you DO NOT perceive to be at risk for HIV 62%
    24. 24. Patient Reactions Vary by Race Q: What are common emotional reactions to the recommendation for HIV testing among your African- American patients? Non-African-American patients? Select all that apply.Understand need to test/eager to take care of 56% their health 60% 55% Questioning reasons for request 49% Calm (trust doctor knows best) 52% 53% 52%* Deny need for testing 45% 24%* Offense 18% 23% Shock/Disbelief 22% 19%* Anger 11% 3% African-American patients Do not routinely recommend HIV testing 5% Non-African-American patients • African-American patients significantly more likely to respond negatively • Anticipation of negative responses likely reduces physicians’ comfort level* Statistically significant between groups
    25. 25. Reasons African-American Patients Give for Not Discussing HIV Testing or Refusing a TestQ: What are common reasons your African American patients give for not discussing HIV testing orrefusing a test? I’m not at risk for HIV 62% I’m in a monogamous relationship 58% I’m not having sex now 56% I’m not gay 55% I don’t use drugs/I’m clean 49% I always practice safe sex 47% I don’t feel sick 42% I’ve only had sex with a few people 39% I don’t like needles/giving blood 37% I don’t want anyone to find out 32% What if I test positive? 30%
    26. 26. Reasons for Refusing Testing Differ by Race Q: What are common reasons your African-American patients give for not discussing HIV testing or refusing a test? Your overall population? Select all that apply. I’m not at risk for HIV 62% 62% I’m in a monogamous relationship 58% 68%* I’m not having sex now 56% 56% I’m not gay 55%* 47% I don’t use drugs/I’m clean 49% 45% I always practice safe sex 47% 52% I don’t feel sick 42%* 35% 39% I’ve only had sex with a few people 38% 37%* I don’t like needles/giving blood 31% 32% I don’t want anyone to find out 28% African-American patients All patients 30% What if I test positive? 26% • Patients do not accurately assess their own risk* Statistically significant between groups
    27. 27. Physicians Discuss Testing with Women More Often than Men Q: How would you raise the issue with African-American men? African-American women? Select all that apply. Bring it up when treating an STD 65% 82%* When patient seeks help for injection drug use 56% 70%* In cases of sexual assault 54% 79%* Bring it up during annual physical/or gyn exam 44% 68%* When doing other blood work 36% 50%* Just say it’s part of a routine exam 34% 48%* 26% Bring it up during patient intake 39%* 14% Whenever the patient has an open wound/ bleeding 19%* 14% Raise during urgent care 19%* African-American men 25%* African-American women Do not see this type of patient 4% Testing is discussed more often with women, but men are twice as likely to be infected1 * Statistically significant between groups1. http://www.cdc.gov/hiv/topics/surveillance/resources/factsheets/prevalence.htm. Accessed Feb 15, 2011.
    28. 28. Physician Comfort and Perceived Patient Discomfort are Barriers to Testing • Physician comfort with raising the issue of testing is associated with level of testing, regardless of patient gender/race* • Physician perception of the patient’s comfort with testing is also associated with level of testing, regardless of patient gender/race* Adjusted for lack of male patients for OB/GYNs
    29. 29. Profiles of Low, Medium, and High Testers
    30. 30. Physician Testing Habits Low Testers High Testers (31% of survey respondents) (36% of survey respondents)• Older (>40 years old) • Younger (<40 years old)• More likely to be men • More likely to be women• More likely to be ER/Urgent • More likely to be OB/GYN care, internal medicine, or family practice • Tend to test routinely and for all• More likely to test only high-risk sexually active patients patients • Most comfortable discussing testing• Least comfortable discussing testing • More likely to themselves have• Less likely to themselves have been been tested for HIV in past year tested for HIV in past year
    31. 31. Perceived HIV Prevalence Rates Appear to Impact Testing RecommendationsQ: What would you estimate is the prevalence of HIV/AIDS in the county/state where you practice? Range 0-100.• Physicians generally overestimate actual prevalence rates – Assume prevalence similar to hypertension (18%) or diabetes (11%)12,13• If physicians assume risk is this high, why not test routinely? Estimated county prevalence Estimated state prevalence 14% 16% 14% 16% 10% 11% Low Medium High Low Medium High
    32. 32. The Reality • Prevalence: The percentage of a population that is affected by a particular disease at a given time State State Population People Living With Estimated AIDS AIDS (2007) Prevalence* California 36,500,000 67,292 0.2% Florida 18,250,000 48,645 0.3% New York 19,300,000 74,652 0.4% Texas 23,900,000 33,278 0.2% Wash DC 590,000 9,030 1.5% • For local statistics, contact local health department or access www.statehealthfacts.orgwww.statehealthfacts.org accessed Feb 11th, 2011* Underestimates HIV prevalence. Does not include undiagnosed infections and patients with HIV but not AIDS.
    33. 33. African-American Physicians See HIV as Crisis in the African-American Community Q: In your opinion, how serious of a problem is HIV today? 14%*  Crisis 55%  Very serious  Somewhat serious 64%*  Not particularly serious  Not at all serious 38% 20% * 3% 1% 6% In general in the US In the African-American Community in the US* Statistically significant vs other category (general US vs African-American community)
    34. 34. Results by Physician Specialty
    35. 35. Testing Practices of OB/GYNs* • OB/GYNs: – Test a much higher percentage of patients than do other specialties (53% vs 24-29%) – Are most likely to see HIV testing as routine for all patients (94% vs 72-80%) – Are most likely to mention relatively positive patient reactions to the recommendation for testing Are OB and GYN practices/attitudes similar?* OB/GYN attitudes and practices likely driven by OBs and requirements for testing during pregnancy
    36. 36. OB/GYNs Are Most Comfortable Raising Issue of HIV Testing Q: How comfortable would you say you are with raising the issue of HIV testing with each of the following patient types? Comfort level of raising the issue of HIV testing Cd 86% Black/African American men 83% C 71% 88%C Black/African American women 83%c 74% 91% bC Non Black/African American men 75% 78% 70% 73% c Non Black/African American women 78% 69% 88%ABC C 89%Patients you perceive to be at risk for HIV 89%C 77% C 93% Patients you DO NOT perceive to be at 66% 66% risk for HIV 58% 75% bCER/Urgent Care (A)Family Practice (B)Internal Med /GP (C)OB/GYN (D) A,B,C,D denotes 95% significance vs that group; a,b,c,d denotes 90% significance vs that group
    37. 37. Internists Are Least Comfortable Raising Issue of HIV Testing Q: How comfortable would you say you are with raising the issue of HIV testing with each of the following patient types? Comfort level of raising the issue of HIV testing 86% Black/African American men 83% 71% 88% Black/African American women 83% 74% 75% Non Black/African American men 78% 70% 73% Non Black/African American women 78% 69% 89%Patients you perceive to be at risk for HIV 89% 77% Patients you DO NOT perceive to be at 66% 66% risk for HIV 58%ER/Urgent CareFamily PracticeInternal Med /GP
    38. 38. Testing Levels by Specialty High Medium Low 47%** 39% 42%* 31%** 28%** 30% 17% 16% 16%* 15%* 12% 8% OB/GYN Family Practice GP/Internal ER/Urgent Care Medicine** 95% statistical significance over other testing groups; * 90% Statistical significance over high testers
    39. 39. Resource and Education Gaps
    40. 40. What Would Support More Testing? Q: What would help you do more testing? Office posters/brochures/info stressing HIV testing is important 52% More media attention raising the issue for patients 51% Having more education/training on HIV testing 44% Government mandate requiring HIV testing become routine 43% Accurate pre-packaged in-office test 42% Increased government attention to HIV issues in general 40% More information about different types of tests available 35% Having a script for easily raising the issue with patients 25% Online community where I could talk with other physicians about the challenges of testing 16% Mentorship program where I get guidance from a peer 14%• Some resources in Top 5 already exist, but physicians may not be aware• Physicians say “make it easier for me” and want patients to meet them half way
    41. 41. Limitations of Survey• Potential response bias due to self reporting; overestimation or skewing of certain data points to favor positive practices• Only physician responses were collected; no correlation or comparison with patient responses• OB/GYN cohort blends OBs and GYNs and may mask deficiencies in testing practices of GYNs – OBs likely test majority of patients (pregnant women), while testing attitudes and practices for GYNs may be more similar to other specialties
    42. 42. Summary: Drivers of Testing• Physician characteristics – Specialty (OB/GYN most likely to test) – Comfort level – Age (younger more likely to test)• Patient characteristics – % Medicaid patients in practice – % African-American patients in practice
    43. 43. Summary• Attitudes do not equate to behaviors – Large disparity between percentage of HCPs who say testing should be routine (74%) and those who actually test routinely (34-37%)• Even among the most routine group of testers (OB/GYN), only 53% of patients are being tested• Stigma and discomfort on behalf of HCPs and patients are significant impediments to testing – HCPs have a responsibility to provide quality care
    44. 44. Summary• A routine approach may remove the emotional charge – Blood pressure and glucose screening are routinely performed without evidence of risk factors• Laws and regulations could help – OB model is most successful for HIV testing – 22 states have opt-out testing laws for pregnant women• NMA role and actions – National HIV Outreach Program – NMA Policy Committee
    45. 45. NMA Actions 1. Identify 44 metropolitan areas2. Contact 2000 primary care providers of African American patients in those metro areas 3. Ask those providers to test their patients for HIV in November as a way of celebrating WAD4. Develop Web support for providers who identify HIV+ client 5. Work with pharma and HealthHIV to develop dinner cme for metro areas where HIV+ identification is high
    46. 46. Acknowledgments• Cheskin Added Value for fielding survey and analyzing data• Edelman for coordinating the survey• Dr. David Malebranche, MD (Emory University) for providing input to survey design and this presentation
    47. 47. Thank you !
    48. 48. Statistical Methods• Statistical tests used to assess the significance of differences between groups varied according to data structure: – For comparisons of percentages, a z-test of proportions was used – For comparisons of means, a t-test was used – All tests were based on 95% confidence unless otherwise noted (90% confidence)
    49. 49. Overall Patient Demographics By Physician Specialty• Percentage of patients with HIV/AIDS – Highest with ER/Urgent Care physicians (11%) – Lowest with OB/GYNs (3%)• Percentage of patients with low socio-economic status – Highest with ER/Urgent Care physicians (36%) – Lowest with OB/GYNs (29%)• ER physicians see more patients without insurance and OB/GYNs more with private insurance

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