Voluntary Physician Switching by HIV-Infected Individuals

A National Study of Patient, Physician, and Organizational Factors

NRSA Trainees Research Conference Slide Presentation (Text Version)

By Hector P. Rodriguez

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On June 24, 2006, Hector Rodriguez made a slide presentation on voluntary physician switching by hiv-infected individuals at the 12th Annual National Research Service Award (NRSA) Trainees Research Conference. This is the text version of the slide presentation. Select to access the slide presentation (PDF File, 245 KB). PDF Help.

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Slide 1

Voluntary Physician Switching by HIV-Infected Individuals: A National Study of Patient, Physician, and Organizational Factors

Hector P. Rodriguez
NRSA Conference, Seattle, WA
June 24, 2006

Slide 2

Voluntary Physician Switching

• Physician switching can be costly for health care systems and difficult for patients.
• Only primary care samples have been examined.
• Interpersonal aspects of care are important determinants of physician switching.

Slide 3

Extending the Existing Voluntary Physician Switching Research

• Voluntary physician switching by patients with a chronic illness.
  • Continuity of care might have a greater impact on health outcomes.
  • Costs of discontinuities could be greatest.
• Physician and organizational characteristics might be important predictors of voluntary physician switching.

Slide 4

Primary Research Questions

• Are physician and care site specialization related to voluntary physician switching?
• Are practice demands, and physician satisfaction and stress, related to voluntary physician switching?
• Are interpersonal aspects of care related to voluntary physician switching after controlling for physician and organizational factors?
• Is visit continuity an important determinant of voluntary physician switching among patients with complex, chronic conditions?

Slide 5

HIV Cost and Services Utilization Study (HCSUS) Patient, Physician, and Site Surveys

Chart depicts the following:

Patient Survey (three boxes that read):

Baseline Survey, Jan 1996-Mar 1997, n=2,864.
Follow-Up 1 Survey, Jan 1997-Jul 1997, n=2,466.
Follow-Up 2 Survey, Aug 1997-Jan 1998, n=2,267.

Arrows point from "Baseline Survey" to "Follow-Up 1 Survey" to "Follow-Up 2 Survey." Another arrow points down from "Follow-Up 1 Survey" to another box below it that reads:

Physician Survey: 692 Identified, 551 Contacted, 411 Completed, n=1,820 patients.

An arrow points down from this box to another box below it that reads:

Site Survey: 282 Identified, 200 Completed, n=2,300 patients.

Slide 6

Results: How Common is Voluntary Physician Switching Among HIV-Infected Patients?

Bar chart depicts percentage of Voluntary Switch patients:

Follow-Up 1: 8.8%
Follow-Up 2: 6.7%
Overall: 14.5%

Slide 7

Results: Physician Characteristics (Single Predictor)

Statistically Significant Physician Characteristic Differences Between Voluntary Switchers and Other Patients	Not Significant
Specialization More likely non-expert generalist: OR=1.54 (1.16-2.01), p<.01. More likely physician with less than 20 HIV patients: OR=1.39 (1.09-1.75), p<.01. Less likely a physician with high anti-retroviral knowledge: OR=0.67 (0.52-0.86), p<.01.	Physician demographic characteristics
Demands/Satisfaction More likely a physician with more patients per hour: OR=1.51 (1.02-2.23), p<.05.

Slide 8

Results: Practice Site Characteristics (Single Predictor)

Statistically Significant Site Characteristic Differences Between Voluntary Switchers and Other Patients	Not Significant
Specialization/Expertise Less likely a site with moderate volume of HIV patients: OR=0.57 (0.36-0.91), p<.05. Less likely a site with clinical trial enrollment: OR=0.72 (0.53-0.97), p<.01. Less likely a site with Ryan White Care Actfunding: OR=0.49 (0.36-0.67), p<.001. Less likely a site with high practice guideline monitoring compliance: OR=0.64 (0.46-0.90), p<.05.	Most Human and Financial Resource Measures
Human Resources Less likely a site with on-site support services: OR=0.73 (0.61-0.88), p<.01.

Slide 9

	Final Model
Patient-Level Predictors
Trust	0.74 (0.61-0.90)**
Physician-Level Predictors
Anti-Retroviral Knowledge	0.26 (0.13-0.53)***
Site-Level Predictors
HIV Patient Volume, % of Overall
HIV site, High volume	-
HIV site, Moderate volume	0.09 (0.03-0.31)***
HIV site, Low volume	1.16 (0.35-3.86)
Non-HIV site	0.50 (0.23-1.11)
Ryan White Care Act Funding	0.27 (0.14-0.52)***
Constant	0.44 (0.20-0.99)*

Slide 10

Summary

• Physician and site specialization are significantly related to voluntary switching.
• Physician practice satisfaction is not related, but site demands appear to be.
• Patient trust is an important measure of the physician-patient relationship.
• Visit continuity is not an important determinant among HIV patients.

Slide 11

Study Limitations

Internal Validity:

• Self-report measures.
• Physician non-response.

Generalizability:

• HIV patients are unique:
  • Tight social networks.
  • Disease complexity.
• Time: 1996-98 was a period of rapid technological change.

Slide 12

Concluding Thoughts...

• Challenge the idea that patients do not make decisions based on technical quality.
• Measures of physician and site specialization were related to voluntary switching.
• Patients use indirect markers to assess quality.
• Potential to reduce switching by facilitating high quality physician-patient relationships and ensuring adequate organizational support.

Current as of August 2006

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Internet Citation:

Rodriguez, H.P. Voluntary Physician Switching by HIV-Infected Individuals: A National Study of Patient, Physician, and Organizational Factors. Text Version of a Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/fund/training/rodrigueztxt.htm

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