Between 1994 and 2001, 1,400 patients were seen at the DEU clinic and of those, 358 preliminarily met the study eligibility criteria based on DEU and administrative hospital computerized records: HIV tested in the previous 12 months and received prior care at Boston Medical Center. Of the eligible 358 patients, medical records of 256 (72%) were located by the hospital records department. After review of the individual medical records, 7% (19/256) of patients were excluded because they did not meet 1 of the 2 eligibility criteria. Among the 237 remaining patient charts, we reviewed a total of 3,742 clinic visits. An additional 16 medical records were excluded because they did not have visits after March 1985, the year that the HIV test became widely available.6
Among the remaining 221 patients’ medical records, 5 were incomplete, but the available data were included in this study. There were 3,424 clinic visits for the 221 patients included in the final analyses.
All 221 patients had one or more triggers for HIV testing found in at least one encounter note. Triggers for HIV testing were noted in 50% (1,702/3,424) of the eligible visits reviewed among the 221 patients. HIV testing was recommended to the patient in 18% (299/1,702) of visits in which triggers were noted. HIV was considered in the note by the clinician without recommending testing in another 10% of visits (169/1,702). In total, HIV testing was recommended or considered in the provider note in 27% (468/1,702) of visits with triggers noted. The median number of visits per patient with a trigger was 5 (mean 7.7). The median number of triggers that a patient had per visit was 2.0 (mean 2.1).
Demographic characteristics of the 221 patients () include the following: 66% male, 49% African-American, 23% immigrants from an HIV endemic country, and 22% homeless. The mean age at the time of a positive HIV test was 39 years. In 44% of patients (96/220), the initial CD4 count was less than 200 cells/µl when diagnosed with HIV. The mean CD4 count was 328 cells/µl, while the median was 256 cells/µl. Only 51% (113/221) of patients had any PC visit in the Boston Medical Center system prior to the date of their initial positive HIV test.
Characteristics of HIV-infected Patients Who Received Medical Care at Boston Medical Center Prior to Their HIV Diagnosis (N = 221)
Thirty-nine percent (670) of the clinical visits (n = 1,702) with HIV triggers were to the ED (370) or UCC (300). Primary care was the second most common clinical site with 18% (306). Hospitalization accounted for 13% (218) of such visits and obstetrics/gynecology 7% (119). Although HIV was addressed in 28% of the 1,702 visits, the percentage of these visits varied widely by site (). While 32% of visits to PC clinic and 39% of visits to UCC addressed HIV, only 12% of ED visits considered HIV infection. The site that most routinely considered HIV was STD clinic (78%), followed by hospitalization (47%). Other sites with low percentages for addressing the issue of HIV testing were other specialists (10%), obstetrics/gynecology (9%), and dermatology (14%).
By Visit Site, the Percentage of Visits Where HIV Testing Was Recommended or Considered by a Clinician Stratified by Trigger Category
The multivariable model for missed opportunities for recommending testing or considering HIV found that gender was a borderline significant predictor, with women being more likely to have a missed opportunity (odds ratio [OR], 1.42; 95% confidence interval [CI], 0.98 to 2.07). There was no overall association between race/ethnicity and discussion (degrees of freedom [d.f.], 4; P = .44). Older age at first HIV diagnosis was associated with missed opportunities (OR, 1.26 for each additional decade of age; 95% CI, 1.02 to 1.55), while homelessness (P = .90) had no significant association with HIV discussion or testing.
The year of the visit had a significant association with addressing HIV, showing that more HIV testing occurred over time (d.f., 3; P < .001). Compared to visits during the periods 1997 to 2001, visits during 1985 to 1988 (OR, 12.0; 95% CI, 6.0 to 23.9), 1989 to 1992 (OR, 3.6; 95% CI, 2.4 to 5.3), and 1993 to 1996 (OR, 1.9; 95% CI, 1.4 to 2.6) had greater odds of missed opportunities. Site of visit was also a significant predictor of missed opportunities for discussion (d.f., 7; P < .0001). Compared to the UCC, visits to the ED (OR, 4.2; 95% CI, 2.6 to 6.7), obstetrics/gynecology clinic (OR, 2.0; 95% CI, 1.1 to 3.6), other specialty clinic (OR, 4.0; 95% CI, 2.3 to 6.9), and surgical clinic (OR, 10.3; 95% CI, 2.0 to 53.3) had greater odds of a missed opportunity. Visits to the PC clinic (OR, 1.0; 95% CI, 0.7 to 1.5) were not significantly different from the UCC, while the STD clinic had lower odds of a missed opportunity (OR, 0.07; 95% CI, 0.04 to 0.15).
Trigger category was significantly associated with missed opportunities for testing (d.f., 3; P < .0001). shows the percentage of time that HIV was discussed in visits stratified by trigger category. Compared to category 4 (borderline triggers), category 1 had lower odds of missed opportunities (OR, 0.05; 95% CI, 0.03 to 0.08), as did category 2 (OR, 0.13; 95% CI, 0.08 to 0.21) and category 3 (OR, 0.27; 95% CI, 0.18 to 0.42). There were also statistically significant differences in missed opportunities among trigger categories 1 to 3. Compared to categories 2 and 3, respectively, category 1 had lower odds of missed opportunities (OR, 0.38, 95% CI, 0.25 to 0.58; OR, 0.18, 95% CI, 0.12 to 0.28). Category 2 had lower odds of missed opportunities than category 3 (OR, 0.49; 95% CI, 0.34 to 0.70).
Examined by Patient Characteristic, Percentage of Visits Where HIV Testing Was Recommended, or Considered by a Clinician Stratified by Trigger Category
In secondary analyses using only visit data from 1993 to 2001, the results were generally consistent, though women had significantly more missed opportunities for HIV testing (P = .01), and the age association was attenuated (P = .16). Results from the regression model were also similar when the category 4 trigger visits were excluded from the analysis.
When individual triggers were compared to one another, there was a significant difference between trigger type and whether HIV testing was recommended or considered (d.f., 9; P = .05), indicating that there were significant differences in clinicians’ perceptions of the associations between the individual triggers and HIV discussion (while controlling for gender, age, location, and period). To help illustrate these differences, lists the unadjusted percentage of visits with specific triggers where HIV was recommended or considered. Men having sex with men as a trigger was associated with the highest proportion of HIV testing being recommended or considered, 71%. When injection drug use was noted, HIV testing was recommended or considered 54% of the time. Zoster was the weakest trigger for HIV testing recommendation or consideration among the 10 individually assessed triggers.
Examination by Specific HIV Triggers in Medical Encounters Between 1994 and 2001 Where HIV Testing Was Recommended or Considered by the Clinician