HIV PREVENTION IN PRIMARY CARE--AN OBJECTIVE ASSESSMENT

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AIDS is one of the most significant health concerns of our time. Providers in primary care have had a significant impact on patients' preventive health behaviors and are appropriate health professionals to address the spread of this disease. Physician self-report, patient report and chart review of HIV preventive performance indicate these activities are not occurring at an acceptable rate. However, these methods of evaluation have inherent inaccuracies, and variability in patient presentation can influence provider performance. Unannounced standardized patients (lay individuals who have been trained to replicate a clinical encounter consistently) offer an objective method of provider assessment, while controlling for patient variability. They also allow for capturing processes of care delivery (sequence and content of the clinical encounter), which are unobtainable using other more established methods. The specific aims of this exploratory study are to assess, using standardized patients (SP): l) the frequency and content of HIV risk factor determination, education and counseling provided to individuals at risk of HIV exposure based on their past sexual history and current sexual practices; 2) the process of non-HIV preventive care in sequence and content of risk assessment and services delivered; 3) the interactions of study variables listed in l and 2 by gender and type of provider and gender of standardized patient; and lastly, 3) the time and cost associated with clinical encounters. The study sample of 40 primary care providers (20 family physician and 20 family nurse practitioners) will be randomly selected from King and Pierce Counties in Washington State. Sampling will be stratified based on gender of provider. Each provider will be randomized to receive either a male or female standardized patient visit in their office. Providers will be kept blind to the specific study variables under assessment and exactly who the standardized patient is and when the visit will take place until after the evaluation period is over. Audiotaping via hidden microphone and recorder will be used to validate accuracy of SP assessment and reproducibility of clinical encounters. Kappa coefficients will be calculated to assess the psychometrics of the SP instrument. Descriptive statistics will be used to analyze frequency and content within study groups. Comparisons by type and gender of provider and gender of SP will be made using the t-test. Summary transcripts of the encounters will be to examine the process of preventive care delivery. The transcripts will be coded and categorized based on sequence and content, and comparisons will be made by type and gender of provider and gender of SP. This research would identify both gaps in HIV risk factor determination, counseling and education and practice priorities in preventive service delivery and how these may very by gender and type of provider and gender o patient. Understanding how primary care providers organize their delivery of preventive health services will assist in the design of interventions to increase providers' skills in identifying, assessing and addressing patient needs.