HIV PREVENTION IN PRIMARY CARE--AN OBJECTIVE ASSESSMENT

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.