Provider Cardiovascular Risk Management in an Urban HIV Practice

Purpose:

With the advancements of antiretroviral therapy (ART) persons living with HIV (PLWH) have experienced the benefits of longer life but may also be at increased cardiovascular disease (CVD) risk.  Care providers for PLWH who are focused on achieving HIV infection control may not prioritize cardiovascular risk management.  There have been few studies examining HIV provider CVD prevention practices among PLWH. This two-phase study examined the use of guideline-driven CVD prevention practices by the care providers for PLWH in an urban HIV clinic.  Phase 1 was a provider survey and phase 2 was a retrospective chart review of patient records of these providers.  In this paper, we will report on phase 1 on the study.

Methods:

Providers within the Johns Hopkins AIDS Service were asked to participate in the study.  They completed a short survey examining self-efficacy and barriers for CVD risk management in their practice.  Approximately ten patient records were randomly selected for each provider.  Patients with a history of CVD were excluded.  Patient records were reviewed for the calendar year of 2010.  Electronic, manual and database reviews of records were used to assess provider adherence to CVD prevention guidelines. 

Results:

Twenty out of 37 (54%) providers (12 physicians, 6 nurse practitioners and 2 physician assistants) agreed to participate. Providers were predominantly female (65%) with an average of 11.3 ± 5.63 years in HIV practice.  While most providers reported feeling familiar or comfortable with CVD risk prevention guidelines (95%) and smoking cessation (90%), providers reported less confidence in dietary modification (65%) and exercise counseling (75%) as well as in managing medicines that reduce CVD risk (75%). Nurse practitioners and physician assistant reported significantly less comfort managing meds to mitigate CVD risk (p< 0.02) compared to physicians. Provider-reported barriers included patient-related factors (71%), time (61%), and patient complexity (39%).  For a BMI >25 dietary counseling was provided for 47% and weight reduction strategies were documented for 23% of patients.  The nature of tobacco use was discussed with most patients who reported smoking (74%), with 66% of smokers received advice to quit smoking.  In addition, blood pressure management strategies were discussed with a small proportion of the hypertensive participants (salt reduction 32%, DASH diet 24%, alcohol reduction 14% and weight reduction 27%).   The patients included in record review were treatment-experienced cohort as 93% had prior/current ART. Half (55%) of these patients had a viral load ≤50copies/mL, indicating optimal control of HIV.  , Patient-related factors that created barriers to effective CVD risk management as identified by providers included substance use, missed clinic visits and poor medication adherence.

 Conclusion:

Provider management of CVD risk factors in PLWH is suboptimal. Given recent calls by the American Heart Association for greater adherence to CVD risk management guidelines, it is essential that HIV care providers, particularly nurse practitioners and physician assistants, receive well-rounded training in CVD prevention. Patient-related characteristics must be considered to ensure adherence to provider recommendations and appropriate measurement of provider adherence to guidelines. Finally, measures to reduce provider barriers to CVD prevention should be addressed to enhance self-efficacy.