Use and Predictors of End-of-Life Care Among HIV Patients in a Safety Net Health System.

CONTEXT: Although highly active antiretroviral therapy has improved survival among many HIV patients, there are still those with advanced illness and limited access to care who may benefit from palliative care and hospice. OBJECTIVES: To examine completion of advance directives, use of palliative care, and enrollment in hospice among HIV patients who receive care at an urban safety net hospital. METHODS: This was a retrospective cohort study of HIV patients in a large, urban safety net hospital in 2010. Physicians abstracted data from the electronic medical record on patient and clinical factors and end-of-life care use. Logistic regression examined predictors of hospice use. RESULTS: Overall, 367 HIV patients identified electronically by International Classification of Disease (ICD)-9 code were hospitalized in 2010. The mean age was 42 years, and 57% were African American. Although 28% died, only 6% of the sample received palliative care consultation, and 6% of the sample enrolled in hospice. Those who received hospice had lower albumin levels (adjusted odds ratio [AOR] 4.53, 95% CI 1.19-17.34) had received palliative care (AOR 9.73, 95% CI 2.10-45.09) and completed an advance directive (AOR 16.33, 95% CI 4.23-61.68). Of those patients who received hospice, the mean time to death after enrollment was 11 days. CONCLUSION: Among an urban cohort of HIV patients, the rates of advance directive completion, palliative care use, and hospice use were low. Despite advancements in the treatment of HIV, many patients with advanced illness may benefit from palliative care and hospice services. Advances should be made in identifying those patients earlier in their disease trajectories.

The impact of a genetics education program on physicians' knowledge and genetic counseling referral patterns.

BACKGROUND: Gaps in the knowledge of general practitioners (GPs) in medical genetics prevent the effective utilization of genetic services and increase the risk of liability. Educators recommend that genetics should be integrated into existing teaching programs but the effectiveness of these types of programs is unknown. AIM: The objective of this study was to provide a 2-year educational program for GPs untrained in genetics and to document its impact on genetic knowledge and referrals to a genetic counselor (GC). METHODS: Eight genetic lectures series were given at quarterly intervals. Family practice residents received additional training in a genetics clinic, and participated in monthly seminars and bi-annual journal clubs. A pretest-post-test study design (n = 143) was used to evaluate the genetic knowledge of GPs. Post-test scores [mean (%) +/- SD; 76.1 +/- 16.8] showed significant improvement compared to pretest scores (61.9 +/- 19.1). The majority of participants (81%) indicated that the program would have an impact on their clinical practice. The number of referrals to a GC from GPs untrained in genetics did not change over the 2-year period of the program. CONCLUSION: The results suggest that an integrated educational program in genetics can enhance physicians' knowledge but may not alter referral patterns to a GC.