SUMMARY The availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced extraordinary complexity into the treatment of HIV-infected persons. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV-infected adults and adolescents. This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring including plasma HIV RNA, CD4 cell counts and HIV drug resistance testing. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Antiretroviral regimens are complex, have major side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance due to non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic

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Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents

Advances in medical, biomedical and health services research have reduced the level of uncertainty in clinical practice. Clinical practice guidelines (CPGs) complement this progress by establishing standards of care backed by strong scientific evidence. CPGs are statements that include recommendations intended to optimize patient care. These statements are informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options. Clinical Practice Guidelines We Can Trust examines the current state of clinical practice guidelines and how they can be improved to enhance healthcare quality and patient outcomes. Clinical practice guidelines now are ubiquitous in our healthcare system. The Guidelines International Network (GIN) database currently lists more than 3,700 guidelines from 39 countries. Developing guidelines presents a number of challenges including lack of transparent methodological practices, difficulty reconciling conflicting guidelines, and conflicts of interest. Clinical Practice Guidelines We Can Trust explores questions surrounding the quality of CPG development processes and the establishment of standards. It proposes eight standards for developing trustworthy clinical practice guidelines emphasizing transparency; management of conflict of interest; systematic review--guideline development intersection; establishing evidence foundations for and rating strength of guideline recommendations; articulation of recommendations; external review; and updating. Clinical Practice Guidelines We Can Trust shows how clinical practice guidelines can enhance clinician and patient decision-making by translating complex scientific research findings into recommendations for clinical practice that are relevant to the individual patient encounter, instead of implementing a one size fits all approach to patient care. This book contains information directly related to the work of the Agency for Healthcare Research and Quality (AHRQ), as well as various Congressional staff and policymakers. It is a vital resource for medical specialty societies, disease advocacy groups, health professionals, private and international organizations that develop or use clinical practice guidelines, consumers, clinicians, and payers.

/pdf/clinical-practice-guidelines-we-can-trust-10au3fvbc7.pdf

Clinical Practice Guidelines We Can Trust

Patient-centredness: a conceptual framework and review of the empirical literature.

Background: We designed this observational cohort study to assess the association between patient-centered communication in primary care visits and subsequent health and medical care utilization. 

Methods: We selected 39 family physicians at random, and 315 of their patients participated. Office visits were audiotaped and scored for patient-centered communication. In addition, patients were asked for their perceptions of the patient-centeredness of the visit. The outcomes were: (1) patients' health, assessed by a visual analogue scale on symptom discomfort and concern; (2) self-report of health, using the Medical Outcomes Study Short Form-36; and (3) medical care utilization variables of diagnostic tests, referrals, and visits to the family physician, assessed by chart review. The 2 measures of patient-centeredness were correlated with the outcomes of visits, adjusting for the clustering of patients by physician and controlling for confounding variables. 

Results: Patient-centered communication was correlated with the patients' perceptions of finding common ground. In addition, positive perceptions (both the total score and the subscore on finding common ground) were associated with better recovery from their discomfort and concern, better emotional health 2 months later, and fewer diagnostic tests and referrals. 

Conclusions: Patient-centered communication influences patients' health through perceptions that their visit was patient centered, and especially through perceptions that common ground was achieved with the physician. Patient-centered practice improved health status and increased the efficiency of care by reducing diagnostic tests and referrals.

The impact of patient-centered care on outcomes.

The effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others. Medicine practiced with narrative competence, called narrative medicine, is proposed as a model for humane and effective medical practice. Adopting methods such as close reading of literature and reflective writing allows narrative medicine to examine and illuminate 4 of medicine's central narrative situations: physician and patient, physician and self, physician and colleagues, and physicians and society. With narrative competence, physicians can reach and join their patients in illness, recognize their own personal journeys through medicine, acknowledge kinship with and duties toward other health care professionals, and inaugurate consequential discourse with the public about health care. By bridging the divides that separate physicians from patients, themselves, colleagues, and society, narrative medicine offers fresh opportunities for respectful, empathic, and nourishing medical care.

/pdf/narrative-medicine-a-model-for-empathy-reflection-profession-4n1xbk2y8w.pdf

Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust

American medicine is in the midst of a professional evolution driven by a refocusing of medicine's regard for the patient's viewpoint. Historically, medicine has been largely physician centered, but physicians have begun to incorporate patients' perspectives in ways that increasingly matter. Some call this shift "patient-centered" care. In support of the view that this refocusing reflects a broad professional shift, we describe the evolution to patient-centered care in many areas of medicine: patient care, health-related law, medical education, research, and quality assessment.

Patient-Centered Medicine: A Professional Evolution

Adherence to antiretroviral therapy by pregnant women infected with human immunodeficiency virus: a pharmacy claims-based analysis

Objective: Hospital and physician experience have been linked to improved outcomes for persons with HIV. Because many HIV-infected patients receive care in clinics, we studied clinic HIV experience and survival for women with AIDS. Design: Retrospective cohort study of women with AIDS whose dominant sources of care were clinics. Clinic HIV experience was estimated as the cumulative number of Medicaid enrollees with advanced HIV who used a particular clinic as their dominant provider up to the year of the patient's AIDS diagnosis: low experience (< 20 patients), medium (20-99 patients), high (≥ 100 patients). Proportional hazards models examined relationships between experience and survival. Setting: A total of 117 New York State clinics. Patients: A total of 887 New York State Medicaid-enrolled women diagnosed with AIDS in 1989-1992. Main outcome measure: Survival after AIDS diagnosis. Results: In later study years (1991-1992), patients in high experience clinics had an approximately 50% reduction in the relative hazard of death (0.53; 95% confidence interval, 0.35-0.82) compared with patients in low experience clinics. Adjusting for demographic and clinical variables, 71% of patients in high experience clinics were alive 21 months after diagnosis compared with 53% in low experience clinics. Experience and survival were not significantly associated in the early study years (1989-1990). Conclusions: In more recent years, women with AIDS receiving care in high experience clinics survived longer after AIDS diagnosis than those in low experience clinics, providing further evidence of a relationship between provider HIV experience and outcomes.

The relationship of clinic experience with advanced HIV and survival of women with AIDS.

Keeping one's personal fund of knowledge current is one of the most formidable challenges that physicians face. This article considers a few strategies that may help physicians as they struggle to keep their knowledge up-to-date. Physicians need to develop their own goals for staying current, systematically and periodically search the literature for high-quality material relevant to the topics on their agendas, become facile with critical appraisal of the literature, and schedule time for reading. One of the responsibilities of any professional is to maintain expertise, and this responsibility is probably nowhere more critical, or more difficult, than in the profession of medicine.

How can physicians keep up-to-date?

Background: Because of the low prevalence of hepatitis C virus (HCV) infection in the general population, massscreeningwouldbeexpensiveandoflowyield.Some researchers advocate targeted screening of persons at elevated HCV risk. Methods: This cross-sectional study aimed to develop a patient-administered tool to assess HCV infection risk. Two hundred seven patients with unknown HCV status from a general medicine practice and 222 HCV-positive patients from a hepatology practice completed a 72item survey about demographic, social, and clinical risk factorsforHCVinfection.Generalmedicinepatientsalso underwent HCV serologic testing. Results: Three (1.5%) of 207 general medicine patients had positive HCV antibody test results. These patients plus the 222 hepatology patients were significantly more likely than HCV-negative patients to report an array of factors. In a multivariable model, 7 factors remainedsignificantlyassociatedwithHCVinfection:sex with a prostitute or an injecting drug user, exposure to blood products, refusal as a blood donor or as a life insurance applicant, witnessing illicit drug use, and selfreported HBV infection. A simplified model that assigned 1 point for each factor present predicted HCV infection as well as a weighted model (based on 2 testing and receiver operating characteristic curve comparison). In a population with a 2% prevalence of HCV infection, people who identified 2 risk factors had a 10% chance of HCV infection, whereas those with 4 or more risk factors had a 50% chance.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/486711/ioi50084.pdf

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