A population-based study comparing patterns of care delivery on the quality of care for persons living with HIV in Ontario

BMJ Open. 2015 May 13;5(5):e007428. doi: 10.1136/bmjopen-2014-007428.


Objectives: Physician specialty is often positively associated with disease-specific outcomes and negatively associated with primary care outcomes for people with chronic conditions. People with HIV have increasing comorbidity arising from antiretroviral therapy (ART) related longevity, making HIV a useful condition to examine shared care models. We used a previously described, theoretically developed shared care framework to assess the impact of care delivery on the quality of care provided.

Design: Retrospective population-based observational study from 1 April 2009 to 31 March 2012.

Participants: 13 480 patients with HIV and receiving publicly funded healthcare in Ontario were assigned to one of five patterns of care.

Outcome measures: Cancer screening, ART prescribing and healthcare utilisation across models using adjusted multivariable hierarchical logistic regression analyses.

Results: Models in which patients had an assigned family physician had higher odds of cancer screening than those in exclusively specialist care (colorectal cancer screening, exclusively primary care adjusted OR (AOR)=3.12, 95% CI (1.90 to 5.13), family physician-dominant co-management AOR=3.39, 95% CI (1.94 to 5.93), specialist-dominant co-management AOR=2.01, 95% CI (1.23 to 3.26)). The odds of having one emergency department visit did not differ among models, although the odds of hospitalisation and HIV-specific hospitalisation were lower among patients who saw exclusively family physicians (AOR=0.23, 95% CI (0.14 to 0.35) and AOR=0.15, 95% CI (0.12 to 0.21)). The odds of antiretroviral prescriptions were lower among models in which patients' HIV care was provided predominantly by family physicians (exclusively primary care AOR=0.15, 95% CI (0.12 to 0.21), family physician-dominant co-management AOR=0.45, 95% CI (0.32 to 0.64)).

Conclusions: How care is provided had a potentially important influence on the quality of care delivered. Our key limitation is potential confounding due to the absence of HIV stage measures.

Keywords: Human Immunodeficiency Virus; PRIMARY CARE; chronic disease; comorbidity; health services delivery.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Anti-HIV Agents / therapeutic use*
  • Colorectal Neoplasms / complications*
  • Colorectal Neoplasms / diagnosis
  • Comorbidity
  • Delivery of Health Care / organization & administration
  • Delivery of Health Care / standards*
  • Emergency Service, Hospital
  • Family Practice
  • Female
  • HIV Infections* / complications
  • HIV Infections* / drug therapy
  • Hospitalization
  • Humans
  • Logistic Models
  • Male
  • Mass Screening*
  • Middle Aged
  • Odds Ratio
  • Ontario
  • Patient Acceptance of Health Care
  • Primary Health Care* / organization & administration
  • Primary Health Care* / standards
  • Quality of Health Care*
  • Retrospective Studies
  • Specialization
  • Young Adult


  • Anti-HIV Agents