Are You a "Doctor Hopper?"

Understanding the Causes and Consequences of Constantly Changing HIV Care

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One of the first clues that a patient will be unable to achieve optimal response to antiretroviral therapy (ART) is when the person is identified as so-called "doctor hopper"—or simply put, someone who visits multiple clinics or doctors over the course of years, months, or even weeks.

There can be any number of reasons why a patient chooses to do so. On occasion, it may be that the patient doesn't like a particular doctor or clinic, or requires treatment for an associated condition, such as hepatitis C (HCV), substance abuse, or mental health.

But, more often than not, it is simply that the patient is unwilling to accept or face some issue related to the diagnosis, management, or treatment of their HIV. Examples include:

  • Denial, or the fear of disclosure and stigma.
  • Patients who have experienced treatment failure due to suboptimal drug adherence and would rather move to another doctor than admit (or confront) the roots of their non-adherence.
  • Patients who are unwilling to accept or unable to cope with a recommended diagnosis, who then jump from doctor to doctor hoping for a different outcome.

Prevalence and Profile of Doctor Hoppers

A 2013 study from the Perelman School of Medicine at the University of Pennsylvania examined the breadth and outcome of doctor-hopping over a two-year period from 2008 to 2010. In their research, the investigators tracked clinic attendance, ART history, and HIV viral load in 13,000 patients in the 26 Ryan White-funded public clinics.

Of that population, nearly 1,000 were identified as having visited multiple clinics.

The research not only confirmed that these multiple-clinic patients were less likely to achieve viral suppression than their single-clinic counterparts (68% versus 78%), they were also far less likely to take ART when needed (69% versus 83%).

Furthermore, while most of the doctor hopping occurred during the first year of care, 20% continued throughout the entire period.

Doctor hoppers in this study were largely identified to be being younger, African American, female, with either no insurance or on public health insurance.

Consequences of Doctor Hopping

The consequences of doctor hopping can often be significant since many of these patients fail to reveal previous history with their new doctor. This can result in prescribing errors and unrecognized drug-drug interactions, exposing the person to otherwise avoidable side effects and/or the premature development of HIV drug resistance.

Moreover, the quality, frequency, and consistency of patient-provider interaction—wherein the patient in retained in care at the same clinic or with the same doctor—are known to improve clinical outcomes. Research from the Vanderbilt University School of Medicine has shown that erratic care in as early as the first year of treatment can more than double the risk of death in patients with HIV, with 2.3 deaths per 100-patient years versus only 1.0 deaths per 100-person years for those with consistent, single-clinic care.

From a public health standpoint, doctor hopping can be equally profound, resulting in the unnecessary duplication of services and wasted resources that increase overall health care costs. Identifying the root causes of this will likely be the next important step if U.S. public health officials hope to achieve sustained reductions in HIV transmissions in line with updated testing and treatment guidelines.

Current recommendations include:

  • Streamlining patient intake by consolidating the testing, linkage to care, and treatment of HIV within an integrated facility, a strategy popularly known as "TLC-Plus."
     
  • Sharing of electronic medical records between authorized health authorities to better identify patients who are either doctor hopping or have a history of erratic medical care.
     
  • Providing greater access to HIV-specific care, particularly for marginalized communities. Increased access to Medicaid and private health insurance under the Affordable Care Act may help alleviate the health disparities in affected populations.

Sources:

Yehia, B.; Schranz, A.; Momplaisir, F.; et al. AIDS and Behavior. "Outcomes of HIV-Infected Patients Receiving Care at Multiple Clinics." September 28, 2013; e-published ahead of print; PMID: 2407731.

Gardner, E.; McLees, M.; Steiner, J.; et al. "The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection." Clinical Infectious Diseases. March 2011; 52(6):793-800.

Herwehe, J.; Wilbright, W.; Abrams, A.; et al. "Implementation of an innovative, integrated electronic medical record (EMR) and public health information exchange for HIV/AIDS." Journal of the American Medical Information Association. May-June 2012; 19(3):448-452.

Mugavero, M.; Lin, H.; Willig, J.; et al. "Missed visits and mortality among patients establishing initial outpatient HIV treatment." Clinical Infectious Diseases. January 15, 2009; 48(2):248-256.

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