BackgroundNon-AIDS-related mortality rates among HIV-infected patients still exceed those of their uninfected peers. A major driver of this excess mortality is a higher risk of non-infectious comorbidities, including cardiovascular disease, chronic kidney disease, type 2 diabetes mellitus, osteoporosis and cancer. The prevalence of mental illness and other chronic non-infectious comorbidities is identified as a primary concern of antiretroviral prescribers in Australia.MethodsWe conducted a cross-sectional, observational study using data from MedicineInsight, a large-scale Australian primary care database comprising longitudinal data from electronic clinical information systems. The HIV-infected cohort included all men with a recorded diagnosis of HIV. The non-HIV-infected cohort comprised all other men from the same practices. The prevalence and risk of cardiovascular disease, chronic kidney disease, type 2 diabetes mellitus, osteoporosis, cancer, anxiety and depression were compared between the groups.ResultsWe included 2,406 HIV-infected males and 648,205 males with no record of HIV diagnosis attending primary care in this study. HIV-infected men were less socioeconomically disadvantaged and more urban-dwelling than men in the primary care cohort. We found that HIV-infected men attending primary care in Australia are at increased risk of chronic kidney disease, cancer, osteoporosis, anxiety and depression. There appears to be a risk of premature onset of cardiovascular disease, osteoporosis and cancer among younger HIV-infected patients. There is a high prevalence of anxiety and depression among HIV-infected men.ConclusionsIncreased prevalence of non-infectious comorbidities among HIV-infected men has broad implications for the effective management of those with these chronic conditions. Education to raise awareness among both HIV-infected men and their care providers, together with a greater focus on risk reduction, monitoring and preventive care, may be effective strategies in primary healthcare settings to further narrow the gap in health outcomes between people living with HIV and their uninfected counterparts.

Objective The objective of this study was to evaluate the effectiveness of implementation strategies aimed at improving the adherence of physical therapists’ treatment choices to clinical practice guidelines for a range of musculoskeletal conditions. Methods For this review, searches were performed in several databases combining terms synonymous with “practice patterns” and “physical therapy” until August 2019. The review included randomized controlled trials that investigated any intervention to improve the adherence of physical therapists’ treatment choices to clinical practice guidelines or research evidence. Treatment choices assessed by surveys, audits of clinical notes, and treatment recording forms were the primary measures of adherence. Self-reported guideline adherence was the secondary measure. Three reviewers independently assessed risk of bias. Because of heterogeneity across studies, only a narrative synthesis of the results was performed. Results Nine studies were included. Four demonstrated a positive effect on at least 1 measure of treatment choices for low back pain and acute whiplash. One involved a comparison to no intervention, and 3 involved a comparison to another active intervention. The interventions that demonstrated a positive effect included dissemination of clinical practice guidelines, with additional elements including interactive educational meetings (3 studies), tailored interventions and monitoring of the performance of health care delivery (1 study), peer assessment (1 study), and local opinion leaders plus educational outreach visits (1 study). Limitations Only 1 study assessed treatment choices by auditing clinical notes; the rest used surveys or treatment recording forms, which may increase the risk of recall and performance bias. Conclusions Although this review revealed limited trials evaluating interventions to increase physical therapists’ use of evidence-based treatments for musculoskeletal conditions compared with no intervention, it highlighted some interventions that may be effective. Impact Dissemination of clinical practice guidelines, interactive educational meetings, tailored interventions and monitoring the performance of health care delivery, peer assessment, and use of local opinion leaders plus educational outreach visits should be implemented to improve physical therapists’ adherence to clinical practice guidelines for a range of musculoskeletal conditions.

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Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS-long-acting β2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS-LABA combinations over ICS alone because they perceived that ICS-LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS-LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. This qualitative study found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be...

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