The present study was designed to prospectively evaluate the frequency of rheumatic symptoms in a cohort of patients infected with the human immunodeficiency virus (HIV), to examine the relationship between such findings and a variety of clinical and epidemiologic variables, and to evaluate the impact of rheumatic symptoms on the natural history of the HIV infection. One hundred seventeen patients were evaluated over a mean of 24.6 months (range 0.5–85 months). Cumulatively, 1.7% had Reiter's syndrome, 1.7% had psoriatic arthritis, and 11.1% had various forms of oligoarticular/monarticular or polyarticular arthritis. The majority of the rheumatic symptoms developed during the longitudinal evaluation and predominantly affected patients with clinically advanced HIV infection. Patients with articular disease tended to have more progressive HIV infection and were more likely to experience disease progression to clinical acquired immunodeficiency syndrome or death. Our data suggest that the occurrence of rheumatic symptoms in the presence of HIV infection is not uncommon and tends to develop over time, in the setting of clinically advanced retroviral infection. Furthermore, the presence of rheumatic symptoms may be a sign of a poor prognosis for patients with HIV infection.
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Context: In 2018, AHRQ developed staffing models with panel sizes, functions, ratios and financing approaches for 3 types of comprehensive primary care clinics. We used this model in an academic health system serving people of differing ages, medical complexity and social risk. Objective: Determine the usability and update the model for post-pandemic academic primary care. Study Design and Analysis: Mixed methods cross-sectional observational study; comparative analysis. Setting: 9 clinics: 2 safety-net, 1 internal medicine, 4 family medicine, 2 pediatric. Population studied: Clinic faculty and staff. Intervention/Instrument: Panel size, full time equivalents (FTEs) by function, encounter volume; interviews with a sample of each clinics' members, with representation across functions. Outcome Measures: Identification of staff functions, panel sizes, staffing ratios, encounter numbers. Results: AHRQ's model was usable in academic primary care, but needed to be modified to align with the blended populations served by clinics. A supplementary tool was needed to identify FTE gaps by function and support planning among clinic and system administration. Using this tool, we found that clinician panel sizes were similar to AHRQ model recommendations, but clinics were short staffed by an average of 9.5 FTE/clinic (range 1-22 FTE). Functional gaps were identified in complex care/care transitions, care coordination, and behavioral health (BH), the latter of which was an increased need since the pandemic. Non-visit-based telephone and portal encounters grew by 73,000 (32%) from 2019 to 2021 and are now approximately double the number of visit-based encounters. These communications take multiple touches and team members to complete, not all of which were counted. The explosion of non-visit-based work, according to staff, contributed to a spiral of work, burnout, and attrition. Conclusion: AHRQ's staffing model is useful in primary care, with the addition of a tool to operationalize this model for leaders and decision makers. The model, however, requires expansion for pediatrics, where not all functions are equally needed, to account for non-visit-based work, and patients expanded BH needs. This expansion requires careful consideration of financing, as clinics are experiencing a double-hit (short-staffed and seeing an explosion of work) and examination of the impact
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