ALTERNATIVES * ALTERNATIVES
Stand-alone HIV cli'nic expected to save money, help patients Cameron Johnston D r. lain Mackie says standalone outpatient clinics that treat patients infected with the human immunodeficiency virus (HIV) can do more than save money for hospitals and the health care system. He thinks they can also help patients escape some of the stigmatization that accompanies the infection and at the same time encourage family doctors to play a more active role in the treatment and care of HIV patients. Mackie, an internist who directs the HIV program at St. Joseph's Health Centre in London, Ont., was speaking at the recent inauguration of the hospital's new HIV outpatient clinic. Located several blocks from the hospital, it is thought to be one of the first Canadian HIV clinics to operate as a remote facility. The clinic also functions as a fully integrated unit of the southwestern Ontario regional hemophilia program. Mackie said the new clinic opened thanks to a $325 000 operating grant from the Ministry of Health, which also provided $60 000 to cover capital equipment costs. He said the expenditure translates into an immediate saving for St. Joseph's global budCameron Johnston is a freelance writer living in London, Ont. 932
CAN MED ASSOC J 1990; 143 (9)
"This facility will provide outreach and support to family physicians. It will let them know that
help is available but at the same time inform
them that there is a lot of work they can do." -
Dr. lain Mackie
get, but will also mean significant savings for the ministry itself. In 1988, for example, the clinic, then based at the hospital, averaged 10 admissions at any given time; an average AIDSrelated hospitalization lasted 17 days and cost $15 000, and at that time most patients needed three or four admissions to hospital per year. With the new clinic handling most patients off site, the hospital now averages just two AIDS-related admissions at a given time. "I think most of this reduction in hospitalization is a result of the treatment we are able to give at the outpatient clinic and the improved treatment on the part of the doctors", Mackie observed. "Certainly the ministry is starting to be aware of the [savings available by] keeping people out of patient beds." Mackie said the concept of a stand-alone clinic was born more of necessity than because of economics. Last year, for instance, the on-site clinic handled more than 250 patients, yet its staff of six worked out of one room in the hospital - there simply wasn't enough space to accommodate the growing caseload. The new, house-sized facility - 232 m2, or 2500 ft2- has two
examination/consultation rooms, offices for social workers and counsellors, and a low-pressure room for patients who are being treated with inhalational pentamidine. Although the new clinic lacks hospital-based services such as xray, nuclear medicine and laboratory facilities, Mackie said it is "absolutely ideal" as an AIDSspecific clinic. Perhaps as important as any cost saving, he said, is the clinic's effect on patients. He said the off-site facility should spare many patients the stigmatization of going to hospital. "Most patients will be able to come here and be assessed medically and psychologically . . . have any treatments that are needed and then get their drugs and go home without ever seeing the hospital." He hopes the clinic will encourage more family doctors to become involved in the treatment of HIV carriers. As it stands, the average family physician has "a very limited knowledge of HIV issues" and therefore relies on hospital clinics and "AIDS specialists" to deal with such patients. "We don't want to be doing all the primary care of HIV patients", Mackie said. "The family
doctor has a major role in the management of AIDS cases, while the specialist's mandate should be to deal with more complicated issues and to deal with treatments that FPs can't provide, such as the pentamidine treatment." In the past 2 years the London HIV clinic has been able to recruit a corps of nine family doctors willing to take referrals from the clinic. "This facility will provide outreach and support to family physicians. It will let them know that help is available but at the same time inform them that there is a lot of work they can do." Mackie finds it distressing that HIV patients are still being treated with drugs whose effectiveness has not been proven. "A lot of my patients have a 1- to 2-year life expectancy once they have been diagnosed . . . they can't wait for new drugs to be approved by HPB [Health Protection Branch] and they are saying 'let me decide'. "We are in a major conflict in terms of the benefit to the patient versus the danger to the public at large. I don't necessarily want to use drugs which are dangerous to the patient but I want my patients to have quick access to the drugs that might save their lives."u
The key is in g your hands. \ Through organ transplants, early detection and treatment and non-stop research, we're contributing to the overall health care of all Canadians. Let's keep it going.
The Kidney Foundation of Canada
10"s homotZ0.
CAN MED ASSOC J 1990; 143 (9)
933
Stand-alone HIV cli'nic expected to save money, help patients Cameron Johnston D r. lain Mackie says standalone outpatient clinics that treat patients infected with the human immunodeficiency virus (HIV) can do more than save money for hospitals and the health care system. He thinks they can also help patients escape some of the stigmatization that accompanies the infection and at the same time encourage family doctors to play a more active role in the treatment and care of HIV patients. Mackie, an internist who directs the HIV program at St. Joseph's Health Centre in London, Ont., was speaking at the recent inauguration of the hospital's new HIV outpatient clinic. Located several blocks from the hospital, it is thought to be one of the first Canadian HIV clinics to operate as a remote facility. The clinic also functions as a fully integrated unit of the southwestern Ontario regional hemophilia program. Mackie said the new clinic opened thanks to a $325 000 operating grant from the Ministry of Health, which also provided $60 000 to cover capital equipment costs. He said the expenditure translates into an immediate saving for St. Joseph's global budCameron Johnston is a freelance writer living in London, Ont. 932
CAN MED ASSOC J 1990; 143 (9)
"This facility will provide outreach and support to family physicians. It will let them know that
help is available but at the same time inform
them that there is a lot of work they can do." -
Dr. lain Mackie
get, but will also mean significant savings for the ministry itself. In 1988, for example, the clinic, then based at the hospital, averaged 10 admissions at any given time; an average AIDSrelated hospitalization lasted 17 days and cost $15 000, and at that time most patients needed three or four admissions to hospital per year. With the new clinic handling most patients off site, the hospital now averages just two AIDS-related admissions at a given time. "I think most of this reduction in hospitalization is a result of the treatment we are able to give at the outpatient clinic and the improved treatment on the part of the doctors", Mackie observed. "Certainly the ministry is starting to be aware of the [savings available by] keeping people out of patient beds." Mackie said the concept of a stand-alone clinic was born more of necessity than because of economics. Last year, for instance, the on-site clinic handled more than 250 patients, yet its staff of six worked out of one room in the hospital - there simply wasn't enough space to accommodate the growing caseload. The new, house-sized facility - 232 m2, or 2500 ft2- has two
examination/consultation rooms, offices for social workers and counsellors, and a low-pressure room for patients who are being treated with inhalational pentamidine. Although the new clinic lacks hospital-based services such as xray, nuclear medicine and laboratory facilities, Mackie said it is "absolutely ideal" as an AIDSspecific clinic. Perhaps as important as any cost saving, he said, is the clinic's effect on patients. He said the off-site facility should spare many patients the stigmatization of going to hospital. "Most patients will be able to come here and be assessed medically and psychologically . . . have any treatments that are needed and then get their drugs and go home without ever seeing the hospital." He hopes the clinic will encourage more family doctors to become involved in the treatment of HIV carriers. As it stands, the average family physician has "a very limited knowledge of HIV issues" and therefore relies on hospital clinics and "AIDS specialists" to deal with such patients. "We don't want to be doing all the primary care of HIV patients", Mackie said. "The family
doctor has a major role in the management of AIDS cases, while the specialist's mandate should be to deal with more complicated issues and to deal with treatments that FPs can't provide, such as the pentamidine treatment." In the past 2 years the London HIV clinic has been able to recruit a corps of nine family doctors willing to take referrals from the clinic. "This facility will provide outreach and support to family physicians. It will let them know that help is available but at the same time inform them that there is a lot of work they can do." Mackie finds it distressing that HIV patients are still being treated with drugs whose effectiveness has not been proven. "A lot of my patients have a 1- to 2-year life expectancy once they have been diagnosed . . . they can't wait for new drugs to be approved by HPB [Health Protection Branch] and they are saying 'let me decide'. "We are in a major conflict in terms of the benefit to the patient versus the danger to the public at large. I don't necessarily want to use drugs which are dangerous to the patient but I want my patients to have quick access to the drugs that might save their lives."u
The key is in g your hands. \ Through organ transplants, early detection and treatment and non-stop research, we're contributing to the overall health care of all Canadians. Let's keep it going.
The Kidney Foundation of Canada
10"s homotZ0.
CAN MED ASSOC J 1990; 143 (9)
933
