The paper by Hekkink et al. reports on a research project with two major aims. First to compare the quality of care that HIV-infected patients receive from HIV nursing consultants, HIV specialists and general practitioners; and second, to compare HIV patients’ opinions about care delivered by HIV nurse consultants with the opinions of patients with rheumatic diseases regarding care received from specialist nurses. The study, conducted in the Netherlands, was a cross sectional questionnaire survey of 226 patients with HIV infection and 128 with rheumatic disease.

The challenges of the HIV epidemic and the respective health care responses have been similar in the UK and the Netherlands. In both countries, the treatment of infected patients has always involved a wide range of services centred largely upon hospital-based specialist HIV services including genitourinary medicine and infectious disease units. Community-based services have been made available from general practitioners and community-based nursing, health and social care staff.

While both nations employ HIV specialist and consultant nurses, the consultant role appears to be most developed in the Netherlands. In the UK, specialist nurses were appointed in the 1980s while the nursing consultant role was not developed until the government paper Making a Difference (Department of Health 1999) was published. No published statistics are presently available showing the number of HIV nurse consultants in post in the UK but a very small number of appointments appear to have been made. In view of the escalating numbers of new HIV infections being reported (Health Protection Agency 2004), it is most likely that the role and function of the HIV nursing consultant will increase in importance as a service leader. Consequently, the evaluation of patient experiences of care presented by Hekkink et al. could provide valuable insights for developing HIV-nursing services in the UK. The arm of the investigation-comparing levels of satisfaction with performance between patients with rheumatic disease and HIV infection, to some extent, distracts from the central theme and may have been better explored by a study designed specifically for that purpose.

The study is underpinned by the assessment of quality of care received by HIV patients from the three different providers, i.e. nurse specialists, nurse consultants and general practitioners. The questionnaire method of assessment is called QUOTE-HIV and is a modified version of a scale designed to measure patient perceptions of care quality developed by the authors for use in other specialties (Hekkink et al. 2003). The QUOTE-HIV schedule comprises 27 items or aspects of care. Of these, 14 have a direct bearing on HIV-specific elements of care while the remainder (13) address generic aspects of care. In the study reported, 23 scale items were used and patients were asked to rate both the importance of each item and the quality of provider performance they experienced. Ratings were made on four point scales scoring from one to four with lower scores reflecting less importance or poorer performance. The actual statement used to elicit the performance rating is not included in the text and given that responses are stated only in terms of ‘yes’ and ‘no’ it is not obvious what it might have been. From these scores, a ratio was calculated by dividing the quality of performance rating by the importance rating. The resulting ratio was interpreted as being satisfactory if it was equal to or greater than one. If it was less than one then it was held to indicate room for improvement in care.

A ‘weighted evaluation score’ (WES) was also calculated to combine the scale items to reflect three different components of care. These were professional performance (seven items), professional attitudes (seven items) and organization of care (nine items). The exact purpose of the WES and how it was calculated is somewhat obscure and a more detailed explanation would probably be appreciated by some readers.

In an earlier paper describing the development of the QUOTE-HIV instrument (Hekkink et al. 2003), it is claimed that the importance component is incorporated to the judgement of quality as a weight factor and consequently it is useful for the ‘… identification of aspects of care that really need improvement’. The manipulations involved to achieve the weighting raise some important questions as to how the resulting ratio can be interpreted. As noted above, the authors’ interpretation is that a ratio score of less than one indicates room for improvement while a score of one or over reflects satisfactory care.

A consideration of the possible combinations of the different scale scores for importance and performance illustrates a possible difficulty. If the importance of an aspect of care is rated as one, i.e. of least importance, then the denominator of the fraction is one, meaning the only possible ratio scores would be one, two, three or four. In other words, it is impossible for the area of care to score below one and consequently it will never be shown as in need of improvement, even if it is given the lowest performance score, i.e. one. On the other hand, ratios for the most important areas of care will be calculated using four as the denominator. The only possible ratios in this instance are 0·25, 0·5, 0·75 and 1. It is possible that areas of highest importance in HIV care will be extraordinarily difficult to attain the highest performance. They will require the most extraordinary inputs to attain the maximum score of four on the quality scale yet this is the only score which would yield a ratio indicating satisfactory care, i.e. one.

As a general rule, across the full range of scale scores, the implication is that the less important an item becomes the less likely it is to be shown as needing improvement and vice versa, regardless of what care is provided. It is not surprising to find that when correlations (Pearson's ‘r’) are carried out on the data published in Tables 2 and 3, the ratio scores are shown to have a significant negative correlation with the ‘importance’ ratings (r = −0·60, P < 0·01) and a significant positive correlation with the ‘performance’ ratings (r = 0·39, P < 0·05).

Fortunately, the original importance and performance scores are included in the data and these provide a much firmer base for the conclusions which the paper leads us to.


  1. Top of page
  2. References
  • Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. Department of Health, London.
  • Health Protection Agency (2004) Annual Report 2004 February 2005.
  • Hekkink CF, Sixma HJ, Wigersma L, Yzermans CJ, van der Meer JTM, Bindels PJ, Brinkman K & Danner SA (2003) Quote-HIV an instrument for assessing quality of HIV care from the patients perspective. Quality and Safety in Health Care 12, 188193.