Cost-effectiveness of Prophylaxis Against Pneumocystis jiroveci Pneumonia in Patients with Crohn's Disease.

BACKGROUND: Emerging evidence suggests that Pneumocystis jiroveci pneumonia is occurring more frequently in Crohn's disease patients on immunosuppressive medications, especially corticosteroids. Considering its excess mortality and the efficacy of chemoprophylaxis in reducing P. jiroveci pneumonia in acquired immunodeficiency syndrome, there is debate without consensus on the need for chemoprophylaxis in Crohn's disease patients on corticosteroids. AIMS: We sought to address this debate using insights from simulation modeling. METHODS: We used a Markov microsimulation model to simulate the natural history of Crohn's disease in 1 million virtual patients receiving appropriate care and who faced P. jiroveci pneumonia risks that varied with corticosteroid use. We examined several chemoprophylaxis strategies and compared their population-level economic and clinical impact using various indices including costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios. We also performed several nested probabilistic sensitivity analyses to estimate the health and economic impact of chemoprophylaxis in patients on triple immunosuppressive therapy. RESULTS: At the current PJP incidence, no PJP chemoprophylaxis was the preferred strategy from a population perspective. Considered chemoprophylactic strategies led to higher average costs and fewer P. jiroveci pneumonia cases. However, they also led to lower average quality-adjusted life expectancy and were thus dominated. Nevertheless, these alternative strategies became preferred with progressively higher risks of P. jiroveci pneumonia. Our results also suggest that PJP chemoprophylaxis may be cost-effective in patients on triple immunosuppressive therapy. CONCLUSION: Our findings support a case-by-case consideration of P. jiroveci pneumonia chemoprophylaxis in Crohn's disease patients receiving corticosteroids.

Prophylaxis for human immunodeficiency virus-related Pneumocystis carinii pneumonia: using simulation modeling to inform clinical guidelines.

BACKGROUND: Human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy (HAART) have experienced a dramatic decrease in Pneumocystis carinii pneumonia (PCP), necessitating reassessment of clinical guidelines for prophylaxis. METHODS: A simulation model of HIV infection was used to estimate the lifetime costs and quality-adjusted life expectancy (QALE) for alternative CD4 cell count criteria for stopping primary PCP prophylaxis in patients with CD4 cell count increases receiving HAART and alternative agents for second-line PCP prophylaxis in those intolerant of trimethoprim-sulfamethoxazole (TMP/SMX). The target population was a cohort of HIV-infected patients in the United States with initial CD4 cell counts of 350/microL who began PCP prophylaxis after their first measured CD4 lymphocyte count less than 200/microL. Data were from randomized controlled trials and other published literature. RESULTS: For patients with CD4 cell count increases during HAART, waiting to stop prophylaxis until the first observed CD4 cell count was greater than 300/microL prevented 9 additional cases per 1000 patients and cost $9400 per quality-adjusted life year (QALY) gained compared with stopping prophylaxis at 200/microL. For patients intolerant of TMP/SMX, using dapsone increased QALE by 2.7 months and cost $4500 per QALY compared with no prophylaxis. Using atovaquone rather than dapsone provided only 3 days of additional QALE and cost more than $1.5 million per QALY. CONCLUSIONS: Delaying discontinuation of PCP prophylaxis until the first observed CD4 cell count greater than 300/microL is cost-effective and provides an explicit "PCP prophylaxis stopping criterion." In TMP/SMX-intolerant patients, dapsone is more cost-effective than atovaquone.

Low-dose dapsone prophylaxis of Pneumocystis carinii pneumonia in AIDS and AIDS-related complex.

The efficacy, toxicity and cost of orally administered dapsone (50-100 mg/day) for prophylaxis of Pneumocystis carinii pneumonia (PCP) were evaluated in 30 patients with AIDS or AIDS-related complex (ARC). Six patients received primary and 24 secondary prophylaxis. Ten patients received a maximum dose of 100 mg/day and 20 a maximum of 50 mg/day for a median duration of 19 weeks; 22 of the 30 patients continue to receive prophylaxis as of May 1989. Four patients have died, none of pneumocystis infection. One patient with AIDS suffered a mild relapse while receiving 50 mg/day. Hematologic toxicity was mild and could not be definitively attributed to dapsone therapy; rash due to dapsone was documented in two patients. A review of 33 patients at our institution with a history of PCP who received no prophylaxis demonstrated seven relapses, three of which were fatal. Cost analysis revealed a significant advantage for oral dapsone over aerosolized pentamidine.

Prevention of Pneumocystis carinii pneumonia: who are we missing?

OBJECTIVE: To obtain population-based information on the characteristics of persons who were not receiving chemoprophylaxis against Pneumocystis carinii pneumonia (PCP) by examining the use of primary and secondary PCP prophylaxis among San Francisco residents whose AIDS-defining opportunistic illness was PCP in 1993. DESIGN: Retrospective medical record review. SETTING: Medical charts were obtained from San Francisco hospitals and outpatient facilities at which AIDS patients received their initial AIDS diagnosis. PARTICIPANTS: San Francisco residents whose AIDS-defining opportunistic illness was PCP in 1993. MAIN OUTCOME MEASURES: Use of primary and secondary PCP prophylaxis. RESULTS: Of the 326 eligible patients, 35% received primary PCP prophylaxis. Non-whites were significantly less likely to have received primary PCP prophylaxis than white patients [22 versus 40%, respectively; odds ratio (OR), 0.49; 95% confidence intervals (CI), 0.28-0.87]. Uninsured individuals-were also less likely to have received primary PCP prophylaxis than those with insurance (18 versus 41%; OR, 0.35; 95% CI, 0.17-0.73). The sociodemographic characteristics of patients who did and did not receive secondary PCP prophylaxis did not differ significantly. The most frequently cited reasons for not receiving primary PCP prophylaxis were that patients were unaware of their infection with HIV or were not receiving regular medical care. CONCLUSIONS: Barriers to receipt of PCP prophylaxis exist and are resulting in cases of preventable disease and unnecessary medical costs. Interventions to increase counseling, testing, and referral to medical care for persons at high risk for HIV infection are needed.

Analysis of life-long strategies to prevent Pneumocystis carinii pneumonia in patients with variable HIV progression rates.

OBJECTIVE: To compare strategies for life-long prophylaxis of Pneumocystis carinii pneumonia (PCP) in a group of AIDS patients with a wide range of disease progression rates. DESIGN: Markov decision models. METHODS: Prophylaxis strategies using high and low doses of trimethoprim-sulfamethoxazole (TS), dapsone, and/or aerosolized pentamidine in sequence, were compared. Efficacy and toxicity rates for prophylaxis regimens were taken from a meta-analysis of pertinent randomized controlled trials. Outcomes measured included lifetime episodes of PCP and drug toxicity per 100 patients treated, average life expectancy, and cost. RESULTS: For patients with an expected survival of 3 years after commencement of prophylaxis, the use of standard or low dose TS as the first choice agent was comparable, and both were superior to the other strategies for preventing PCP (between nine and 26 fewer episodes of PCP per 100 patients treated) though they were more toxic (11-44 more episodes of toxicity per 100 patients treated). Life expectancy was similar for all of the treatment strategies. With slower rates of disease progression (expected survival > 3.8 years), as seen with current antiretroviral regimens, the use of low dose TS as the first choice agent dominated the use of standard dose TS; when the expected survival time was 7 years, initial use of low dose TS led to 2.8 fewer episodes of PCP per 100 patients treated, 32 fewer episodes of toxicity per 100 patients treated, and US$1381 per patient lower cost, compared with prophylaxis with standard dose TS. CONCLUSION: For patients with AIDS and expected survival > 3.8 years, low dose TS is better than standard dose TS as the first choice agent for preventing PCP. As patients with AIDS live longer, the routine use of low dose TS will be more than adequate for patients at risk for PCP.

The safety of i.v. pentamidine administered in an ambulatory setting.

I.v. pentamidine is well known to cause severe multiorgan adverse effects and is usually given to hospitalized patients under close monitoring. The primary purpose of this retrospective quality assurance study is to assess the safety of administering i.v. pentamidine in the medical daycare unit (MDCU) for outpatients. Thirty-five outpatients infected with the HIV made 306 visits to the MDCU from January 1991 to December 1993. They received i.v. pentamidine in a dosage of either 300 mg once a month for prophylaxis or 4 mg/kg/d 5 days a week for treatment of Pneumocystis carinii pneumonia (PCP). BP was monitored every 15 to 30 min over 3 to 4 h and clinical side effects were noted. CBC count, BUN, creatinine, amylase, and blood glucose values were taken twice a week. The records were reviewed retrospectively and analyzed for clinical and biochemical derangement. GI side effects occurred in 59 of 306 (19%) visits; 43 (73%) of the side effects were nausea. Routine normal saline solution boluses before and after pentamidine infusion prevented the drop in BP and actually significantly elevated BP after i.v. pentamidine. The most common biochemical derangement was elevated BUN level in eight patients and creatinine in nine patients, but they were mild and required no intervention. Significant neutropenia occurred in three, anemia in two, hyponatremia in two, hyperamylasemia in two, and hyperglycemia in two patients. No palpitation or irregular pulse was encountered. No death was associated with the administration of i.v. pentamidine. Three patients required hospital admission. Only one hospital admission was definitely related to adverse drug effects. In conclusion, the side effects of i.v. pentamidine are common but minor. We conclude that it is safe to administer i.v. pentamidine in carefully selected patients with appropriate monitoring in an ambulatory setting. This has a major health economic implication, because ambulatory i.v. pentamidine can result in significant cost savings and can also enhance quality of life. Further studies regarding the feasibility of home administration of i.v. pentamidine is warranted as even further cost savings and improvement in the quality of life of HIV-infected patients may be achieved.

The impact of prophylaxis on outcome and resource utilization in Pneumocystis carinii pneumonia.

STUDY OBJECTIVE: Pneumocystis carinii pneumonia (PCP) is a major late complication of HIV infection associated with morbidity and mortality. Because chemoprophylaxis is highly effective, cases of PCP can be viewed as failures in the management of HIV disease. METHODS: We reviewed demographic, clinical, and cost data for all cases of confirmed HIV-related PCP at The Johns Hopkins Hospital in 1991 to determine consequences of missed prophylaxis. We also analyzed hospital discharge data for Maryland in 1991 to assess hospital charges, length of stay, and outcome for all patients with a principal diagnosis of HIV-related PCP. RESULTS: Pneumocystis carinii pneumonia was diagnosed in 79 patients. Of the 79 patients, 61 (77%) did not receive prophylaxis, including 26 who were not previously known to have HIV infection, 17 who did not have prophylaxis prescribed, and 18 who had prophylaxis prescribed, but were not compliant with the regimen. Patients not taking prophylaxis accounted for all 12 deaths ascribed to PCP. This group also accounted for 85% of the hospital days, 100% of the ICU days, and 89% of the inpatient charges. The total hospital charges were $849,540. Extrapolation of these figures for the state of Maryland suggest that the failure to receive prophylaxis in 1991 resulted in 62 patient deaths and a cost of approximately $4.7 million. CONCLUSION: Patients who developed PCP despite prophylaxis had a better outcome and used fewer resources than patients not receiving preventive therapy. This study emphasizes the impact of PCP prophylaxis on the morbidity, mortality, and economics of HIV health care.

Estimating the cost effectiveness of atovaquone versus intravenous pentamidine in the treatment of mild-to-moderate Pneumocystis carinii pneumonia.

Pneumocystis carinii pneumonia (PCP) is the most common severe opportunistic infection, and one of the most costly, among people with AIDS. Over 50% of patients experience toxic effects of the major anti-PCP medications- cotrimoxazole (trimethoprim-sulfamethoxazole) and pentamidine. Recently, the US Food and Drug Administration approved a new oral drug therapy, atovaquone, as an alternative to pentamidine for the treatment of people with mild-to-moderate PCP who are intolerant of cotrimoxazole. We developed a decision tree model to estimate the costs and cost effectiveness of atovaquone therapy compared with intravenous pentamidine therapy for cotrimoxazole-intolerant patients with mild-to-moderate PCP. Clinical outcomes were based on data from a phase III trial comparing the 2 medications. Our economic outcomes were based on treatment algorithms derived from discharge data, published reports and the clinical judgement of the co-authors. We estimate the total expected cost of treating a patient for an episode of PCP with atovaquone to be $US3990 compared with $US6545 for pentamidine under our baseline scenario (1995 dollars). Our decision model also provides insight into the large cost-savings benefits of treating mild-to-moderate PCP on an outpatient basis.

Pharmacoeconomics of Pneumocystis carinii pneumonia in HIV-infected and HIV-noninfected patients.

Despite the proven effectiveness of Pneumocystis carinii pneumonia (PCP) prophylaxis in both HIV-infected and HIV-noninfected patients, PCP remains an important cause of serious pulmonary infection. Because PCP is a frequent event requiring inpatient admission at our institution, we conducted a study to define the pharmacoeconomics of this infection and the incidence of adverse events associated with anti-PCP therapy. In a retrospective review, 133 patients (101 HIV-positive, 32 HIV-negative) with documented PCP were identified. Significant differences in age, initial arterial oxygen tension (paO2), intensive care unit admission and mortality were evident between HIV-infected and non-HIV-infected patients; however, there were no differences in the duration of hospitalisation or the duration of anti-PCP therapy. The incidence of biochemical abnormalities was similar between the groups. Leucopenia occurred at an incidence of 52 and 31%, while thrombocytopenia occurred at a rate of 7 and 44%, in HIV-positive and HIV-negative patients, respectively. Drug toxicity or treatment failure necessitated a change of therapy in 43% of HIV-positive and 59% of HIV-negative patients. PCP treatment cost, pharmacy cost, hospital cost and net loss (i.e. the difference between hospital cost and reimbursement) were all significantly greater in HIV-negative than in HIV-positive patients. The duration of anti-PCP therapy and the hospital cost for cotrimoxazole (trimethoprim-sulfamethoxazole)- and pentamidine-treated patients were similar, although the treatment cost and pharmacy cost were statistically different in favour of cotrimoxazole. Overall, cotrimoxazole is an inexpensive treatment option. However, the high incidence of adverse events attributed to this agent often necessitates a change to a more costly therapy.

Does experience improve hospital performance in treating patients with AIDS?

This paper examines how experience affects hospital performance in treating patients with AIDS. The most common life-threatening medical complication of AIDS is Pneumocystis carinii pneumonia (PCP). Studies of patients with PCP demonstrate that patients who received care at hospitals that were more experienced with AIDS had lower immediate mortality. These higher volume medical facilities did not use more resources but used resources more efficiently and provided better medical care. Better outcomes for experienced providers suggest three policy implications for improving quality of patient care: (1) create regionalized centers where large numbers of patients with a particular illness are treated; (2) encourage low volume providers to rapidly increase their experience; or (3) establish targeted educational programs for low volume providers. Historical review of experience with other medical problems such as tuberculosis indicate that one policy option, creating regional medical centers, did not have the desired effect of better patient outcomes. These facts support policies to provide targeted educational programs and opportunities for low volume facilities to rapidly increase their familiarity with AIDS. Outcomes could be improved by such policies.

[Diagnostic strategies of pulmonary pneumocystis infection in patients with HIV infection. Decision analysis and medico-economic consequences]. / Stratégies diagnostiques de la pneumocystose pulmonaire chez les patients infectés par le VIH. Analyse décisionnelle et conséquences médico-economiques.

P. carinii pneumonia is one of the most frequent opportunistic infections in HIV-infected patients. Clinical and radiological manifestations are non-specific and reference diagnostic procedure remains broncho-alveolar lavage which is costly and invasive. Alternative diagnostic strategies have been proposed. We report here our experience as well as literature date in this field with the purpose to show the usefulness of decision analysis techniques in choosing an optimal cost-effective strategy.

Health care quality versus economics in HIV.

AIDS: AIDS treatment costs are astronomical, and insurance considerations have forced many HIV-positive persons into managed care programs. In many cases of treating opportunistic infections, the most effective treatment is also the least costly. Prophylaxis with Bactrim dramatically reduces the incidence of Pneumocystis carinii pneumonia (PCP), and is significantly less expensive than the care of acute PCP. A study by the Community Medical Alliance (CMA) in Boston evaluated treatment options provided by teams of home care professionals and found that the treatments worked well for manageable infections like PCP. It is unclear if this system will work as well for conditions such as CMV and wasting.^ieng

Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression.

OBJECTIVE: Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings. DESIGN: Systematic review and meta-regression. METHODS: Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies). RESULTS: The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10(3/)ml. CONCLUSIONS: There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii, ubiquitous in all settings, then becomes a greater relative threat.

Nosocomial Pneumocystis jirovecii pneumonia: lessons from a cluster in kidney transplant recipients.

BACKGROUND: Pneumocystis jirovecii pneumonia (PJP) is an important infection-related complication, whose mode of transmission remains uncertain. METHODS: We investigated a nosocomial cluster of 14 PJP cases (11 confirmed and 3 probable) in kidney transplant recipients using epidemiological and genotyping methods. RESULTS: Poisson regression calculated an incidence density ratio of 42.8 (95% confidence interval [CI], 14.1-129.3) versus background 0.64 cases of 1000 patient-years (P<0.001). All patients presented with respiratory failure, 10 required ventilation, two died, and six transplants failed, costing $31,854 (±SD $26,048) per patient. Four-locus multilocus sequence typing analysis using DNA extracts from 11 confirmed cases identified two closely related genotypes, with 9 of 11 sharing an identical composite multilocus sequence typing genotype. Contact tracing found colocalization of cases within clinic waiting areas, suggesting person-to-person transmission. Minimal and maximal PJP incubation periods were 124±83 to 172±71 days, respectively. Oropharyngeal washes from outpatient staff and ambient air samples were negative for P. jirovecii DNA. Cohort analysis (14 cases vs. 324 unaffected clinic control patients) identified independent risk factors including previous cytomegalovirus infection (odds ratio [OR], 65.9; 95% CI, 7.9-550; P<0.001), underlying pulmonary disease (OR, 10.1; 95% CI, 2.3-45.0; P=0.002), and transplant dysfunction (OR=1.61 per 10 mL/min/1.73 m, 95% CI, 1.15-2.25, P=0.006). The outbreak was controlled by reintroduction of trimethoprim/sulfamethoxazole prophylaxis to all potentially exposed clinic patients and its extension to 12 months in recent recipients. CONCLUSIONS: Nosocomial PJP clusters are likely due to interhuman transmission by airborne droplets to susceptible hosts. Prompt recognition and a strategy of early preemptive blanket PJP prophylaxis to all exposed transplant clinic recipients from the third confirmed case are recommended to limit outbreak escalation.

Challenges in the provision of ICU services to HIV infected children in resource poor settings: a South African case study.

The HIV/AIDS epidemic has placed increasing demands on limited paediatric intensive care services in developing countries. The decision to admit HIV infected children with Pneumocystis carinii pneumonia (PCP) into the paediatric intensive care unit (PICU) has to be made on the best available evidence of outcome and the ethical principles guiding appropriate use of scarce resources. The difficulty in confirming the diagnosis of HIV infection and PCP in infancy, issues around HIV counselling, and the variance in the outcome of HIV infected children with PCP admitted to the PICU in African studies compound this process. Pragmatic decision making will require evaluation of at least three ethical questions: are there clinical and moral reasons for admitting HIV positive children with PCP to the PICU, should more resources be committed to caring for HIV children who require the PICU, and how can we morally choose candidates for the PICU? Those working in the PICU in HIV endemic regions need to make difficult personal decisions on effective triage of admissions of HIV infected children with PCP based on individual case presentation, availability of resources, and applicable ethical principles.

Insurance coverage, usual source of care, and receipt of clinically indicated care for comorbid conditions among adults living with human immunodeficiency virus.

BACKGROUND AND OBJECTIVES: Associations of insurance coverage and source of care with use of human immunodeficiency virus (HIV)-related health, mental health, and substance abuse services are examined in a large, diverse, highly active antiretroviral therapy-era cohort. METHODS: Adults who were infected with HIV (n = 3818) were interviewed in clinics and community agencies in Los Angeles, Milwaukee, New York, and San Francisco regarding drug use behaviors, health status, and health care utilization. RESULTS: Most participants were insured by Medicaid. During the previous 3 months, 90% of privately insured, 87% of publicly insured, and 78% of uninsured participants had visited any provider. Publicly and privately insured participants were similar in receipt of antiretrovirals, prophylaxis against Pneumocystis carinii pneumonia, substance abuse services, and antidepressants. Uninsured participants were less likely to receive antiretrovirals but were more likely to use substance abuse services. Participants with no usual source of care were less likely to receive PCP prophylaxis. CONCLUSIONS: A lack of insurance is associated with barriers to care, but the advantage of private over public coverage appears smaller than in previous studies. PCP prophylaxis, substance abuse treatment, and antidepressants remain markedly underutilized. Educational initiatives about these treatments targeting providers and patients are indicated.

Cost reduction in diagnosing Pneumocystis carinii pneumonia. Sputum induction versus bronchoalveolar lavage as the initial diagnostic procedure.

Sputum induction (SI) is a sensitive and specific method for diagnosing Pneumocystis carinii pneumonia (PCP) in patients with AIDS. Although less expensive than bronchoscopy with bronchoalveolar lavage (BAL), SI followed by BAL does not necessarily reduce costs compared with BAL alone. Cost analysis demonstrates that the cost of diagnosing PCP is dependent on the prevalence of PCP (PCPprevalence) in the studied population, the sensitivity of SI (SIsensitivity) for diagnosing PCP, and the relative costs of SI and BAL (SIcost and BALcost) for diagnosing PCP. In any given clinical setting, SI reduces the cost of diagnosing PCP if (PCPprevalence)(SIsensitivity) greater than SIcost/BALcost. A graphic approach relating these parameters is also presented. Evaluation of reported PCPprevalence and SIsensitivity from recent literature illustrates that SI is not always the least costly method for diagnosing PCP. Cost reduction is not the only measure of a diagnostic procedure's value, and other aspects, such as discomfort, availability, risks, and patient prognosis, must be considered. The cost analysis approach used in this study identifies those variables that can be manipulated to reduce the cost of diagnosing PCP.

The relationship between outpatient drug costs and disease progression in the human immunodeficiency virus-infected population. The Military Medical Consortium for Applied Retroviral Research.

As the focus of the management of human immunodeficiency virus (HIV) infection turns from the treatment of AIDS to the entire continuum of the disease, projection of long-term healthcare costs becomes increasingly important. Rather than a fulminant disease treated primarily inside the hospital, HIV infection will become a chronic condition requiring years of outpatient monitoring and pharmacologic intervention with attending increases in pharmacy costs. The objective of this study was to characterize outpatient drug costs by Walter Reed (WR) disease stage in order to estimate the association of disease progression and outpatient prescription drug costs. We hypothesized that there was an association between HIV disease progression, measured by the WR Staging Classification System, and outpatient prescription drug costs. Outpatient drug costs were summarized for 190 HIV-positive patients during a three-month period who presented at Walter Reed Army Medical Center for staging and follow-up. The overall median cost per day per patient for all stages was $3.21 (range $0.01-53.45) with wide variation between patients. Daily costs for patients in WR stage V were the greatest (median $9.26). There was a significant association between WR stage of disease and outpatient drug costs (Spearman rho = 0.51, t = 6.9, df = 188, p less than 0.001). The association was not completely linear because costs in WR stage VI were less than WR stages IV or V. Annual extrapolated outpatient drug costs for these 190 patients would be nearly $0.5 million.

U.S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals.

Hospitals are a major provider of medical care for human immunodeficiency virus (HIV)-infected persons. Although utilization and patterns of care profiles in public and private hospitals have been evaluated for acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), one of the most costly and common severe complications of AIDS, information from Veterans Administration (VA) hospitals has not been reported previously. This article reports on inpatient care for PCP patients by obtaining data from VA, private, and public hospitals. Cost and resource utilization data were obtained from reviews of medical records, claims, and provider bills from 26 non-VA hospitals and 18 VA hospitals in 10 cities in the United States. Data on severity of illness, patterns of care, and outcomes for PCP were obtained from medical record reviews from 2,174 PCP cases treated in 82 non-VA and 14 VA hospitals in five U.S. cities. Estimates were made of the average costs and the rates of use of diagnostic tests, anti-PCP medications, and intensive care units for samples of public hospital, private hospital, and VA patients with PCP. With mean charges for a single PCP episode of $14,500 to $16,060, PCP remains one of thea most costly complications of AIDS. Although the severity of PCP illness at admission was greatest at public hospitals, the intensity of care was lowest: for frequency of cytologic diagnosis (48% at public, 62% at VA, and 66% at private hospitals), bronchoscopy (45% at public, 60% at VA, and 66% at private hospitals), and intensive care unit use (11% at public, 22% at VA, and 19% at private hospitals). In-hospital mortality rates for PCP also differed in the three types of hospitals (20% at public, 24% at VA, and 18% at private hospitals). Patterns of PCP care differ among VA, public, and private hospitals. Future studies on the HIV epidemic should include data collected from uniform data sources from VA hospitals, in addition to public and private hospitals, to provide insight on the processes of care and outcomes for HIV-infected persons.