Cost and outcome of intensive care for patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure.

OBJECTIVE: To determine the costs and outcomes associated with intensive care unit (ICU) admission for patients with acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), and severe respiratory failure. DESIGN: Survival and cost-effectiveness analysis. SETTING: A large municipal teaching hospital serving an indigent population. PATIENTS: Consecutive patients intubated and mechanically ventilated for AIDS, PCP, and respiratory failure from 1981 through 1991 (n = 113). The cohort was separated into three groups for analysis: patients admitted to the ICU in 1981 through 1985 (era I, n = 43), those admitted in 1986 through 1988 (era II, n = 33), and those admitted in 1989 through 1991 (era III, n = 37). MAIN OUTCOME MEASURES: Hospital charges and survival time; cost per year of life saved, using a zero-cost, zero-life assumption. RESULTS: Twenty-eight (25%) of the 113 patients mechanically ventilated for PCP and respiratory failure survived to hospital discharge: six (14%) of 43 in era I, 13 (39%) of 33 in era II, and nine (24%) of 37 in era III (P = .04). Post-ICU admission charges averaged $57,874 for the entire cohort, remaining relatively stable across the three eras. Cost of care for survivors was significantly more expensive than for those dying before discharge. The cost of ICU admission and subsequent hospitalization averaged $174,781 per year of life saved; $305,795 in era I, $94,528 in era II, and $215,233 in era III. Improved survival rates and shorter lengths of ICU stay led to the improved cost-effectiveness in era II, while the opposite trends resulted in worsening cost-effectiveness in recent years. The strongest predictors of hospital mortality in era III were low CD4 cell counts on hospital admission and the development of pneumothorax during mechanical ventilation. CONCLUSIONS: The cost-effectiveness of intensive care for patients with PCP and severe respiratory failure improved during the first 8 years of the AIDS epidemic but fell in recent years such that it is now below that of many accepted medical interventions.

"The high cost of dying" revisited.

This review of the literature of the past decade on medical care costs at the end of life finds that the data do not support the often-voiced hypothesis that the rise in medical care costs is due largely to the disproportionate use of high-technology medical care by persons who die. It also shows that although the intensity of care, as indicated by hospital expenditures, declines with age, any savings on hospital costs of very old decedents are offset by nursing-home costs. Studies of hospice care and advance directives are reviewed for their effectiveness in reducing end-of-life costs, but these strategies are not promising at this time, largely because of the difficulty of predicting when an individual patient will die. It is suggested that curbing the rise in medical care costs will require basic changes in the physician-patient relationship and in our attitude to death.

Effects of the use of AZT on the medical care costs of persons with AIDS in the first 12 months.

It is important in planning to meet resource needs and financing of care of people with acquired immune deficiency syndrome (AIDS) to determine the effect of the use of azidothymidine (AZT) on overall medical care costs. This study compares the medical care costs of people with AIDS (PWAs) who received AZT with those of PWAs not receiving it. Seven of the nine PWAs who were on the AZT arm of the phase II drug trial of AZT at San Francisco General Hospital (SFGH) in 1986 and a matched sample of PWAs at SFGH who were eligible for the trial but did not participate in it were included in the study and followed for 12 months. It was found that costs in the first 12 months and especially in the first 6 months were lower for persons using AZT, primarily because of significantly lower use of hospital services. However, costs began to rise in the second 6 months for those using AZT. The authors therefore doubt that the lifetime costs of PWAs are lowered by the use of AZT and conclude that they are likely to be the same as those of PWAs not using the drug. If this is indeed the case, the use of the drug is likely to be relatively cost-effective.

Studying the cost of HIV-related illnesses: reflections on the moving target.

Although medical care costs of the HIV epidemic by 1991 may reach $6 billion, or 1.2 percent of all estimated personal health care expenditures in the United States, costs per patient of treating AIDS appear to be declining. Calculating the epidemic's costs is difficult, however, in that data are lacking on health care expenditures for HIV-infected persons other than those with AIDS, intravenous drug users, women, and children. Shifts in demographic segments affected, changes in medical treatments, and diffusion beyond initial urban centers will alter the economics of AIDS. Prospective studies at both national and local levels are needed to gauge the epidemic's costs and demands on health services.

The cost of AIDS: an agenda for research.

It is generally not appreciated how much we have learned about AIDS in the relatively short time - about 7 or 8 years - since it made its first appearance in the United States. We have learned not only its cause and its way of transmission, but we also have data, though not perfect data, on its incidence and prevalence as well as an increasing body of data on the medical care costs of persons with AIDS. There are few other diseases for which we have as much information on incidence and prevalence, and especially on costs. In addition, various models have been constructed to project the future incidence and prevalence of the disease and the medical care costs associated with it. Nevertheless, serious gaps in our knowledge remain: inadequacies of current data on the number of persons with AIDS and especially on the number of persons infected with HIV; inadequacies and limitations of the data on the medical care costs of persons with AIDS; and an almost total lack of data on the number of persons infected with HIV with symptoms and conditions other than AIDS and their medical care costs. These gaps in our knowledge will be discussed in detail, and various types of studies to fill them will be suggested.

AIDS: costs of care in the developed and the developing world.

PIP: The costs of care for AIDS patients in developed and developing countries, expressed in patient-years and in patient lifetimes, as well as by total national costs are analyzed here. In industrialized countries, known as WHO Pattern I countries, the costs of AIDS care is generally proportional to GNP, and has been declining as caregivers learn how to manage the disease. Much of the decline is due to less intensive hospital care and more ambulatory care. Although the U.S. has the highest number of AIDS cases, the countries with the highest rate of disease are Canada (59.2/million), Australia (48.1) and New Zealand (22.4). In the U.S. 92% of patients are male, and 87% are 20-49 years old. In Pattern II countries, the sex ratio is less than 2.0. Cost information is very sparse, especially for children. Some representative lifetime costs for Pattern I countries are $19,000-147,000 in the U.S., $21,000 in France, $40,200 in Germany, $13,400-46,000 in U.K., and $15,800 in Australia. Costs per person-year are generally comparable, depending on whether hospitalization is more or less common in given countries. In the developing world, expenditures are much lower, because of the limited budget for health care available. Although costs tend to be in line with a country's GNP, costs are expected to become more standardized in the future as clinical experience with AIDS treatment increases and costing methodology becomes more uniform. Estimates of AIDS treatment costs for the U.S. in the near future range widely, but range from 1% to 3.3% of the total personal health-care expenditures of the nation. An estimate for Australia predicts $58.5 million by 1991, including hospital expenses only. None of the available costs estimates even deal with the costs of managing HIV-infected persons who have not developed AIDS. Needs in cost estimation methodology are discussed.^ieng

Medical care in the last twelve months of life: the relation between age, functional status, and medical care expenditures.

Medical care expenditures of a group of decedents during their last year of life suggest that high-technology medical services may be allocated most rationally than is generally assumed. Patients who received intensive hospital and physician services were largely the "young old," aged 65 to 79 years with good functional status, while the frail "older old," aged 80 years and over, received largely supportive care. Total care expenses of the older old were only slightly below those of the most expensive decedents, however, as expenses for nursing home and home health care more than offset lower medical service expenses. Further studies are needed before concluding that the major cause of high costs at teh end of life is the inappropriate use of high-technology care.

Estimates of the direct and indirect costs of acquired immunodeficiency syndrome in the United States, 1985, 1986, and 1991.

This study presents three estimates ranging from low to high of the direct and indirect costs of the acquired immunodeficiency syndrome (AIDS) epidemic in the United States in 1985, 1986, and 1991, based on prevalence estimates provided by the Centers for Disease Control (CDC). According to the author's best estimates, personal medical care costs of AIDS in current dollars will rise from $630 million in 1985 and $1.1 billion in 1986 and $8.5 billion in 1991. Nonpersonal costs (for research, screening, education, and general support services) are estimated to rise from $319 million in 1985 to $542 million in 1986 to $2.3 billion in 1991. Indirect costs attributable to loss of productivity resulting from morbidity and premature mortality are estimated to rise from $3.9 billion in 1985 to $7.0 billion in 1986 to $55.6 billion in 1991. While estimated personal medical care costs of AIDS in 1985 and 1986 represent only 0.2% and 0.3%, respectively, of such estimated expenditures for the U.S. population in these 2 years, they represent 1.4% of these estimated costs in 1991. Similarly, while estimated indirect costs of AIDS represent 1.2% in 1985 and 2.1% in 1986 of the estimated indirect costs of all illness, they are projected to rise to almost 12% in 1991. For estimating the indirect costs, the human capital method was used, and it was assumed that average wages and labor force participation rates of persons with AIDS were the same as those for the general population by age and sex.

Estimates of the direct and indirect costs of acquired immunodeficiency syndrome in the United States, 1985, 1986, and 1991.

This study presents three estimates--ranging from low to high--of the direct and indirect costs of the AIDS epidemic in the United States in 1985, 1986, and 1991, based on prevalence estimates provided by the Centers for Disease Control (CDC). According to what the authors consider their best estimates, personal medical care costs of AIDS in current dollars will rise from $630 million in 1985 to $1.1 billion in 1986 to $8.5 billion in 1991. Nonpersonal costs (for research, screening, education, and general support services) are estimated to rise from $319 million in 1985 to $542 million in 1986 to $2.3 billion in 1991. Indirect costs attributable to loss of productivity resulting from morbidity and premature mortality are estimated to rise from $3.9 billion in 1985 to $7.0 billion in 1986 to $55.6 billion in 1991. While estimated personal medical care costs of AIDS represent only 0.2 percent in 1985 and 0.3 percent in 1986 of estimated total personal health care expenditures for the U.S. population, they represent 1.4 percent of estimated personal health care expenditures in 1991. Similarly, while estimated indirect costs of AIDS represent 1.2 percent in 1985 and 2.1 percent in 1986 of the estimated indirect costs of all illness, they are estimated to rise to almost 12 percent in 1991. Estimates of personal medical care costs were based on data from various sources around the United States concerning average number of hospitalizations per year, average length of hospital stay, average charge per hospital day, and average outpatient charges of persons with AIDS. For estimating the indirect costs the human capital method was used, and it was assumed that average wages and labor force participation rates of persons with AIDS were the same as those for the general population by age and sex.

Medical care costs of patients with AIDS in San Francisco.

This article reports on the findings of a study of medical care expenditures of persons with acquired immunodeficiency syndrome (AIDS) treated at San Francisco General Hospital in 1984. We found that mean charges per AIDS hospital admission were $9024, mean charges of patients with AIDS who received all their hospital inpatient and outpatient care at San Francisco General Hospital in 1984 ranged from $7026 to $23,425, and mean lifetime inpatient charges of patients with AIDS who died and who had received all their inpatient care at the hospital were $27,571. These latter charges were considerably lower than previously published estimates of lifetime direct medical care costs of patients with AIDS, and the possible reasons for the differences include much lower lifetime use of hospital services and somewhat lower cost per hospital day.

Changes in the costs of treatment of selected illnesses, 1971-1981.

This study, like two earlier studies by the author, examines the effects of changing medical technologies on medical care costs by comparing the costs of treatment of a number of common illnesses at two points in time, 1971 and 1981. While the earlier studies, covering the periods 1951-1964 and 1964-1971, showed that the main cost-raising changes had been a steep rise in the use of relatively low-cost ancillary services, such as laboratory tests and x-rays ("little-ticket" technologies), this study shows that in the period 1971-1981 the use of these technologies hardly changed but that several new and expensive technologies ("big-ticket" technologies) came into use, which raised medical care costs considerably.

"The high cost of dying": what do the data show?

Assertions that we now spend too much of our medical dollar on the dying often imply a ready target for cost-containment efforts: frequency and intensity of expenditures at the end of life, especially for the aged. But available, although meager data suggest there has been neither a dramatic rise in the last 20 years in the use of the hospital as a place to die, nor of widespread use of "heroic" interventions on behalf of those who die. Rather, very sick patients receive intensive and expensive care; our ability to project rates of survival vs. terminal patient status warrants caution in approaches to medical economy.

Out-of-plan use under two prepaid plans.

This analysis of out-of-plan use of physician and paramedical services under a Kaiser plan and under a prepaid option offered by a predominantly fee-for-service group practice (Clinic plan) deals primarily with services that members could have obtained from plan providers ("covered services"). The extent and pattern of out-of-plan use were found to be similar. While 16-20 per cent of plan members used some out-of-plan covered services and the mean number of such services was about one half visit per member per year, most out-of-plan user were occasional user, 10-12 per cent of user (or 2 per cent of plan members) accounting for 50 per cent of all out-of-plan covered services. The principal members characteristics associated with out-of-plan use were dissatisfaction, health status and having other insurance. The literature on out-of-plan use is also reviewed.