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(Chest. 2004;125:548-556.)
© 2004 American College of Chest Physicians

US Hospital Care for Patients With HIV Infection and Pneumonia*

The Role of Public, Private, and Veterans Affairs Hospitals in the Early Highly Active Antiretroviral Therapy Era

Constance R. Uphold, PhD, ARNP, RN; Maria Deloria-Knoll, PhD; Frank J. Palella, Jr, MD; Jorge P. Parada, MD, MPH; Joan S. Chmiel, PhD; Laura Phan, MPH and Charles L. Bennett, MD, PhD

* From the Rehabilitation Outcomes Research Center (Dr. Uphold), North Florida/South Georgia Veterans Health System, Gainesville, FL; Department of Preventive Medicine (Dr. Deloria-Knoll), Department of Medicine (Dr. Chmiel), Division of Infectious Diseases (Dr. Palella), Feinberg School of Medicine, Northwestern University, Chicago; Stricht School of Medicine-Loyola University, Maywood, IL, and Midwest Center for Health Services Research and Policy Research (Dr. Parada), Hines VA Hospital, Hines, IL; and VA Chicago Health Care System-Lakeside Division (Dr. Bennett and Ms. Phan), Chicago, IL.

Correspondence to: Constance R. Uphold, PhD, ARNP, RN, North Florida/South Georgia Veterans Health System, Research Department, Stop 151, 1601 SW Archer Rd, Gainesville, FL 32608-1197; e-mail: Connie.Uphold{at}med.va.gov


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: We evaluated differences in processes and outcomes of HIV-related pneumonia care among patients in Veterans Affairs (VA), public, and for-profit and not-for-profit private hospitals in the United States. We compared the results of our current study (1995 to 1997) with those of our previous study that included a sample of patients receiving care during the years 1987 to 1990 to determine how HIV-related pneumonia care had evolved over the last decade.

Setting/patients: The sample consisted of 1,231 patients with HIV infection who received care for Pneumocystis carinii pneumonia (PCP) and 750 patients with HIV infection who received care for community-acquired pneumonia (CAP) during the years 1995 to 1997.

Measurement: We conducted a retrospective medical record review and evaluated patient and hospital characteristics, HIV-related processes of care (timely use of anti-PCP medications, adjunctive corticosteroids), non–HIV-related processes of care (timely use of CAP treatment medications, diagnostic testing, ICU utilization, rates of endotracheal ventilation, placement on respiratory isolation), length of inpatient hospital stay, and inpatient mortality.

Results: Rates of timely use of antibiotics and adjunctive corticosteroids for treating PCP were high and improved dramatically from the prior decade. However, compliance with consensus guidelines that recommend < 8 h as the optimal time window for initiation of antibiotics to treat CAP was lower. For both PCP and CAP, variations in processes of care and lengths of in-hospital stays, but not mortality rates, were noted at VA, public, private not-for-profit hospitals, and for-profit hospitals.

Conclusions: This study provides the first overview of HIV-related pneumonia care in the early highly active antiretroviral therapy era, and contrasts current findings with those of a similarly conducted study from a decade earlier. Quality of care for patients with PCP improved, but further efforts are needed to facilitate the appropriate management of CAP. In the third decade of the epidemic, it will be important to monitor whether variations in processes of care for various HIV-related clinical diagnoses among different types of hospitals persist.

Key Words: community-acquired pneumonia • HIV • Pneumocystis cariini pneumonia • quality of care


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
In the 1980s, AIDS was predictably fatal, with Pneumocystis carinii pneumonia (PCP) being the most common opportunistic pneumonia, presenting AIDS diagnosis, and cause of death. Most medical expenditures among persons with HIV infection were for inpatient HIV-related care. Hospitalizations for PCP were typically long and costly, averaging from 12 to 20 days and $14,500 to $16,000.1 However, the duration, acuity, and quality of inpatient care for PCP varied, with Veterans Affairs (VA) hospitals having the longest mean length of stay (LOS) and highest rates of ICU use, and private hospitals most likely to utilize diagnostic bronchoscopy.1 In the mid-1990s, marked reductions in opportunistic diseases and AIDS-related mortality were achieved with the introduction and prevalent use of highly active antiretroviral therapy (HAART).2 This, as well as the continued and widespread use of prophylaxes for such opportunistic infections as PCP, allowed HIV infection to be transformed from an almost invariably terminal disease to a controllable chronic illness.3

Despite these changes, inpatient care costs continued to account for the largest component of HIV-related medical expenditures during these years.4 Data on variations in inpatient HIV-related pneumonia care for persons in VA, public, for-profit private, and not-for-profit private hospitals in the second decade of AIDS have yet to be reported.

In this study, we evaluated whether differences in processes and outcomes of care for patients with HIV infection and PCP persisted into the second decade of the HIV epidemic. In order to broaden as well as temporally extend our previous findings, we added two components to our study. First, we compared VA hospitals with public hospitals and two types of private hospitals: for-profit and not-for-profit. Second, we evaluated variations in processes and outcomes of care in patients with HIV infection with community-acquired pneumonia (CAP). This provided additional information and increased the generalizability of our findings, as the spectrum of HIV-related pneumonia has changed since the advent of HAART. Although PCP remains an opportunistic infection of concern and an important potential cause of morbidity and hospitalizations of patients with HIV,5 the incidence of CAP is now greater than that of PCP.6 7 8 The purpose of this study is to provide a systematic view of how HIV-related pneumonia care has evolved over the last decade.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Sampling of Cities, Hospitals, and Patients
We studied 1,231 patients with HIV infection who received care for PCP in 34 hospitals, and 750 patients with HIV infection who received care for CAP in 30 hospitals. The hospitals were located in three high-HIV/AIDS-incidence cities in the United States: Los Angeles, Miami, and Chicago. In the current study, we only included cities for which data were obtained from both VA and non-VA hospitals. Information was abstracted for medical care that was provided between January 1, 1995, and December 31, 1997. The Institutional Review Board of each participating hospital approved the study protocol prior to initiation of data collection, and patient, physician, and hospital confidentiality were maintained throughout the study. As in our previous studies,9 10 our sampling methodology employed two hierarchical levels: hospitals within cities, and patients within hospitals. A few hospitals did not participate in both the PCP and CAP studies because the chart reviews for these studies were conducted at different time periods. All discharges including International Classification of Diseases, Ninth Revision codes for HIV-related disease (042–044) were screened if they also contained codes for either PCP (136.3) or bacterial pneumonia (481–486). Exclusion criteria were the following: age < 18 years; transfer from another acute-care hospital inpatient service; history of cancer; cytologically proven PCP, proven pulmonary tuberculosis, or CAP within the past 30 days; or hospitalization for any reason within the past 30 days.

Data Acquisition and Quality
Registered nurses with experience in both HIV treatment and utilization review were trained to abstract medical records. Two physicians trained in quality assurance for the project maintained data quality by overreading medical chart abstraction forms. The physician overreaders categorized < 1% of entries as possibly inaccurate. Data abstracted from medical charts included the following: patient sociodemographics; insurance status; HIV-related and non–HIV-related comorbid conditions; cigarette, alcohol and drug use history; preadmission use of antiretroviral and opportunistic infection prophylactic medications; CD4+ cell counts and HIV viral load (HIV-1 RNA) levels; initial vital signs; arterial blood gas measurements and laboratory data; treatment medications received; principal and secondary diagnostic and procedure codes; LOS; and discharge status.

Study Variables
Hospital Characteristics: Hospitals were characterized according to ownership (public, not-for-profit private, for-profit private, and VA) as documented in the American Hospital Association guide.11 Patients with HIV infection received care for PCP in 3 public hospitals, 19 not-for-profit private hospitals, 7 for-profit private hospitals, and 5 VA hospitals. Patients received care for CAP in 3 public hospitals, 19 not-for-profit private hospitals, 3 for-profit private hospitals, and 5 VA hospitals.

Patient Characteristics: Patients were characterized by age, gender, race, employment, preadmission place of residence, HIV-acquisition risk factors, insurance status, smoking status, history of pulmonary diseases, PCP prophylaxis, and antiretroviral drug therapy before hospital admission. Age at hospital admission was derived using date of birth or was abstracted from the medical record. Race was recorded as white, African American, and Hispanic/other. Employment status was categorized as full/part-time, unemployed, retired, or disabled. Information collected on preadmission place of residence noted whether the patient was homeless, living in a hotel, or in prison. HIV-acquisition risk factors were categorized according to information provided by the medical records and included the following: men who have sex with men, patients reporting injection drug use, patients reporting noninjection drug use, and patients with unknown or unreported risk factors. Heterosexual acquisition of HIV infection without recreational drug use was infrequently noted. Insurance status was recorded as private insurance (including fee-for-service and preferred provider organizations), public insurance (including Medicaid, Medicare, and government-sponsored veterans insurance), and self-pay/no insurance. Smoking status was categorized on the basis of whether the patient was or was not a current smoker. A patient having had any of the following diagnoses before hospital admission was considered to have history of pulmonary disease: chronic pulmonary disease, emphysema, asthma, chronic bronchitis, pneumothorax, lung resection, PCP pneumonia, and non-PCP pneumonia. PCP prophylaxis and antiretroviral medication use prior to hospital admission were categorized as yes or no.

Severity of Illness: We have previously developed etiology-specific severity of illness stages that have been validated for both PCP and CAP. For PCP, severity of illness at hospital admission was based on wasting (operationally defined as documentation of weight loss > 20% and/or wasting syndrome), alveolar-arterial oxygen gradient (P[A-a]O2), serum albumin levels, and defined as follows: stage 1, no evidence of wasting, P(A-a)O2 <= 53 mm Hg (mortality rate, 3.7%); stage 2, wasting, P(A-a)O2 <= 53 mm Hg (mortality rate, 8.5%); stage 3, no evidence of wasting, P(A-a)O2 > 53 mm Hg (mortality rate, 16.1%); stage 4, wasting, P(A-a)O2 > 53 mm Hg, and a serum albumin level > 2.55 g/dL (mortality rate, 23.3%); and stage 5, wasting, P(A-a)O2 > 53 mm Hg, and a serum albumin <= 2.55 g/dL (mortality rate, 49.1%). A detailed summary appears in Arozullah et al.9

The CAP severity staging system is based on neurologic symptoms, the respiratory rate, and serum creatinine level, and is defined as follows: stage 1, no evidence of neurologic symptoms and respiratory rate < 25 breaths/min (mortality rate, 2.3%); stage 2, no evidence of neurologic symptoms, respiratory rate >= 25 breaths/min, and serum creatinine level <= 1.2 mg/dL (mortality rate, 5.8%); stage 3, evidence of neurologic symptoms and respiratory rate < 25 breaths/min (mortality rate, 12.9%); stage 4, no evidence of neurologic symptoms, respiratory rate >= 25 breaths/min, and serum creatinine level > 1.2 mg/dL (mortality rate, 22.0%); and stage 5, evidence of neurologic symptom and respiratory rate >= 25 breaths/min (mortality rate, 40.5%). The staging system has been shown to predict the hospital discharge status (alive vs dead) correctly for 85.2% of the patients in the CAP data set.12 For CAP, we also calculated a Fine score for each patient, which is based on demographic factors, comorbid illnesses, physical examination findings, and laboratory findings.13

HIV-Related and Non–HIV-Related Process of Care and Outcomes: The timing and intensity of care were evaluated and based on the treatment and outcome of the pneumonia episode, as outlined by physician consultants to the project. For HIV-related processes of care, we examined the timely use of anti-PCP medications (within 2 days of hospital admission) and adjunctive corticosteroids (within 3 days of initiation of anti-PCP medications). For non–HIV-related care process measures, we examined the timely use of CAP treatment medications within 24 h of hospital admission and at anytime during hospital stay, ICU utilization, rates of endotracheal intubation for ventilatory support, and placement on respiratory isolation while ruling out pulmonary infection with Mycobacterium tuberculosis. We examined the timing and intensity of diagnostic testing: cytologic confirmation (PCP only), bronchoscopic evaluation within 2 days of hospital admission, and at any time during the hospital stay, and whether chest radiographs were obtained. In patients with either CAP or PCP, we examined the use of do-not-resuscitate (DNR) orders and rates of patient discharge against medical advice (AMA).

We evaluated mortality rates using discharge status (alive or dead). LOS was measured in days and calculated only for patients who were alive at discharge.

Statistical Analysis
Hospital and patient characteristic data from the PCP and CAP studies are shown combined when both frequency of occurrence and association with the four hospital ownership categories were similar, and separately for these two diagnoses otherwise. Pairwise comparisons of hospital and patient characteristics evaluating VA hospitals vs the three other hospital ownership types, as well as heterogeneity among the four hospital types, were undertaken using {chi}2 or Fisher exact tests for comparisons of proportions, t tests and analysis of variance for comparisons of means, and Wilcoxon rank-sum or Kruskal-Wallis tests for comparisons of medians. For analyses of combined data from the CAP and PCP studies, heterogeneity among the four hospital types was adjusted for using a Cochran-Mantel-Haenszel test for categorical variables or analysis of variance for continuous variables. However, these results are not presented because they did not differ meaningfully from unadjusted comparisons. In addition, variations in ICU use and in-hospital mortality rates (as independent variables) were evaluated using logistic regression models. For evaluating relationships between hospital ownership types and length of in-hospital stay, a multiple regression model was constructed. The basic multivariate models adjusted for age, gender, race or ethnicity, risk group, city, smoking status, severity stage of PCP and CAP, discharged AMA, history of pulmonary disease, prior HIV and AIDS diagnoses, and PCP prophylaxis and antiretroviral therapy prior to hospital admission. These analyses excluded patients with DNR orders. The SAS statistical package (version 8.0; SAS Institute; Cary, NC) was used for all analyses. Significance was defined as p < 0.05 based on two-sided tests.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Patient Characteristics
Characteristics differed among patients treated at VA (n = 142), public (n = 591), not-for-profit (n = 944), and for-profit (n = 304) hospitals (Table 1 and Table 1A ). Patients at VA hospitals were oldest, all male, most likely to use injection drugs, most likely to be current smokers, and differed from patients who received care in other hospitals with respect to race/ethnicity, employment status, and preadmission residence. Rates of Medicaid coverage varied among the cohorts of patients who received care at the three non-VA hospitals. VA hospital patients were least likely to have had AIDS-related problems prior to hospital admission, least likely to have ever received a diagnosis of PCP, and least likely to have been hospitalized for pneumonia or COPD in the 12 months prior to hospital admission (4.2% vs 22.7% for patients at public hospitals, 14.9% for not-for-profit hospitals, and 10.5% for for-profit hospitals). Patients who received care at VA hospitals (12%) and public hospitals (14%) were more likely to have had a prior tuberculosis diagnosis than patients seen at not-for-profit hospitals (6.8%) and for-profit private hospitals (3%). Rates of PCP prophylaxis prior to hospital admission differed significantly (46.5% for patients at VA hospitals, 41.6% at public hospitals, 48.7% at not-for-profit hospitals, and 54.3% at for-profit hospitals [p = 0.002], as did antiretroviral therapy use prior to hospital admission (43% for patients at VA hospitals, 27.6% for public hospitals, 42.2% for not-for-profit hospitals, and 52.3% at for-profit hospitals [p < 0.001]). In contrast, the proportion of patients with severe cases of PCP or CAP illness at hospital admission (graded as stage 4 or 5 in disease-specific staging systems) was similar for patients who received care at the four groups of hospitals (range was 10.6% for for-profit hospitals to 14.4% for not-for-profit hospitals, p = 0.31).


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  		Table 1.. Comparisons of VA Hospitals vs Non-VA Hospitals*

 

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  		Table 1A.. Continued

 
Process of Care and Outcomes
Patterns of care differed among patients who received care at the four types of hospitals. The rates of bronchoscopy for patients with a PCP diagnosis were 37.8% for patients at VA hospitals, 20.9% at public hospitals, 51.2% at not-for-profit hospitals, and 31.5% at for-profit hospitals (p < 0.001); for patients with CAP, the rates were 15.8% for patients at VA hospitals, 10.4% at public hospitals, 27.8% at not-for-profit hospitals, and 19% at for-profit hospitals (p < 0.001).

Rates of respiratory isolation while ruling out tuberculosis infection were higher for patients with HIV infection and pneumonia who received care at public hospitals (83.3%) and VA hospitals (69.7%) vs those who received care at not-for-profit hospitals (48.5%) or for-profit private hospitals (12.5%) [p < 0.001]. Patients with PCP, but not CAP, were more likely to be discharged AMA at VA hospitals (11.8%) than at public hospitals (6.5%), not-for-profit hospitals (2.5%), and for-profit hospitals (2.5%) [p < 0.001].

The timeliness of PCP-specific treatment initiation (within 2 days of hospital admission) and adjunctive corticosteroids (within 3 days of initiation of anti-PCP medications) were similar, while the timeliness of CAP-specific treatment initiation (within 24 h of hospital admission) was poorer for patients at not-for-profit hospitals (58.5% vs rates of 66.7% to 77.0% for patients who received care at the other three types of hospitals) [p < 0.001].

Patterns of resource utilization differed. Patients at VA hospitals had the longest inpatient stays for PCP (median of 10 days at VA hospitals, 7 days at public hospitals, 8 days at not-for-profit hospitals, and 6 days at for-profit hospitals [p < 0.001]) and for CAP (median of 7 days for patients at VA hospitals, 5 days at public hospitals, 6 days at not-for-profit hospitals, and 5 days at for-profit hospitals [p < 0.001]). These differences persisted after adjustments for clinical covariates. Rates of ICU use were highest for patients with PCP who received care at VA hospitals (22.4% for patients at VA hospitals, 12.6% for patients at public hospitals, 19.3% for patients at not-for-profit hospitals, and 18.6% for patients at for-profit hospitals [p = 0.04]), but after adjusting for severity of illness at hospital admission, the ICU use rates were similar among the four types of hospitals (data not shown). Patients with CAP had similar rates of ICU use across hospital types in both univariate analyses and after adjustment for differences in severity of illness at hospital admission. After adjustment for differences in severity of illness at hospital admission, inpatient mortality rates were similar for patients with CAP and PCP who received care at each of the different types of hospitals (data not shown).


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Despite marked reductions in rates of AIDS-related mortality and opportunistic infections consequent to the prevalent use of HAART that began in 1996,2 the most recent data (from mid-1997 through 1998) indicate that inpatient care still accounts for 40% of the adjusted total monthly medical expenditures of persons with AIDS.4 PCP and CAP, the two most common pulmonary illnesses that affect patients with HIV infection in the HAART era, account for a significant portion of the total inpatient medical care of patients with HIV infection.7 14 In this study, we found that among cohorts of inpatients with HIV infection and PCP who received care at one of four different types of hospital systems, median durations of hospitalization were between 6 days and 10 days, 12 to 22% received care in an ICU, 21 to 51% underwent diagnostic bronchoscopy, and 8 to 13% died during hospitalization. In contrast, among cohorts with CAP, median durations of hospitalization were between 5 days and 7 days, 6 to 12% received care in an ICU, 10 to 27% underwent diagnostic bronchoscopy, and 6 to 12% died during hospitalization.

Only one prior study1 has addressed variations in patterns of care and outcomes for patients with HIV infection and PCP at VA vs public and private hospitals. That study1 included 2,174 hospitalized patients with PCP who received care during the years 1987 to 1990, while the current study includes 1,231 hospitalized patients with PCP who received care during the years 1995 to 1997. Taken together, the studies identify large temporal changes in PCP care. Lengths of hospitalization were twice as great in the first decade vs the second decade at VA, public, and private hospitals (ranging, 12 to 20 days vs 6 to 10 days in the more recent era). The intensity of diagnostic evaluation diminished, with bronchoscopy rates ranging from 44 to 66% in the first decade vs 20 to 40% in the second decade, and PCP confirmation rates ranging from 48 to 66% in the first decade vs 23 to 50% in the second decade at private, public, and VA hospitals. Multiple studies15 16 17 from the 1980s and early 1990s indicated that empiric treatment for PCP was both clinically effective as well as cost-effective. In contrast, however, the overall treatment of PCP decidedly improved: rates of delayed initiation of PCP medication were twice as great in the first decade; rates of use of adjunctive corticosteroids were < 5% for severely ill patients with PCP in the first decade vs between 73% and 83% in the more recent era; and inpatient death rates were almost three times as great in the earlier era (18%, 20%, and 24% in 1987 to 1990 vs 11%, 11%, and 8% in 1995 to 1997 at private, public, and VA hospitals, respectively). It is reassuring that following the publication of an 1990 National Institutes of Health consensus statement18 recommending adjunctive corticosteroids for severe cases of PCP, more than three fourths of those with severe cases of PCP received this treatment during the years 1995 to 1997.

Our study provides the first data on patterns of care for large numbers of patients with HIV infection and CAP. At the different types of hospital systems, the intensity of CAP care was about 1.5-fold to twofold less than that associated with PCP care with respect to rates of bronchoscopy, ICU use, and early initiation of appropriate antibiotics, while the median duration of hospitalization was approximately two thirds as long. Inpatient mortality for CAP ranged from 6 to 12%, similar to the rates reported in an observational study19 of HIV-associated CAP. Of note, approximately one third of the patients with CAP did not receive antibiotics within 24 h of hospital admission, suggesting that it will be important to develop strategies that facilitate more timely administration of appropriate antibiotics for CAP. Such measures would be in keeping with consensus guidelines for managing CAP,20 21 and with quality improvement projects22 23 recommended by the Joint Commission for Accreditation of Healthcare Organizations that targets < 8 h as the optimal time window for initiation of antibiotic therapy for CAP after clinical diagnosis.

We also identified large variations in HIV-related pneumonia care according to hospital system. In particular, patients with HIV infection who received pneumonia care in public and VA hospitals were less likely to undergo diagnostic bronchoscopy than those who received care in private hospitals, a finding similar to that which we reported previously for the years 1987 to 1990.1 Because VA and public hospitals rely on tax revenues and government allocations, they may have less flexibility in their budgets and may be more limited in the use of diagnostic tests than private hospitals. In contrast, median durations of hospitalization were longest in the VA system. Among veterans with HIV infection, as well as those who have other medical illnesses, complex medical and social situations are common, and these can contribute to inefficiencies in the coordination of posthospital care in the outpatient setting and often result in extended hospitalizations.24 25 26 Mortality rates for PCP and CAP were similar among the four types of hospitals evaluated. This finding contrasts with those we reported previously that showed VA patients hospitalized with PCP during from 1987 to 1990 had 4% and 6% higher mortality rates than those who received care in public and private hospitals, respectively.1

We also identified large variations in tuberculosis awareness among the four types of hospitals. Physicians at VA and county hospitals were twice to three times as likely as those at private hospitals to order respiratory isolation for patients with HIV infection and pneumonia. These variations in tuberculosis awareness can have public health implications. In the late 1980s and early 1990s, 30 to 40% of patients with HIV infection who were hospitalized with pneumonia were not placed in respiratory isolation rooms early in the hospitalization.27 In a study of tuberculosis care during 1994 to 1996, patients with tuberculosis as well as patients with HIV infection and pneumonia who received care at a county vs a private hospital were more likely to be placed in respiratory isolation.28 The only nosocomial outbreak of multidrug-resistant tuberculosis reported in the mid-1990s occurred at a private hospital in Chicago that had low usage rates of respiratory isolation rooms for patients who subsequently received a diagnosis of TB.28 Physicians at private hospitals should improve their rates of ordering respiratory isolation for high-risk individuals with pulmonary infections. Infection control personnel can help with these efforts by ensuring that individuals who have sputum studies ordered that include acid-fast bacilli smears are also placed in pulmonary isolation, a practice that was initiated at most public and VA hospitals following the occurrence of several outbreaks of multidrug-resistant tuberculosis in the late 1980s.

The limitations of our study should be noted. First, the study addresses inpatient care for individuals with HIV infection and pneumonia during 1995 through 1997, while much of the care for these persons has moved to the outpatient setting. Despite this, the HIV Costs and Services Utilization Study4 indicates that inpatient care still accounts for a substantial percentage of the annual medical costs of care for patients with HIV infection. Nonetheless, more recent data are needed and additional studies are recommended to evaluate patterns of care in the outpatient setting for individuals who receive care at VA, public, not-for-profit private, and for-profit private hospitals. Second, retrospective medical record review studies are limited by the potential for large amounts of incomplete data. However, we have developed and validated quality assurance systems for data retrieval, and focus primarily on data elements that are routinely available in most medical records. We did not collect information on other organizational characteristics (eg, clinician or institution experience caring for CAP and PCP patients) that might have shed light on additional factors that differentiate processes and outcomes between various hospital ownership types. Because our study population was obtained from three cities geographically dispersed across the United States, caution must be exercised in generalizing our findings to patients in other hospitals and cities.

In summary, this study provides the first overview of HIV-related pneumonia care in the early HAART era. For both PCP and CAP, large variations in the patterns of care, but not outcomes, were noted at VA, public, private not-for-profit, and for-profit hospitals. Overall, the quality of PCP care was quite good and showed dramatic improvement from the prior decade. There clearly evolved a higher degree of compliance with the National Institutes of Health HIV-related PCP management guidelines with respect to timely initiation of antibiotics and corticosteroids. However, in contrast, we found far worse compliance with guidelines for the management of CAP. Significant numbers of hospitalized persons did not receive appropriate antibiotics during the first day of hospitalization, raising concern that adverse outcomes may have occurred as a result of delays in care. Finally, PCP represents a unique experience where comprehensive assessments of quality and outcomes of care have been conducted since the identification of the first cases of the illness.29 30 31 It will be important to reassess these measures in the third decade of the epidemic, as awareness and familiarity with PCP continues to decline.


   Footnotes
 
Abbreviations: AMA = against medical advice; CAP = community-acquired pneumonia; DNR = do not resuscitate; HAART = highly active antiretroviral therapy; LOS = length of stay; P(A-a)O2 = alveolar-arterial oxygen gradient; PCP = Pneumocystis carinii pneumonia; VA = Veterans Affairs

This study was supported in part by grants from the National Institute of Drug Abuse (5R01DA10628-02), and the Health Services Research Division of the Department of Veteran Affairs (RCD 99 011 and RCD 00 004).

Received for publication June 12, 2003. Accepted for publication August 19, 2003.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Bennett, CL, Curtis, JR, Achenbach, C, et al (1996) U. S. hospital care for HIV-infected persons and the role of public, private, and Veterans Administration hospitals. J Acquir Immune Defic Syndr Hum Retrovirol 13,416-421[ISI][Medline]
  2. Palella, FJ, Delaney, KM, Moorman, AC, et al Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998;338,853-860[Abstract/Free Full Text]
  3. Sepkowitz, KA AIDS: the first 20 years. N Engl J Med 2001;344,1764-1772[Free Full Text]
  4. Bozzette, SA, Joyce, G, McCaffrey, DF, et al Expenditures for the care of HIV-infected patients in the era of highly active antiretroviral therapy. N Engl J Med 2001;344,817-823[Abstract/Free Full Text]
  5. Arno, PS, Gourevitch, MN, Drucker, E, et al Analysis of a population based Pneumocystis carinii pneumonia index as an outcome measure of access and quality of care for the treatment of HIV disease. Am J Public Health 2002;92,395-398[Abstract/Free Full Text]
  6. Afessa, B, Green, B Bacterial pneumonia in hospitalized patients with HIV infection: the Pulmonary Complications, ICU Support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study. Chest 2000;117,1017-1022[Abstract/Free Full Text]
  7. Bartlett, JG Pneumonia in the patient with HIV infection. Infect Dis Clin North Am 1998;12,807-820[ISI][Medline]
  8. Wolff, AJ, O’Connell, AE Pulmonary manifestations of HIV infection in the era of highly active antiretroviral therapy. Chest 2001;120,1888-1893[Abstract/Free Full Text]
  9. Arozullah, AM, Yarnold, PR, Weinstein, RA, et al A new preadmission staging system for predicting inpatient mortality from HIV-associated Pneumocystis carinii pneumonia in the early highly active antiretroviral therapy (HAART) era. Am J Respir Crit Care Med 2000;161,1-6[Free Full Text]
  10. Oken, C, Archibald, N, Cvitanic, M, et al Multi-city study of quality of care for HIV-related Pneumocystis carinii pneumonia: successfully collecting highly sensitive information. Clin Perform Qual Health Care 1995;3,140-146[Medline]
  11. American Hospital Association guide to the health care field 2001/2002 American Hospital Association. Chicago, IL:
  12. Arozullah, AM, Parada, J, Bennett, CL, et al A rapid preadmission staging system for predicting inpatient mortality among HIV patients with community-acquired pneumonia. Chest 2003;123,1151-1160[Abstract/Free Full Text]
  13. Fine, MJ, Auble, TE, Yealy, DM, et al A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336,243-250[Abstract/Free Full Text]
  14. Park, DR, Sherbin, VL, Goodman, MS, et al The etiology of community-acquired pneumonia at an urban public hospital: influence of human immunodeficiency virus infection and initial severity of illness. J Infect Dis 2001;184,268-277[CrossRef][ISI][Medline]
  15. Miller, R, Millar, AB, Weller, IVD, et al Empirical treatment without bronchoscopy for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. JAMA 1989;44,559-564
  16. Pozniak, A, Tung, KT, Swinburn, CR, et al Clinical and bronchoscopic diagnosis of suspected pneumonia related to AIDS. BMJ 1986;293,797-799[Medline]
  17. Tu, JV, Biem, HJ, Detsky, AS Bronchoscopy versus empirical therapy in HIV-infected patients with presumptive Pneumocystis carinii pneumonia: a decision analysis. Am Rev Respir Dis 1993;148,370-377[ISI][Medline]
  18. The National Institutes of Health–University of California Expert Panel for Corticosteroid as Adjunctive Therapy for Pneumocystis Pneumonia. Consensus statement on the use of corticosteroids as adjunctive therapy for pneumocystis pneumonia in AIDS. N Engl J Med 1990;323,1500-1504[ISI][Medline]
  19. Hirschtick, RE, Glassroth, J, Jordan, MC, et al Bacterial pneumonia in persons infected with the human immunodeficiency virus: Pulmonary Complications of HIV Infection Study Group. N Engl J Med 1995;333,845-851[Abstract/Free Full Text]
  20. American Thoracic Society. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med 2001;163,1730-1754[Free Full Text]
  21. Bartlett, JG, Dowell, SF, Mandell, LA, et al Practice guidelines for the management of community-acquired pneumonia in adults. Clin Infect Dis 2000;31,347-382[CrossRef][Medline]
  22. Englert, J, Davis, KM, Koch, KE Using clinical practice analysis to improve care. Jt Comm J Qual Improv 2001;27,291-301[Medline]
  23. Metersky, ML, Galusha, DH, Meehan, TP Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project. Jt Comm J Qual Improv 1999;25,182-190[Medline]
  24. Kaboli, PJ, Barnett, MJ, Fuehrer, SM, et al Length of stay as a source of bias in comparing performance in VA and private sector facilities: lessons learned from a regional evaluation of intensive care outcomes. Med Care 2001;39,1014-1024[CrossRef][ISI][Medline]
  25. Ritchie, JL, Maynard, C, Chapko, MK, et al A comparison of percutaneous transluminal coronary angioplasty in the Department of Veterans Affairs and in the private sector in the state of Washington. Am J Cardiol 1998;81,1094-1099[Medline]
  26. Thomas, JW, Bates, EW, Hofer, T, et al Interpreting risk-adjusted length of stay patterns for VA hospitals. Med Care 1998;36,1660-1675[Medline]
  27. Cegielski, JP, Goetz, MB, Jacobson, JM, et al Gender differences in early suspicion of tuberculosis in hospitalized, high-risk patients during 4 epidemic years, 1987 to 1990. Infect Control Hosp Epidemiol 1997;18,237-243[ISI][Medline]
  28. Bennett, CL, Schwartz, D, Lane, DR, et al Variations in inpatient care for HIV-related tuberculosis patients during a recent nosocomial outbreak of multidrug-resistant tuberculosis. J Acquir Immune Defic Syndr 1999;21,348-349[Medline]
  29. Bennett, CL, Garfinkle, JB, Greenfield, S, et al The relation between hospital experience and in-hospital mortality for patients with AIDS-related PCP. JAMA 1989;261,2975-2979[Abstract]
  30. Bennett, CL, Adams, J, Gertler, P, et al Relation between hospital experience and in-hospital mortality for patients with AIDS-related Pneumocystis carinii pneumonia: experience from 3, 126 cases in New York City in 1987. J Acquir Immune Defic Syndr 1992;5,856-864
  31. Mathews, W, Ferdon, E, Bennett, CL, et al Evaluating institutional performance in AIDS-associated Pneumocystis carinii pneumonia: a risk-adjustment model. J Clin Epidemiol 1989;42,421-425[CrossRef][ISI][Medline]



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M. J. Rosen
Intensive Care of Patients With Human Immunodeficiency Virus Infection: Time to Take Another Look
J Intensive Care Med, December 1, 2005; 20(6): 312 - 315.
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