GMHC Treatment Issues, Volume 10, Number 6/7 - June/July 1996
Gabriel Torres, M.D.

Occasionally, the highest quality of care may be the most cost-efficient. For example, prophylaxis with Bactrim (trimethoprim/sulfamethoxazole, or TMP/SMX), oral dapsone or aerosolized pentamidine can dramatically reduce the incidence of Pneumocystis carinii pneumonia (PCP) and is significantly less expensive than care of acute PCP. Several studies have shown that TMP/SMX is significantly more cost-effective than aerosolized pentamidine in patients at risk for PCP.1,2 In addition, if the signs and symptoms of PCP are identified early in the course of the infection, less costly and better tolerated oral regimens can be used for treatment.

Some managed care companies have developed working "models of care" that reduce costs through lessened utilization of acute care hospitals, emergency rooms, lung specialists, diagnostic procedures and intravenous therapies for PCP. One such model has been implemented by the Community Medical Alliance (CMA). This organization was prepaid by the Massachusetts Medicaid Program on a fully capitated basis to provide comprehensive services to a subset of the greater Boston AIDS population receiving Supplemental Security Income (SSI, a federal disability program). The CMA's model used physician/nurse practitioner teams to direct a contracted network of medical specialty, home health, personal care, private duty nursing, home infusion, day care, foster care, mental health, substance abuse, hospital, hospice care and skilled nursing facility providers.

A study was performed to evaluate the cost-effectiveness and quality of care that this model provided.3 The endpoints in the study were the incidence of PCP, general health outcome and location of care. (Due to episodes of illness or disability, over one-third of all medical visits were made in the home by one of the team members or providers in the network.)

An analysis looked at 113 enrollees with median CD4 counts of 61 who received over 81 patient-years of care. During this period, fourteen PCP cases occurred -- a rate of 17.2 per 100 patient-years. This rate is significantly less than that observed in the same population before enrollment in the program (58.7 per 100 patient-years) or the rate in a comparable New York City population (39.6 per 100 patient- years).4 Over half (57 percent) of the episodes were managed at home, three partially in the hospital and three totally in the hospital. There was just one death, for a total PCP mortality of 7.1 percent, which compares favorably with rates of 12 to 33 percent reported in the literature.

Review of patient medical records demonstrated that 73 percent of the patients had evidence of adequate PCP prophylaxis. The study's author, Robert J. Master, M.D., of the Boston University School of Public Health, inferred that compliance with PCP prophylaxis through the coordinated team approach had reduced the incidence of PCP. In addition, the author implied that the shift to home care was possible due to the early identification of the signs and symptoms of PCP. Timely diagnosis allowed for treatment at a stage when the infection was comparatively mild and treatable with oral antibiotics under the supervision of a nurse practitioner.

Although this model may be possible for such easily manageable infections as PCP, it is unclear whether it could work for other conditions such as disseminated MAC or CMV infections, wasting and diarrheal disorders and systemic lymphoma. These have rapidly become the leading causes of hospitalization of AIDS patients over the last several years.

MAC and CMV can be prevented to some degree through the use of drugs such as clarithromycin and oral ganciclovir, but those drugs are more costly and toxic than TMP/SMX or dapsone. They also have more drug-drug interactions that require intensive monitoring. The rates of infection that occur despite prophylaxis are higher, too. When infections do break through, they may require multi-drug regimens, intravenous infusions and more intense monitoring or nursing care during their acute treatment phase. Lymphomas usually require expensive diagnostic work-ups followed by radiation and combination chemotherapy. These regimens are costly in themselves and toxic. Their use necessitates extremely close monitoring, which usually is possible only in an acute care hospital.

Nevertheless, many of these treatments may be administered at home these days, as intravenous infusions administered through either peripherally inserted or central venous catheters. Establishing whether costs are reduced and quality of life improved in this new era will require further studies of nonhospital care models, including the use of allied health professionals such as nurse practitioners to coordinate care.

Physician and Hospital Experience

Additional studies suggest that other trends at some health care management organizations -- such as not reimbursing for certain procedures and limiting the choice of primary health care providers to doctors who have agreed with HMOs to charge less but who have little or no experience treating AIDS patients -- may decrease quality of care.

A recently published study has demonstrated that experience of primary care physicians in management of AIDS is significantly associated with survival of their patients. The study conducted at a health care maintenance organization in Seattle by Kitahata et al5 evaluated outcomes of 403 adult male patients diagnosed between 1984 and 1994 and cared for by 125 primary care physicians. The researchers rated physicians based on their experience caring for AIDS patients during their residency and the cumulative number of patients with AIDS that they had cared for in their practices.

The median survival of patients who had physicians with the least experience in managing AIDS was fourteen months, as compared to 26 months for the patients of physicians with the most experience. The authors controlled for CD4 count, severity of illness and year of diagnosis. They were still able to show a 43 percent reduction in the risk of death for patients in the hands of the most AIDS-experienced physicians as compared to those cared for by the least experienced physicians. CD4 monitoring was more frequent, and PCP prophylaxis and antiretroviral therapies more extensively utilized by those doctors with the longest AIDS track record.

Several studies have demonstrated that hospitals that have treated more AIDS-related PCP had a lower in-patient AIDS mortality rate.6,7 This may be due to earlier recognition of the disease, more aggressive diagnostic evaluations and appropriate treatment regimens in facilities with the most AIDS-experienced staff

Reimbursement and Outcome

Whatever practitioners' skill, problems obtaining reimbursement for medical procedures or treatments can undermine their ability to provide quality care. A recently published survey of 387 HIV/AIDS specialists8 found that 40 percent of all the drugs they prescribed were for indications that were not officially approved (mostly for treatment and prevention of opportunistic infections). Although such usage frequently reflected the accepted standard of care, half of the doctors responding reported that they had seen third- party payers deny reimbursement for "off-label" prescriptions. The authors concluded that when faced with such obstacles many patients will receive less effective, albeit covered, therapies or be hospitalized to gain access to the preferred therapy.

In another study, the survival for patients insured under Medicaid was lower than those who were privately insured.9 This seemed to be related to fewer diagnostic procedures such as bronchoscopies (used to diagnose PCP), which are reimbursed at a very low rate by Medicaid and thus less frequently used in people covered by this program. Medicaid patients with PCP in the study were 1.7 times more likely to die in the hospital, and only nine percent had bronchoscopy within two days of hospitalization compared to 32 percent of privately insured patients.

It remains to be seen how the health care experience of people with HIV will be affected by the advent of intensive viral monitoring early in disease and of high-priced but potent antiretroviral agents such as protease inhibitors. This added cost may be offset by prevention or delay of opportunistic infections and malignancies that require expensive clinical management. For many people, access to these new measures may depend on how the cost equation balances out.

1 Freedberg KA et al. Journal of Acquired Deficiency Syndromes. May 1991; 4(5):521-31.

2 Castellano AR, Nettleman MD. Journal of the American Medical Association. August 14, 1991; 266(6):820-4.

3 Master RJ. Journal of Ambulatory Care Management. Jan 1996; 19(1):38-45.

4 Bennett C et al. Journal of Acquired Deficiency Syndromes. Jan 1992; 5(1):1-6.

5 Kitahata MM et al. New England Journal of Medicine. Mar 14, 1996; 334(11):701-6.

6 Bennett C et al. Journal of the American Medical Association. May 26, 1989; 261(20):2975-9.

7 Stone VE et al. Journal of the American Medical Association. Nov 18, 1992; 268(19):2655-61.

8 Brosgart C et al., Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology. May 1, 1996; 12(1):56-62.

9 Horner RD et al. American Journal of Respiratory Critical Care Medicine. Nov 1995; 152(5 Pt 1):1435-42.

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