Impact of Potent Combination Antiretroviral Therapies on Health Care Resource Utilization by Patients with HIV Infection
Three studies presented at the 4th National Conference on Retroviruses and Opportunistic Infections in Washington, DC reported dramatic decreases in inpatient and outpatient hospital utilization by patients with HIV infection at the largest AIDS Center in New York, a large group private practice in Los Angeles, and 9 centers in France. The studies reported declining numbers of hospital admissions coincident with the advent of combination retroviral therapies, which included protease inhibitors. The major effect of hospital, hospice and home care utilization was observed during 1996, when protease inhibitors became widely available to the general population. At St. Vincent's Hospital and Medical Center of New York, where the numbers of hospital admissions for HIV-related illness had been continually increasing since the mid-1980s, a 10.5% reduction in admissions was observed from 1995 to 1996, in addition to a 2.5 day reduction in average length of hospital stay, and a 24% decrease in average monthly AIDS census. This was accompanied, however, by a dramatic increase in ambulatory visits (33%), and a 21% increase in individuals seeking health care at the Center. Antiretroviral drug utilization and inpatient pharmacy costs increased ten-fold, suggesting that the factor most related to the changing trend is the increasing use of antiretroviral combination therapies. "With the shortening of the average length of hospital stay, our patients' quality of life and productivity has been greatly improved," said Dr. Ramon Torres, who conducted the study.
In Los Angeles, Dr. Peter Ruane reported a 56% reduction in episodes of hospitalization and home care over the base year of 1994. 80% of the patient population in the group practice (N=450-500) experienced rises in CD4 counts in 1996 as compared to 1995, with fewer patients (17.3%) having dangerously low counts (<50) in 1996 as compared to 1995 (28.5%). Dr. Ruane also reported a downward trend in AIDS-related deaths from 1993 to 1996 among the patients in the practice, which was more evident in the last quarter of 1996, which probably reflects the decline in the number of opportunistic infections and malignancies suffered by patients as their immune systems improve on the potent antiretroviral treatments. Patients also required fewer costly AIDS related treatments such as Neupogen, erythropoetin and CMV therapy and fewer specialty referrals than in the pre-protease era.
In France at 9 AIDS reference centers the same trends were evident; in a study of 7,391 patients followed from September 1995 to October 1996, increasing percentages were placed on triple combination therapies, which included protease inhibitors. At four of the centers decreases in AIDS defining events were observed, whereas at two additional centers there were no increases. This was related to the higher percentage of patients on triple therapies at the group of 4 centers. The money saved by the difference between hospitalizations that were avoided and the cost of the antiretroviral treatments was estimated at $650,000 at the four centers where the triple therapies were being widely utilized.
Another study presented at the conference utilized a mathematical model to project the cost effectiveness of triple combination therapy with indinavir, AZT and 3TC. In this study, conducted by Cook and others from Merck Pharmaceuticals, makers of idinavir, disease progression was estimated according to data from a triple combination therapy trial being sponsored by the company, which compared the triple combination with indinavir alone, and the dual combination of AZT and 3TC. The cost-effectiveness was estimated from the length of suppression of viral replication observed in the trial, which was expected to extend beyond the clinical trial follow-up period. The incremental cost per year of life gained was estimated to be under $10,000 for indinavir alone, $30,000 for the triple combination compared to AZT and 3TC. The model suggested that initiation of indinavir alone, and in combination before the first AIDS-defining illness will increase survival compared to AZT and 3TC a cost that is generally acceptable by cost-effectiveness standards.
These studies all indicate that the overall impact of the potent combination antiretroviral therapies is beneficial to both the health care providers and the patient, as the former are able to lower hospital costs and maximize outpatient care, and the latter have improved quality of life and productivity as they spend less time lying in hospital beds, losing productive days from work, school or other activities.
This article was provided by TheBodyPRO. It is a part of the publication The 4th Conference on Retroviruses and Opportunistic Infections.