OPTIMAL MANAGEMENT STRATEGIES FOR HIV-INFECTED PATIENTS WHO PRESENT WITH COUGH OR DYSPNEA - A COST-EFFECTIVENESS ANALYSIS

被引：18

作者：

FREEDBERG, KA

TOSTESON, ANA

COTTON, DJ

GOLDMAN, L

机构：

[1] the Section of General Internal Medicine and the Clinical AIDS Program, Boston City Hospital, Boston University School of Medicine

[2] Department of Medicine and Thorndike Memorial Laboratory, Boston City Hospital, Boston University School of Medicine

[3] Department of Medicine, Brigham and Women's Hospital and Beth Israel Hospital, Harvard Medical School

[4] the Department of Health Policy and Management, Harvard School of Public Health

[5] the Division of Infectious Disease, Department of Medicine, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts

来源：

JOURNAL OF GENERAL INTERNAL MEDICINE | 1992年 / 7卷 / 03期

关键词：

AIDS; HIV; PNEUMOCYSTIS-CARINII PNEUMONIA; COST EFFECTIVENESS; DECISION ANALYSIS;

D O I：

10.1007/BF02598081

中图分类号：

R19 [保健组织与事业（卫生事业管理）];

学科分类号：

摘要：

Objective: To determine the effectiveness and costs of alternative management strategies for patients infected with the human immunodeficiency virus (HIV) who present with pulmonary symptoms. Design: Decision analysis comparing initial testing (arterial blood gas analysis, induced sputum analysis, or bronchoscopy with bronchoalveolar lavage) with empiric antibiotics (trimethoprim-sulfamethoxazole or erythromycin). Subsequent steps in management are detailed based on the results of initial management. Patients were stratified by initial CD4 lymphocyte count (< 200/mm3, 200-500/mm3, or > 500/mm3) and results of chest radiography. Setting: Hypothetical. Measurements and main results: The estimated levels of effectiveness among strategies were relatively similar, but costs varied markedly. If potentially reasonable strategies are defined as those that have incremental cost-effectiveness ratios below $50,000 per quality-adjusted life year (QALY), the recommended strategies would be for patients at highest risk for Pneumocystis carinii pneumonia (PCP), with a probability of PCP above 30% (CD4 < 200/mm3 and abnormal chest radiograph or prior history of PCP), begin with induced sputum analysis ($34,174/QALY); for intermediate-risk patients, with a probability of PCP between 6% and 30% (CD4 < 200/mm3 and normal chest radiograph; or CD4 200-500/mm3, regardless of chest radiograph findings), begin with arterial blood gas analysis ($4,593 to $8,310/QALY); for low-risk patients, with a probability of PCP below 6 % (CD4 > 500/mm3, regardless of chest radiograph findings), begin with one week of erythromycin, followed by induced sputum examination if symptoms persist ($675 to $3,306/QALY). For highest-risk patients, if empiric trimethoprim-sulfamethoxazole was considered entirely to be outpatient therapy, it was preferred management if the probability of PCP was above 38%. Conclusions: The authors conclude that preferred management strategies are determined more by differences in costs than by differences in levels of effectiveness, and that they vary depending on the probability of PCP in definable patient subgroups.

引用

页码：261 / 272

页数：12

共 63 条

[11]

Golden J.A., Chernoff D., Hollander H., Feigal D., Conte J.E., Prevention of Pneumocystis carinii pneumonia by inhaled pentamidine, Lancet, 1, pp. 654-7, (1989)

[12]

Brenner M., Ognibene F.P., Lack E.E., Et al., Prognostic factors and life expectancy of patients with acquired immunodeficiency syndrome and Pneumocystis carinii pneumonia, Am Rev Respir Dis, 136, pp. 1199-206, (1987)

[13]

Wachter R.M., Luce J.M., Turner J., Volberding P., Hopewell P.C., Intensive care of patients with the acquired immunodeficiency syndrome: outcome and changing patterns of utilization, Am Rev Respir Dis, 134, pp. 891-6, (1986)

[14]

Klatt E.C., Diagnostic findings in patients with acquired immune deficiency syndrome (AIDS), J Acquir Immune Defic Syndr, 1, pp. 459-65, (1988)

[15]

Gordin F.M., Simon G.L., Wofsy C.B., Mills J., Adverse reactions to trimethoprim-sulfamethoxazole in patients with the acquired immunodeficiency syndrome, Ann Intern Med, 100, pp. 495-9, (1984)

[16]

Jaffe H.S., Abra D.I., Ammann A.J., Lewis B.J., Golden J.A., Complications of co-trimoxazole in treatment of AIDS-associated Pneumocystis carinii pneumonia in homosexual men, Lancet, 2, pp. 1109-11, (1983)

[17]

Stahl-Bayliss C.M., Kalman C.M., Laskin O.L., Pentamidine-induced hypoglycemia in patients with the acquired immune deficiency syndrome, Clin Pharmacol Ther, 39, pp. 271-5, (1986)

[18]

Wharton J.M., Coleman D.L., Wofsy C.B., Et al., Trimethoprim — sulfamethoxazole or pentamidine for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a prospective randomized trial, Ann Intern Med, 105, pp. 37-44, (1986)

[19]

Anderson R., Boedicker M., Ma M., Goldstein E.J.C., Adverse reactions associated with pentamidine isethionate in AIDS patients: recommendations for monitoring therapy, Drug Intell Clin Pharm, 20, pp. 862-8, (1986)

[20]

Waskin H., Stehr-Green J.K., Helmick C.G., Sattler F.R., Risk factors for hypoglycemia associated with pentamidine therapy for Pneumocystis carinii pneumonia, JAMA, 260, pp. 345-7, (1988)

← 1 2 3 4 5 6 7 →