Journal of General Internal Medicine

, Volume 7, Issue 3, pp 261–272 | Cite as

Optimal management strategies for HIV-infected patients who present with cough or dyspnea

A cost-effectiveness analysis
  • Kenneth A. Freedberg
  • Anna N. A. Tosteson
  • Deborah J. Cotton
  • Lee Goldman
Original Articles

Abstract

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/mm 3,200–500/mm 3,or >500/mm 3)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 cariniipneumonia (PCP), with a probability of PCP above 30% (CD4<200/mm 3 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/mm 3 and normal chest radiograph; or CD4 200–500/mm 3,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/mm 3,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.

Key words

AIDS HIV Pneumocystis carinii pneumonia cost - effectiveness decision analysis 
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Copyright information

© Society of General Internal Medicine 1992

Authors and Affiliations

  • Kenneth A. Freedberg
    • 1
  • Anna N. A. Tosteson
    • 2
    • 3
    • 4
    • 5
  • Deborah J. Cotton
    • 4
    • 5
    • 6
  • Lee Goldman
    • 2
    • 3
  1. 1.the Section of General Internal Medicine and the Clinical AIDS ProgramBoston City Hospital, Boston University School of MedicineUSA
  2. 2.Department of Medicine and Thorndike Memorial LaboratoryBoston City Hospital, Boston University School of MedicineUSA
  3. 3.the Division of Clinical EpidemiologyUSA
  4. 4.Department of Medicine, Brigham and Women’s Hospital and Beth Israel HospitalHarvard Medical SchoolUSA
  5. 5.the Department of Health Policy and ManagementHarvard School of Public HealthUSA
  6. 6.the Division of Infectious Disease, Department of Medicine, Beth Israel HospitalHarvard Medical SchoolBoston

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