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Use and cost of hospital services by HIV-infected children during the era of antiretroviral monotherapy

Mandalia, Sundhiyaa; Beck, Eduard J.a; Beecham, Jenic; Griffith, Rebeccaa; Walters, Samb; Boulton, Marya; Miller, Davida

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The change in recent years from antiretroviral monotherapy to combination therapy may have important consequences for the use and cost of service provision. We studied the use and costs of hospital services for HIV-infected children managed at St Mary‚s Hospital, London, between 1 January 1986 and 31 December 1994, before the introduction of combination antiretroviral therapy. At this time approximately a quarter of HIV-infected children, short-term survivors, progressed rapidly to AIDS and death during their first year of life, whereas for the remainder, long-term survivors, disease progression was slower. The annual rate of progression to AIDS and death for the long-term survivors was between 6 and 8% after the first year of life[1-4]. When the data were analysed by the stage of HIV infection, we found that the use and cost of hospital services increased with disease severity, but considerable differences were observed between short- and long-term survivors.

During the study period, 119 HIV-infected children attended St Mary‚s, 44% of all reported HIV-infected children in England[5]. Data were abstracted from case notes for 118 of these children and analysed using SAS[6,7]. Service use was recorded for each child at each visit alongside a clinical classification based on the Centers for Disease Control categories of indeterminate, asymptomatic, symptomatic non-AIDS and AIDS [8] (Table 1).

Table 1
Table 1:
Mean use and average cost (1995/96 prices) of hospital services per patient-year by stage of HIV infection and different years.

The mean use of services were calculated per patient-year; one ‚patient-year‚ was defined as 365 days of follow-up at St Mary‚s by stage of HIV infection, and the analytical methods adopted were similar to those used in previous studies[9,10]. The denominator consisted of the total follow-up time for all children by each stage of HIV infection, whereas numerators were calculated by summing the use of each service by all children attending the clinic during the period. Prescribed drugs were summed in the same manner and a ‚drug-day‚ constituted one day on which one drug was prescribed. Prescriptions for multiple drugs for the same patient were added, and therefore the mean number of drug-days per patient-year could exceed 365. For inpatient days and outpatient visits, the χ2 test was used to compare results between short- and long-term survivors, whereas χ2 for trend was used to analyse time trends. Unit cost estimates were obtained from relevant hospital departments through a research-based service-specific costing exercise[11]. Total cost estimates were calculated by linking activity data with relevant units costs. Financial data related to the 1993/94 financial year, indexed to 1995/96 prices[12].

The mean number of inpatient days per patient year for indeterminate children decreased significantly (χ12trend=120.86, P<0.001), but a significant increase was seen for children with symptomatic non-AIDS (χ12trend=174.13, P<0.001); no significant changes were observed for asymptomatic children or children with AIDS (χ12trend=0.03, P<0.9 and χ12trend=3.6, P<0.06, respectively). The mean number of outpatient visits increased significantly for children with symptomatic non-AIDS (χ12trend=9.96, P=0.002), but no changes were observed for indeterminate, asymptomatic or children with AIDS (χ12trend=2.6, P=0.11; χ12trend=0.01, P=0.75; χ12trend=1.54, P=0.21, respectively). Hospital costs paralleled these changes (Table 1).

Profound differences in the use and cost of hospital services have been observed among adults with AIDS before and during their final 6 months of life[13,14]. In this study, 19 of the 44 children with AIDS died, 11 within 8 months (246 days) of diagnosis with AIDS. The use and cost of hospital services were estimated for the final 6 months of life in the 11 short-term survivors and compared with the final 6 months of life for the long-term survivors. The mean number of inpatient days during the final 6 months on the general ward was 118.3 for short-term survivors compared with 18.3 for long-term survivors (χ12=503.0, P<0.001). The mean number of days spent in paediatric intensive care was 17.3 for short-term survivors compared with 0.3 for long-term survivors (χ12=80.7, P<0.001). The mean number of outpatient visits for short- and long-term survivors were 10.2 and 4.4, respectively (χ12=23.4, P<0.001). The mean number of drug-days for short-term survivors was 1060.3 compared with 1718.2 for long-term survivors, whereas the mean number of tests and procedures performed for short-term survivors was 635.0 compared with 139.1 for long-term survivors. Total hospital costs for the final 6 months of life were higher for short-term survivors, £107888 compared with £24502 for long-term survivors; both figures were higher than average costs per AIDS patient-year (Table 1).

Contrary to trends observed among English adults treated for HIV infection during the same period[9,10], no overall trend from an inpatient- to outpatient-based service was observed among these children. This could be due to policy decisions within the hospital, but evidence of such a shift is now beginning to accumulate, probably related to the increased use of combination antiretroviral therapy[15-17]. However, without access to baseline data such as those provided by this study, the impact of clinical decisions, such as changes in drug therapy, on other aspects of service provision cannot be measured. Future changes in the use, cost and outcome of service provisions for HIV-infected children ought to be monitored through multi-centre prospective information systems[18,19].


1. Peckham C, Gibb D. Mother-to-child transmission of the human immunodeficiency virus. N Engl J Med 1995, 333:298-302.
2. Italian Register for HIV Infection in Children. Features of children perinatally infected with HIV-1 surviving longer than 5 years. Lancet 1994, 343:191-195.
3. Turner BJ, Eppes S, McKee LJ, Cosler L, Markson LE. A population-based comparison of the clinical course of children and adults with AIDS. AIDS 1995, 9:65-72.
4. The European Collaborative Study. Natural history of vertically acquired human immunodeficiency virus-1 infection. Pediatrics 1994, 94:815-819.
5. PHLS Communicable Disease Surveillance Centre. AIDS and HIV-1 infection in the United Kingdom: monthly report. Communicable Disease Report 1995, 5:79-80.
6. Beck EJ, Mandalia S, Griffith R et al. The Hospital and Community Services Study of Families with HIV Infection: initial analyses of hospital service provision and costs for HIV-infected children, St Mary‚s Hospital, 1986-1994. Walters MDS, Levin M, Boulton M, Miller DL (editors). London, UK: Department of Epidemiology and Public Health, Imperial College School of Medicine at St.Mary‚s; 1997.
7. SAS/STAT User‚s Guide, Version 6, 4th ed. Cary, NC, USA: SAS Institute Inc.; 1990.
8. Centers for Disease Control. Classification system for human immunodeficiency virus (HIV) infection in children under 13 years of age. MMWR 1987, 36:225-231.
9. Beck EJ, Kennelly J, McKevitt C, et al. Changing use of hospital services and costs at a London AIDS Referral Centre 1983-1989. AIDS 1994, 8:367-377.
10. Beck EJ, Whitaker L, Kennelly J, et al. Changing presentation and survival, service utilization and costs for AIDS patients: insights from a London referral centre. AIDS 1994, 8:379-384.
11. NHS Executive. Hospital and community health services revenue (pay and prices) inflation index. Leeds: NHS Executive Finance and Performance Department A; 1997.
12. Griffith R, Beck EJ, Beecham JK. Unit costs of services for HIV-infected children, St Mary‚s Hospital, 1993-1994. London, UK: Department of Epidemiology and Public Health, Imperial College School of Medicine at St Mary‚s; 1996.
13. Hellinger FJ, Fleishman JA, Hsia DC. AIDS treatment costs during the last months of life: evidence from the ACSUS. Health Serv Res 1994, 29:569-581.
14. Postma MJ, Tolley K, Leidl RM, et al. Hospital care for persons with AIDS in the European Union: assessment of current and future impact controlled for severity-stages. Health Policy 1997; 41:157-176.
15. Rutstein RM, Feingold A, Meisleich D, Word B, Rudy B. Protease inhibitor therapy in children with perinatally acquired HIV infection. AIDS 1997, 11:F107-111.
16. Samson LM, King SM, Asad S, et al. A prospective analysis of the immunologic and virologic responses to protease inhibitors in children. Seventh Annual Canadian Conference on HIV/AIDS Research [abstract 422]. Can J Infect Dis 1998, 9 (Suppl. A):63A.
17. Canani BR, Spagnuolo IM, Cirillo P, Guarino A. Decreased needs for hospital care and antibiotics in children with advanced HIV-1 disease after protease inhibitor-containing combination therapy. AIDS 1999, 13:1005-1006.
18. Beck EJ. Counting the cost of HIV service provision in England: where do we go from here? J HIV Comb Ther 1997, 2:29-32.
19. Beck, EJ, Tolley K, Power A, et al. Use and cost of HIV service provision in England, 1996. PharmacoEconomics 1998, 14:639-652.
© 1999 Lippincott Williams & Wilkins, Inc.