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May 26, 1989, Vol 261, No. 20 >
ARTICLE | May 26, 1989

The Relation Between Hospital Experience and In-Hospital Mortality for Patients With AIDS-Related PCP FREE

Charles L. Bennett, MD; Jeffrey B. Garfinkle, MS; Sheldon Greenfield, MD; David Draper, PhD; William Rogers, PhD; W. Christopher Mathews, MD, MSPH; David E. Kanouse, PhD
[+] Author Affiliations

The opinions and conclusions expressed herein are solely those of the authors and should not be construed as representing the opinions or policies of The RAND Corp or the National Center for Health Services Research.

Reprint requests to The RAND Corporation, 1700 Main St, Santa Monica, CA 90406 (Dr Bennett).


JAMA. 1989;261(20):2975-2979. doi:10.1001/jama.1989.03420200065039
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References

There is marked debate by physicians and policymakers regarding the creation of regionalized acquired immunodeficiency syndrome (AIDS) centers. A central issue is whether outcomes of care, particularly mortality, differ as a function of hospital experience with patients with AIDS. We evaluated the experience of 257 patients with AIDS and Pneumocystis carinii pneumonia treated at 15 California hospitals between October 1986 and October 1987. An overall 15.2% in-hospital mortality rate was observed. However, a markedly lower in-hospital mortality rate was observed in the group of patients treated at hospitals that had a high level of experience with patients with AIDS (≥30 human immunodeficiency virus-related discharges per 10 000 hospital discharges) relative to the group treated at hospitals with less experience (<30 human immunodeficiency virus-related discharges per 10 000 hospital discharges): 12% vs 33%. Other factors significantly associated with in-hospital mortality included intensive care unit use, admission from an emergency department or through an interhospital transfer, and a history of hospitalizations. A logistic regression model indicated that, after controlling for severity indicators, AIDS experience remained significantly related to mortality. Our findings suggest that policymakers should consider three options: creating regional AIDS centers, implementing policies that promote a rapid but carefully monitored increase in experience of low-volume hospitals with human immunodeficiency virus-infected individuals, or providing highly focused educational efforts at low—AIDS-experience facilities. Without such policy initiatives, differences in mortality rates like those we have found might persist as cases of AIDS begin to occur in every area of the country.

(JAMA 1989;261:2975-2979)

REFERENCES

1 +
Glaft AE, Chirgwin K, Landesman SH.  Treatment of infections associated with human immunodeficiency virus . N Engl J Med. 1988;;318:1439-1448.
2 +
Luft HS, Bunker JP, Enthoven AS.  Should operations be regionalized? the empirical relation between surgical volume and mortality . N Engl J Med . 1979;;301:1364-1369.
3 +
Kelly JV, Hellinger FJ.  Heart disease and hospital deaths: an empirical study . Health Serv Res . 1987;;22:369-395.
4 +
Luft HS, Hunt SS, Maerki SC.  The volumeoutcome relationship: practice-makes-perfect or selective referral patterns . Health Serv Res . 1987;;22:157-182.
5 +
Maerki SC, Luft HS, Hunt SS.  Selecting categories of patients for regionalization: implications of the relationship between volume and outcome . Med Care. 1986;;24:148-158.
6 +
Shortell S, LoGerfo J.  Hospital and staff organization and quality of care: results for myocardial infarction and appendectomy . Med Care . 1981;;19: 1041-1053.
7 +
Wolfe R, Roi LD, Flora JD, et al.  Mortality differences and wound closure among specialized burn facilities . JAMA . 1983;;250:763-766.
8 +
DuBois RW, Brook RH, Rogers WH:  Adjusted hospital death rates: a potential screen for quality of medical care . Am J Public Health . 1987;;77:1162-1167.
9 +
Armstrong D, Gold JWM, Dryanski T, et al.  Treatment of infections in patients with the acquired immunodeficiency syndrome . Ann Intern Med . 1985;;103:738-743.
10 +
Leong GS, Mills J, Hopewell PC, et al.  Dapsone-trimethoprim for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome . Ann Intern Med . 1986;;105:45-48.
11 +
Wharton JM, Coleman DL, Wofsy CB, et al.  Trimethoprim-sulfomethoxazole or pentamidine for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a prospective/ randomized trial . Ann Intern Med . 1986;;105:37-44.
12 +
Kales CP, Murren JR, Torres RA, et al.  Early predictors of in-hospital mortality for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome . Arch Intern Med . 1987;;147:1413-1417.
13 +
Kizer K, Rodriguez J, McHolland GF, et al. A Quantitative Analysis of AIDS in California . Sacramento: California Department of Health Services; 1987;.
14 +
Grant IH, Armstrong D.  Management of infectious complications in the acquired immunodeficiency syndrome . Am J Med . 1986;:81:59-72.
15 +
Stover DE, White DA, Romano PA, et al.  Spectrum of pulmonary diseases associated with the acquired immune deficiency . Am J Med . 1985;;78:429-437.
16 +
Brewster AC, Karlin BG, Hyde LA, Jacobs CM.  MEDISGRPS: a clinically based approach to classifying hospital patients at admission . Inquiry . 1985;:22:377-387.
17 +
Horn SD, Horn RA, Sharkey PD.  The severity of illness index as a severity adjustment to diagnostic-related groups . Health Care Financ Rev . 1984;;annual (suppl) :33-45.
18 +
Knaus WA, Draper EA, Wagner DP.  A severity of disease classification system . Crit Care Med . 1985;;13:818-829.
19 +
Greenfield S, Aronow H, Elashoff RM, Watanabe D.  Flaws in mortality data: the hazards of ignoring comorbid diseases . JAMA . 1988;;260:2253-2255.
20 +
Gordon T, Kannel W, Halperin M.  Predictability of coronary heart disease . J Chronic Dis . 1979;;32:427-440.

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1 +
Glaft AE, Chirgwin K, Landesman SH.  Treatment of infections associated with human immunodeficiency virus . N Engl J Med. 1988;;318:1439-1448.
2 +
Luft HS, Bunker JP, Enthoven AS.  Should operations be regionalized? the empirical relation between surgical volume and mortality . N Engl J Med . 1979;;301:1364-1369.
3 +
Kelly JV, Hellinger FJ.  Heart disease and hospital deaths: an empirical study . Health Serv Res . 1987;;22:369-395.
4 +
Luft HS, Hunt SS, Maerki SC.  The volumeoutcome relationship: practice-makes-perfect or selective referral patterns . Health Serv Res . 1987;;22:157-182.
5 +
Maerki SC, Luft HS, Hunt SS.  Selecting categories of patients for regionalization: implications of the relationship between volume and outcome . Med Care. 1986;;24:148-158.
6 +
Shortell S, LoGerfo J.  Hospital and staff organization and quality of care: results for myocardial infarction and appendectomy . Med Care . 1981;;19: 1041-1053.
7 +
Wolfe R, Roi LD, Flora JD, et al.  Mortality differences and wound closure among specialized burn facilities . JAMA . 1983;;250:763-766.
8 +
DuBois RW, Brook RH, Rogers WH:  Adjusted hospital death rates: a potential screen for quality of medical care . Am J Public Health . 1987;;77:1162-1167.
9 +
Armstrong D, Gold JWM, Dryanski T, et al.  Treatment of infections in patients with the acquired immunodeficiency syndrome . Ann Intern Med . 1985;;103:738-743.
10 +
Leong GS, Mills J, Hopewell PC, et al.  Dapsone-trimethoprim for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome . Ann Intern Med . 1986;;105:45-48.
11 +
Wharton JM, Coleman DL, Wofsy CB, et al.  Trimethoprim-sulfomethoxazole or pentamidine for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a prospective/ randomized trial . Ann Intern Med . 1986;;105:37-44.
12 +
Kales CP, Murren JR, Torres RA, et al.  Early predictors of in-hospital mortality for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome . Arch Intern Med . 1987;;147:1413-1417.
13 +
Kizer K, Rodriguez J, McHolland GF, et al. A Quantitative Analysis of AIDS in California . Sacramento: California Department of Health Services; 1987;.
14 +
Grant IH, Armstrong D.  Management of infectious complications in the acquired immunodeficiency syndrome . Am J Med . 1986;:81:59-72.
15 +
Stover DE, White DA, Romano PA, et al.  Spectrum of pulmonary diseases associated with the acquired immune deficiency . Am J Med . 1985;;78:429-437.
16 +
Brewster AC, Karlin BG, Hyde LA, Jacobs CM.  MEDISGRPS: a clinically based approach to classifying hospital patients at admission . Inquiry . 1985;:22:377-387.
17 +
Horn SD, Horn RA, Sharkey PD.  The severity of illness index as a severity adjustment to diagnostic-related groups . Health Care Financ Rev . 1984;;annual (suppl) :33-45.
18 +
Knaus WA, Draper EA, Wagner DP.  A severity of disease classification system . Crit Care Med . 1985;;13:818-829.
19 +
Greenfield S, Aronow H, Elashoff RM, Watanabe D.  Flaws in mortality data: the hazards of ignoring comorbid diseases . JAMA . 1988;;260:2253-2255.
20 +
Gordon T, Kannel W, Halperin M.  Predictability of coronary heart disease . J Chronic Dis . 1979;;32:427-440.

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