Evolution of Case Management of Patients With HIV Infection in France, 1995-1996

To the Editor.—We studied the evolution of the use of hospital services and health spending secondary to the recent therapeutic changes among patients followed up in public hospitals in southwestern France by the Groupe d'Epidemiologie Clinique du SIDA en Aquitaine (GECSA).¹ This regional hospital-based information system on infection with the human immunodeficiency virus (HIV) includes at least 80% of the patients known to be infected with HIV in the Aquitaine region.²

In France, most HIV-infected patients currently are treated in public hospitals,³ where 3 types of services are provided outpatient clinic, inpatient hospital ward, and day hospital. The day hospital mostly is intended for patients who need short, intense, and repeated care (eg, chemotherapy of HIV-associated neoplasms). Futhermore, initial prescription of antiretroviral agents has to be approved by a hospital-based physician. Treatment with 2 nucleoside analogs became common during the second half of 1995; protease inhibitors were introduced in March 1996 at the same time viral load measurement became routinely available.

The number and types of hospital contacts with a physician during 1995 through 1996 are shown in Figure 1. The number of patients followed up remained stable at about 1800 for each interval. The total number of hospital contacts increased by 14.4%, from 4924 in the first half of 1995 to 5632 in the second half of 1996. The number of hospitalizations in hospital wards decreased, and the proportion of hospitalizations relative to total hospital contacts decreased 32.9%, from 15.1% of the hospital contacts during the first half of 1995 to 10.2% during the second half of 1996. The average length of stay decreased from 10.8 days in 1995 (N=1439) to 9.9 days in 1996 (N=1249). Between the second half of 1995 and the first half of 1996, the number of outpatient clinic contacts increased; the proportion of total contacts also increased, from 32.9% to 36.3% (+10.3%). The proportion of day hospital contacts remained stable during this period at 51%, while the absolute number increased from 2427 to 2702. Finally, in the second half of 1996, when protease inhibitors were widely introduced, the proportion of outpatient clinic contacts reached a plateau, but the proportion of day hospital contacts continued to increase by 5.6%.

The wide use of viral load measurement in outpatients in 1996 resulted in a marked increase in the charges associated with outpatient clinic visits, from $94000 in the first half of 1995 to $216000 in the second half of 1996. Thus, despite the observed decrease in the use of inpatient services and reductions in the average length of hospital stay, spending for hospital case management of HIV-infected patients increased 11.4% between the beginning of 1995 and the end of 1996, drug expenses excluded. During the same period, expenditures for antiretroviral treatments increased from $1024000 to $2573000. Total spending for hospital case management and treatment of this stable number of patients increased by 60% between the first half of 1995 and the second half of 1996.

Our results suggest that the decrease in hospital stays among HIV-infected patients in 1996 reported in the United States^{4 - 5} also is observed among patients with HIV infection followed up in French hospitals. The rapid changes in case management of HIV-infected patients⁶ have important consequences for the health care system, with clinical benefits being obtained at the price of more intense surveillance with increased expenditures in case load and related costs.