THE LEARNING-CURVE FOR AIDS-RELATED PNEUMOCYSTIS-CARINII PNEUMONIA - EXPERIENCE FROM 3,981 CASES IN VETERANS AFFAIRS HOSPITALS 1987-1991

Previous studies have found lower mortality rates for AIDS-related Pne umocystis carinii pneumonia (PCP) in hospitals with higher levels of e xperience with PCP. It is not known if patients are selectively referr ed to better hospitals or if there is a learning curve whereby outcome s improve as physicians gain experience in treating PCP. We assessed c ases of PCP at 140 Veterans Administration (VA) Medical Centers in the United States. During 1987-1991, 3,981 patients were hospitalized wit h first-episode AIDS-related PCP. Mortality at 30 days after admission . For these 3,981 hospitalizations at the 140 study hospitals, the 30- day mortality was 19%. Logistic regression models indicate that older age, race, geographic area, earlier year of treatment, hospitalization in the previous 12 months, and lower levels of hospital experience wi th AIDS were significant predictors of mortality at 30 days after admi ssion. Compared with hospitals that had treated three cases or fewer o f first-episode PCP, the odds of mortality at 30 days at hospitals tha t treated >50 cases of first-episode PCP were 0.73 (95% confidence int erval 0.58-0.91), after controlling for differences in characteristics of the patients, year, and region. Mortality of patients with AIDS-re lated PCP decreases as VA hospitals gain experience. Longitudinal anal yses over a 5-year period suggest that a learning curve best explains this finding.