COST AND OUTCOME OF INTENSIVE-CARE FOR PATIENTS WITH AIDS, PNEUMOCYSTIS-CARINII PNEUMONIA, AND SEVERE RESPIRATORY-FAILURE

Objective.-To determine the costs and outcomes associated with intensi ve care unit (ICU) admission for patients with acquired immunodeficien cy syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), and s evere respiratory failure. Design.-Survival and cost-effectiveness ana lysis. Setting.-A large municipal teaching hospital serving an indigen t population. Patients.-Consecutive patients intubated and mechanicall y ventilated for AIDS, PCP, and respiratory failure from 1981 through 1991 (n=113). The cohort was separated into three groups for analysis: patients admitted to the ICU in 1981 through 1985 (era I, n=43), thos e admitted in 1986 through 1988 (era II, n=33), and those admitted in 1989 through 1991 (era III, n=37). Main Outcome Measures.-Hospital cha rges and survival time; cost per year of life saved, using a zero-cost , zero-life assumption. Results.-Twenty-eight (25%) of the 113 patient s mechanically ventilated for PCP and respiratory failure survived to hospital discharge: six (14%) of 43 in era I, 13 (39%) of 33 in era II , and nine (24%) of 37 in era III (P=.04). Post-ICU admission charges averaged $57 874 for the entire cohort, remaining relatively stable ac ross the three eras. Cost of care for survivors was significantly more expensive than for those dying before discharge. The cost of ICU admi ssion and subsequent hospitalization averaged $174 781 per year of lif e saved; $305 795 in era 1, $94 528 in era II, and $215 233 in era III . Improved survival rates and shorter lengths of ICU stay led to the i mproved cost-effectiveness in era II, while the opposite trends result ed in worsening cost-effectiveness in recent years. The strongest pred ictors of hospital mortality in era III were low CD4 cell counts on ho spital admission and the development of pneumothorax during mechanical ventilation. Conclusions.-The cost-effectiveness of intensive care fo r patients with PCP and severe respiratory failure improved during the first 8 years of the AIDS epidemic but fell in recent years such that it is now below that of many accepted medical interventions.