CHANGING USE OF HOSPITAL SERVICES AND COSTS AT A LONDON AIDS REFERRALCENTER, 1983-1989

Objective: To describe the use of hospital-based services and associat ed costs over time for HIV-infected individuals by disease stage and y ear of treatment. Methods: Data on service use were abstracted from in patient and outpatient case-notes of 459 HIV-infected patients (121 as ymptomatic and 338 AIDS patients) treated at St Mary's Hospital, Londo n between 1983 and 1989. Cost estimates were derived from a survey of the 37 departments involved with HIV-related care. The number and type of admissions and outpatient visits, referral and discharge venues, n umber and type of tests and procedures performed, drugs prescribed and associated costs for the study period were the outcome measures used. Results: Most patients were homosexual men. At the time of first HIV- related visit, 80.7% lived in London. Most day cases and planned admis sions were organized through the outpatient clinic; 31% of emergency a dmissions were initiated by patients themselves. For people with AIDS the number of day case admissions increased while planned admissions d ecreased. There was a marked reduction in the duration of inpatient st ays, especially for AIDS patients. Costs associated with inpatient car e decreased concomitantly. The number of outpatient visits for patient s with symptomatic disease increased, resulting in increased outpatien t expenditure. Asymptomatic patients had fewer inpatient tests,while o utpatient tests did not change over time; costs followed similar patte rns. Mean inpatient and outpatient drug-days prescribed did not change nor did average inpatient drug-costs although outpatient drug-costs i ncreased. Inpatient tests performed on symptomatic non-AIDS patients d ecreased, while mean outpatient tests increased; average costs followe d similar patterns. Inpatient drug-days prescribed and costs remained the same, while outpatient drug-days and average drug-costs increased during the study period. For AIDS patients, the number of inpatient te sts performed and their average costs decreased but outpatient tests p erformed increased, though their average costs remained the same. Mean inpatient drug-days prescribed and average drug-costs decreased, whil e number of outpatient drug-days prescribed and average drug-costs inc reased markedly over time. For each disease category, expenditure on a dmissions and related tests decreased over time, while expenditure on outpatient visits and drug-costs increased. Conclusions: The shift fro m an inpatient- to an outpatient-based service has resulted in fewer p atients being investigated and treated in hospital and more as outpati ents. This has resulted in a reduction of inpatient-related costs, whi le outpatient-related costs have increased. The overall contribution o f drug-costs to the total cost has increased greatly over time. With t he anticipated advent of new antiviral compounds, the importance of as certaining their effectiveness as well as their efficacy will become c rucial.