Decreased medical expenditures for care of HIV-seropositive patients - Theimpact of highly active antiretroviral therapy at a US Veterans Affairs Medical Center

Objective: To identify any changes in expenditures and in morbidity and mor tality with the progression of treatment of the HIV-seropositive population from monotherapy with a nucleoside reverse transcriptase inhibitor (NRTI) [1993] through dual NRTI therapy (1995) to highly active antiretroviral the rapy (HAART) [1997]. Design and setting: This study retrospectively compared 3 separate years of the total expenditures encountered in the management of HIV-seropositive i ndividuals seen at a US Veterans Affairs Medical Center. Interventions: Utilising a computerised hospital database, we identified th ose patients with HIV-related International Classification of Diseases, ver sion 9 (ICD-9) codes and collected all healthcare-related expenditure data. The 3 eras selected for comparison were controlled for similar utilisation of prophylaxis against opportunistic infections, access to investigational antivirals, consistency between primary care providers and distribution of new anti-HIV therapies relative to that era. Cost data for inpatient and o utpatient activities (visits and admissions) were derived from actual expen ditures. Major categories were then compared, including total inpatient/out patient expenditures and utilisation, laboratory and prescription costs, an d morbidity and mortality rates. Main outcome measures and results: The 3 periods had similar patient popula tions, with 86, 86 and 82% of patients in 1993, 1995 and 1997, respectively , having some degree of immunosuppression (defined as CD4+ lymphocyte count s <500 cells/mm(3)). Morbidity and mortality were not changed by the additi on of dual NRTI therapy. HAART therapy produced 60 and 70% declines in rela tive mortality when compared with the single and dual NRTI eras. Dual NRTI or HAART therapy decreased overall expenditures as compared with NRTI monot herapy. HIV-related outpatient resource utilisation other than pharmacy and laboratory costs fell by 25 and 59% in 1997 as compared with 1993 and 1995 , respectively. The greatest fall in resource utilisation was for inpatient bed-days of care, where the average cost per patient fell by $US2782 betwe en 1993 and 1997. Pharmacy and laboratory expenditures increased by $US1825 and $US231 per patient from 1993 to 1997, respectively. Overall, the impac t of HAART was a decrease of $US 1193 in the average total cost per patient from 1993 to 1997. Conclusions: The introduction of HAART provided a positive outcome on patie nt morbidity and mortality and on medical centre expenditures. The end resu lt was a cost shift of expenditures from inpatient utilisation to outpatien t pharmacy and laboratory costs. This information is important for patients and providers, who need to make clinical decisions on lifelong therapies, and for healthcare financial planners, who need to predict inpatient and ou tpatient healthcare utilisation during an era of limited healthcare dollars .