Use and Cost of Hospital and Community Service Provision for Children with HIV Infection at an English HIV Referral Centre
Eduard J. Beck
M. D. Sam Walters
David L. Miller
Objective: To describe the use of hospital and community services for children infected with HIV and estimate the cost per patient-year by stage of HIV infection during the era of antiretroviral monotherapy. Design: Data on the use of hospital services were collected from case notes; the use of statutory and nonstatutory community services was recorded through diaries and interviews. Total cost estimates were calculated from unit costs from relevant hospital departments and community organisations. Setting: Children managed at St. Mary's Hospital (London, England) between 1 January 1986 and 31 December 1994, some of whom used statutory and nonstatutory community services in South East England between 1 November 1994 and 31 May 1996. Patients and participants: 118 children with positive HIV antibody status. Main outcome measures and results: Mean inpatient days, outpatient visits, tests and procedures performed, drugs prescribed, community services used, associated unit costs and average cost estimates per patient-year by stage of HIV infection (1995/1996 values), and lifetime costs. Service provision during the study period was predominantly hospital-based. The use of services increased for different stages of HIV infection and increased with increasing severity of HIV infection. A shift from an inpatient-based to an outpatient-based service was seen between the periods 1986 to 1991 and 1992 to 1994. As symptoms evolved, children used more hospital inpatient services, with an accompanying shift in the use of community services from general services, such as schooling, to increased use of nurses, social care and home help. The estimated total cost of hospital and community care was Lstg 18 600 per symptomatic non-AIDS patient per year and Lstg 46 600 per AIDS patient per year. Similar estimates for children with indeterminate HIV infection and asymptomatic infection amounted to Lstg 8300 and Lstg 4800 per patient-year, respectively. Nondiscounted lifetime costs for hospital care amounted to Lstg 152 400 (Lstg 44 300 to Lstg 266 800) compared with discounted lifetime costs of Lstg 122 700 (Lstg 42 000 to Lstg 182 200); nondiscounted lifetime costs for community care amounted to Lstg 24 300 (Lstg 7900 to Lstg 41600) compared with discounted lifetime costs of Lstg 21 000 (Lstg 6800 to Lstg 32 000). Conclusions: The continued emphasis on the use of hospital services may be due to the small number of children infected with HIV, most of whom lived in the London metropolitan area where specialist care was concentrated in a few centres. A shift from an inpatient- to an outpatient-based service was observed over time; the advent of the use of combination antiretroviral therapy in this population may further facilitate a shift in service provision and promote shared care between specialist centres, local hospitals and community-based services.
Antivirals, Children, Cost analysis, HIV infections, Hospitalisation, Pharmacoeconomics
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