1397
seasonality of mortality. Our findings confirm those for the seasonality of births.21 In the southern hemisphere, a mortality peak exists around July during the winter months.22 Seasonal climatic change must have an important influence. The importance of the photoperiod in the study of human seasonality is increasingly recognised-eg, in seasonal affective disorder and in seasonality of birth. Human beings possess a circadian clock that is affected by photoperiod. Alteration of this clock by the daily photoperiod may create seasonal patterns that give the appearance of a circannual clock. Photoperiod helps to keep the clock to time. The amplitude of the seasonal fluctuation of day length is more than three times greater in Grampian than in Kuwait. Photoperiod may entrain circadian and circannual rhythms, which in turn are altered by climatic and socioeconomic variables. This work was in progress before the Iraqi invasion of Kuwait in August, 1990, which prevented amplification of some
humidity, precipitation and sunshine for the world. London: HM Stationery Office, 1982; part III Europe and Azores: 165. 6. Nautical Almanac for the year 1991. London: HMSO, 1990. 7. Halberg F, Johnson EA, Nelson W, Runge W, Southern R. Autorhythmometry: procedures for physiological self measurements and their analysis. Physiol Teacher 1972; 1: 1-11. 8. Jenkins GM, Watts DG. Spectral analysis and its applications. San Francisco: Holden-Day, 1968. 9. Choi K, Thacker SB. An evaluation of influenza mortality surveillance 1962-1979. Am J Epidemiol 1981; 113: 215-35.
Sakamoto-Momiyama M. Seasonality of human mortality. Tokyo: Tokyo University Press, 1977. 11. Aschoff J. Annual rhythms in man. In: Aschoff J, ed. Handbook of behavioural neurology vol 4. New York: Plenum, 1981: 475-87. 12. Quetelet MA. A treatise on man and the development of his faculties. Edinburgh: William and Robert Chambers, 1842: 34-39. 13. Allan TM. Seasonal distribution of deaths from cancer. Br Med J 1966; 1:
10.
673-74.
Rogot E, Padgett SJ. Associations of coronary and stroke mortality with temperature and snowfall in selected areas of the United States, 1962-1966. Am J Med 1976; 103: 565-75. 15. Anderson TW, Le Riche WH. Cold weather and myocardial infarction.
14.
Lancet 1970; i: 291-96.
of our data.
Wirz-Justice A, Feer H, Richter K. Circannual rhythm in human plasma of free and total tryptophan, platelet serotonin, monoamine oxidase activity and protein. Chronobiologia 1977; 4: 165-66. 17. Arora RC, Kregel L, Meltzer HY. Seasonal variation of serotonin uptake in normal controls and depressed patients. Biol Psych 1984; 19:
16.
We thank the Ministry of Public Health, the Ministry of Planning, Mr Mustafa M. Mustafa (Chairman of the Statistics Division), Kuwait, and the Department of Community Medicine, University of Aberdeen. A. S. D. held a Leverhulme senior emeritus research fellowship. We also thank Mrs M. Burnett for secretarial assistance, the University of Aberdeen Medical School Library, and the Department of Medical Illustration.
REFERENCES Allan TM, Rawles JM. Composition of seasonality of disease. Scot Med J (in press). 2. United Nations Demographic Yearbooks 1974, 1978, 1985. New York: United Nations, 1975, 1979, 1987. 3. Al Kulaib AA. Weather and climate of Kuwait 1955-1973: report from Climatological Section, State of Kuwait, Directorate General of Civil Aviation, Meteorological Service: 68-82. 4. Meteorological Office (UK) 1960. Tables of temperature, relative humidity and precipitation for the world. London: HM Stationery Office, 1958; MO 617C part III: 109. 5. Meteorological Office (UK) 1982. Tables of temperature, relative
1. Douglas AS,
795-804. 18. McLaren M, Lou C, Forbes CD, Belch JP. Seasonal variation in fibrinolysis in patients with rheumatoid arthritis. Fibrinolysis 1990; 4 (suppl 2): 116-17. 19. Riggs HE, Boles RS, Reinhold JG, Shore PS. Observations on the chemical composition of the blood and on some cardiovascular reactions in chronic peptic ulcer throughout the year. Gastroenterology 1944; 3: 480-89. 20. Izzo JL, Larrabee PS, Sander E, Lillis LM. Haemodynamics of seasonal adaptation. Am J Hypertension 1990; 3: 405-07. 21. Pasamanick B, Dinitz S, Knobloch H. Socioeconomic and seasonal variation in birth rates. Millbank Mem Fund Q 1960; 38: 248-54. 22. Douglas AS, Russell D, Allan TM. Seasonal regional and secular variations of cardiovascular and cerebrovascular mortality in New Zealand. Aust NZ J Med 1990; 20: 669-76.
PUBLIC HEALTH Improving the cost-effectiveness of AIDS health care
in San Juan, Puerto Rico
decreasing availability of funds and increasing demand, the AIDS epidemic threatens to In
an era
of
overwhelm health-care services in some countries. We describe a comprehensive model for the treatment of AIDS in San Juan, Puerto Rico, and compare it with traditional hospital-based services. Given the existing allocation of funds, the comprehensive model emphasised prevention, education, surveillance, early detection, and outpatient care to reduce hospital care. In 1987, the last year of the traditional system, there were 95 admissions of AIDS patients to hospital, and in 1988, the first year of the comprehensive model, there were 100 admissions. The mean length of stay of AIDS inpatients was reduced from 22·3 days in 1987 to 11·3 days in 1988, a 46·8% reduction (p = 0·001). The annual mean (SE) cost of inpatient care per
patient fell from $15 118 (1699) in 1987 to $3869 (659) in 1988. Savings were used to improve services, non-hospital including outreach, and education, emergency outpatient care, laboratory and epidemiological services, and research, and to introduce an employee incentive scheme. Management strategies that reduce the length of inpatient care and provide less costly treatment alternatives can improve AIDS health care AIDS
in developing nations.
ADDRESSES: Harvard Institute for International Development, Harvard University, 1 Eliot Street, Cambridge, Massachusetts 02138, USA (Y H. Kouri, MD, DrPH, D. S. Shepard, PhD, G. A. Gellert, MDCM, MPH); and San Juan City Department of Health (F. Borras, MD), and Suan Juan AIDS Institute (J. Sotomayor, MPH), San Juan, Puerto Rico. Correspondence to DrY H. Kouri.
1398
Introduction The increasing number of patients with acquired immune deficiency syndrome (AIDS) has exacerbated the crisis in health-care financing in industrialised and developing countries.1,2 The human immunodeficiency virus (HIV) pandemic warrants reforms in health-care systems to decrease expenditures and improve the range and quality of services. Successful cost-cutting strategies include reducing inpatient hospital care,3privatisation of services, and the setting of budgets that encourage efficient management. We describe reforms in AIDS health care in San Juan, Puerto Rico, that apply management strategies from industrialised nations to a developing nation. San Juan (population about 500 000) is predicted to have 2500 AIDS cases by 1992, and by 2000 the number of cases in Puerto Rico may exceed 50 000.4 Annual expenditure on AIDS in Puerto Rico was predicted to rise to$93 million by 1992 and to$2 billion by 2000.AIDS threatened to overwhelm the health-care system of San Juan. No additional funds were available to respond to the epidemic. Inpatient care accounted for 86 % of AID S costs in San Juan and emergency care consumed the remaining resources. Outpatient, home, and hospice care were not available. To solve the problems of high costs, low productivity, lack of access to care, and lack of accountability, municipal officials decided to reform AIDS health care. The municipality contracted with a private, non-profitmaking organisation, the San Juan AIDS Institute (SJAI), to provide comprehensive AID S therapeutic and preventive services. The same funds were provided as under the previous system, but preventive services were to be emphasised and inpatient care reduced. The following reforms were proposed: (1) a shift of emphasis to preventive services, outreach, education, and early detection; (2) creation of an AIDS outpatient care centre and casemanagement system to decrease the number of inpatient days and emergency room visits; (3) provision of alternative forms of care (home, extended, and hospice care); (4) development of a new rapid diagnostic laboratory for all HIV antibody tests and contracts with private laboratories for other tests; (5) implementation of an epidemiological surveillance system; and (6) establishment of grant-funded AIDS health-care research and clinical trials to evaluate advances in AIDS therapy. Traditional AIDS health care ended in 1987, and the reformed programme started in 1988. We assessed the impact of the programme on AIDS health care and report our findings.
Methods Inpatient length of stay (LOS) was used as a measure of changes in hospital use.The LOS and inpatient costs in 1987 and 1988 were compared. Data were taken from the medical records of all AIDS patients (Centers for Disease Control definition7) admitted to the Municipal Hospital of San Juan in 1987 and 1988. Reliability of coding of hospital admission data was assessed by two independent groups of coders. There was 99% agreement on LOS and 85% agreement on use of ancillary services. Every hospital admission of an AIDS patient was assigned to a diagnostic related group (DRG)$with the ’ICD-9-CM’ computer software (Health Systems International, New Haven, USA). Each DRG is intended to reflect a similar level of consumption of hospital resources. The DRG of each patient admission is based on the primary discharge diagnosis, secondary diagnoses, age, sex, and discharge status (home, self-care, or dead). Since hospital LOS patterns are determined in part by case mix,9,10 adjustment was made for possible changes in case mix between 1987 and 1988. To control for severity of disease each
TABLE I-MEAN LENGTH OF STAY (NUMBER OF ADMISSIONS) BY DISEASE SEVERITY AND YEAR OF ADMISSION
LOS
in
days *See text for definition
admission was classified into one of three degrees of disease severity. Classification depended upon the standard LOS (as defined by the US Department of Health and Human Servicesll) for the DRG to which the admission was assigned-ie, mild disease = standard LOS 35-86days, moderate = standard LOS 87days, and severe = standard LOS 8-8-22-7 days. Case mix was also assessed by the ratio of mean actual LOS to mean standard LOS for the appropriate DRGs.
Results There were 95 admissions of AIDS patients available for analysis in 1987 and 100 in 1988 (140 patients). The number of bed days per inpatient episode averaged 17. Patients’ mean age was 31 years; 72 % were male; 91 % were adults and the remainder were children under 5 years old. 38% had Pmumocystis carinii pneumonia, 49% had other opportunistic infections, 3% had Kaposi’s sarcoma, and 11 % other diagnoses. The mean LOS for inpatients declined from 22-3 days in 1987 to 11-9 days in 1988 (p=0001, 2-tailed t test). The 1987 mean LOS was twice the US national mean (10-5 days) for equivalent DRGs, but the 1988 mean LOS was only 30% above the US national mean (8-8 days). The most common DRGs were reticuloendothelial and immune disorders with complications (75 admissions), and simple pneumonia and pleurisy with complications in a patient older than 17 (25 admissions). The decrease in LOS occurred despite an increase in the average number of care episodes per patient (including outpatient) per year from 2-11 in 1987 to 2.3 in 1988. Severity of illness accounted for variations in LOS: patients first admitted to hospital in 1988 tended to be less severely ill than those first admitted in 1987 (table I); overall reduction in LOS was 46-8%. After controlling for case mix and adjusting the 1988 mean LOS for relative frequencies of admissions by severity categories observed in 1987, the 1988 mean LOS was 12-8 days, a decline of42-9%. The ratios of standard mean LOS to actual mean LOS for appropriate DRGs showed a 36-6% reduction between 1987 and 1988. As well as reducing the length of inpatient stay the reformed programme also improved the quality of inpatient care. All services needed by San Juan’s HIV-infected patients were moved into one facility. Separate waiting, examining, and treatment rooms were created, as were an isolation area, offices for health professional, administrative, and support staff, and a laboratory, dental unit, and conference room. The range and quality of non-hospital services also improved during the first year of the reformed AIDS health-care programme. Outreach services did not exist under the traditional system, but in 1988 25 SJAI personnel contacted about 2500 individuals; 384 home-care visits were made, and 404 nursing home (extended-care) admission provided. The budget for HIV education rose from$10 000
1399
TABLE II-EXPENDITURES
(US$) ON AIDS IN SAN JUAN, PUERTO RICO
*For 1987, laboratory and pharmacy expenditures were divided equally between between inpatient and outpatient care according to estimated shares of use. Figures in parentheses are percentages of total expenditure
in 1987 to$360 000 in 1988. Educational activities included public and media presentations on AIDS, training for outpatient services, and counselling services. Outpatient contacts rose from 220 in 1987 to 1224 in 1988 (an average of 44 outpatient episodes [SD 5-8] per patient in 1988). The number of visits made by patients to emergency wards decreased from 225 in 1987 to 133 in 1988. Under the traditional system, patients’ access to doctors was restricted to daytime and patients were looked after by a different doctor during each admission. Following reform of the system, patients were assigned to a doctor or case manager who was accessible 24 hours a day and managed the patient during all admissions. The mean waiting period for results of all laboratory tests fell from 15 days (range 3-30) in 1987 to 2 days (1-7) in 1988, and the mean waiting period for results of HIV antibody testing decreased from 21 to 7 days. The reformed AIDS health-care system began a contacttracing programme and a research programme which included eight projects. Employees were offered more competitive salaries, support for continuing education, and opportunities for research. Doctors’ salaries were threefold higher than at the Municipal Hospital, and nurses’ wages increased 67%. The 1988 budget for SJAI was identical to that allocated by the Municipal Hospital for AIDS inpatient care in 1987. Table II compares expenditure on AIDS by year and activity in San Juan. Mean (SE) annual per capita cost of inpatient AIDS care fell from$15 118 (1699) in 1987 to$3869 (659) in 1988.
Several newly created services may have long-term effects. The research programme, counselling services for intravenous drug abusers and AIDS patients, and improved epidemiological surveillance may yet influence the need for clinical care. Cost savings for inpatient care could increase with earlier detection of and prevention of HIV infection. The model we describe is particularly relevant in an era of increasing AIDS expenditures and diminishing general availability of funds. The cost of AIDS health care need not be seen as prohibitive by developing nations burdened with a high incidence of HIV infection. Health officials from Brazil and the Dominican Republic are investigating whether the model can be adapted to their countries. It is important for health-care managers and policy formulators in developing nations to recognise the need to maximise cost-effectiveness in AIDS care. Our results show that even within the health infrastructure of a developing economy, strategic management of health care through appropriate resource allocation, public-private collaboration, and systematic evaluation can result in savings that can be used to increase the range and quality of services. The authors acknowledge the contribution of the following researchers: Dr J. Balling, Dr J. Garib, Ms C. Lucas, Dr J. Rivera-Dueno, Dr J. Valadez, Dr C. Myers, and Ms V. Vargas.
=
REFERENCES AA. The economic impact of AIDS in the United States. Connecticut Med 1988; 52: 727-33. 2. Scitovsky AA. AIDS: costs of care in the developed and the developing world. AIDS 1988; 2 (suppl 1): S71-81. 3. Winkelstein W Jr, Wiley JA, Padian NS, et al. The San Francisco men’s health study: continued decline in HIV seroconversion rates among homosexual/bisexual men. Am J Public Health 1988; 78: 1472-74. 4. Shepard D S. Costs of AID S in a developing area: indirect and direct costs of AIDS in Puerto Rico. In: Schwefel D, Leidl R, Rovira J, Drummond MF, eds. Economic aspects of AIDS and HIV infection. New York: Springer Verlag, 1990: 226-37. 5. Lozada Alameda J, Martinez Gonzalez A. Economic-analysis of AIDS in Puerto Rico. Vth International Conference on AIDS, Montreal 1989: 1049. 6. Arons RR. New economics of health care DRGs case mix and length of stay. New York: Prager Publishing, 1984. 7. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrom. MMWR 1989; 36 (suppl 1S): 3-15S. 8. Hsiao WC, Dunn DL. The impact of DRG payment on New Jersey hospitals. Inquiry 1987; 24: 212-20. 9. Kelly JV, Ball JK, Turner BJ. Duration and costs of AIDS hospitalizations in New York. Med Care 1989; 27: 1085-98. 10. Epstein A, Stern R, Tagnetti J, et al. The association of patients’ socioeconomic characteristics with the length of hospital stay and hospital charges within diagnosis-related groups. N Engl J Med 1988; 318: 1579-85. 11. Rules and regulations. Federal Register. 1989, 52 N 169: 33155-20. 1.
Scitovsky
Discussion The
comprehensive reformed AIDS health-care substantially decreased the mean LOS for patients and narrowed the gap between the LOS
From The Lancet
programme
AIDS under the traditional system and the US national mean. Antiviral therapy was not available to patients during the study period and thus could not have contributed to the change. The reformed programme provided better care for a larger number of AIDS patients by decreasing the average length and cost of each hospital admission. The number of outpatient visits, a far less costly alternative to inpatient care, increased, but all demands for hospital admission were met. Patients were directed to the most cost-effective care for their clinical status. Although we cannot quantify their individual contributions to decreased length of inpatient stay, the newly instituted outpatient-care, home-care, and extended-care services
were
all
important in effecting change.
Food for thought? "Solanum anthropophagorum, used with man-meat by the Feejees." Such was the somewhat startling label affixed to a very mild and harmless-looking plant exhibited at the soiree of the Pharmaceutical Society. The plant is said to be the favourite condiment of those accomplished cannibals in their moments of gastronomic indulgence... In our present state of society it may not be a very useful addition to the table; unless, indeed, it were introduced on the table of the House of Commons, and were employed by Mr Gladstone to heighten that useful feeling of terror which Mr Disraeli confessed this week to having suffered under the influence of the threatening glances and devouring wrath of the distinguished leader of the House. seem to
(May 19,1866)
seasonality of mortality. Our findings confirm those for the seasonality of births.21 In the southern hemisphere, a mortality peak exists around July during the winter months.22 Seasonal climatic change must have an important influence. The importance of the photoperiod in the study of human seasonality is increasingly recognised-eg, in seasonal affective disorder and in seasonality of birth. Human beings possess a circadian clock that is affected by photoperiod. Alteration of this clock by the daily photoperiod may create seasonal patterns that give the appearance of a circannual clock. Photoperiod helps to keep the clock to time. The amplitude of the seasonal fluctuation of day length is more than three times greater in Grampian than in Kuwait. Photoperiod may entrain circadian and circannual rhythms, which in turn are altered by climatic and socioeconomic variables. This work was in progress before the Iraqi invasion of Kuwait in August, 1990, which prevented amplification of some
humidity, precipitation and sunshine for the world. London: HM Stationery Office, 1982; part III Europe and Azores: 165. 6. Nautical Almanac for the year 1991. London: HMSO, 1990. 7. Halberg F, Johnson EA, Nelson W, Runge W, Southern R. Autorhythmometry: procedures for physiological self measurements and their analysis. Physiol Teacher 1972; 1: 1-11. 8. Jenkins GM, Watts DG. Spectral analysis and its applications. San Francisco: Holden-Day, 1968. 9. Choi K, Thacker SB. An evaluation of influenza mortality surveillance 1962-1979. Am J Epidemiol 1981; 113: 215-35.
Sakamoto-Momiyama M. Seasonality of human mortality. Tokyo: Tokyo University Press, 1977. 11. Aschoff J. Annual rhythms in man. In: Aschoff J, ed. Handbook of behavioural neurology vol 4. New York: Plenum, 1981: 475-87. 12. Quetelet MA. A treatise on man and the development of his faculties. Edinburgh: William and Robert Chambers, 1842: 34-39. 13. Allan TM. Seasonal distribution of deaths from cancer. Br Med J 1966; 1:
10.
673-74.
Rogot E, Padgett SJ. Associations of coronary and stroke mortality with temperature and snowfall in selected areas of the United States, 1962-1966. Am J Med 1976; 103: 565-75. 15. Anderson TW, Le Riche WH. Cold weather and myocardial infarction.
14.
Lancet 1970; i: 291-96.
of our data.
Wirz-Justice A, Feer H, Richter K. Circannual rhythm in human plasma of free and total tryptophan, platelet serotonin, monoamine oxidase activity and protein. Chronobiologia 1977; 4: 165-66. 17. Arora RC, Kregel L, Meltzer HY. Seasonal variation of serotonin uptake in normal controls and depressed patients. Biol Psych 1984; 19:
16.
We thank the Ministry of Public Health, the Ministry of Planning, Mr Mustafa M. Mustafa (Chairman of the Statistics Division), Kuwait, and the Department of Community Medicine, University of Aberdeen. A. S. D. held a Leverhulme senior emeritus research fellowship. We also thank Mrs M. Burnett for secretarial assistance, the University of Aberdeen Medical School Library, and the Department of Medical Illustration.
REFERENCES Allan TM, Rawles JM. Composition of seasonality of disease. Scot Med J (in press). 2. United Nations Demographic Yearbooks 1974, 1978, 1985. New York: United Nations, 1975, 1979, 1987. 3. Al Kulaib AA. Weather and climate of Kuwait 1955-1973: report from Climatological Section, State of Kuwait, Directorate General of Civil Aviation, Meteorological Service: 68-82. 4. Meteorological Office (UK) 1960. Tables of temperature, relative humidity and precipitation for the world. London: HM Stationery Office, 1958; MO 617C part III: 109. 5. Meteorological Office (UK) 1982. Tables of temperature, relative
1. Douglas AS,
795-804. 18. McLaren M, Lou C, Forbes CD, Belch JP. Seasonal variation in fibrinolysis in patients with rheumatoid arthritis. Fibrinolysis 1990; 4 (suppl 2): 116-17. 19. Riggs HE, Boles RS, Reinhold JG, Shore PS. Observations on the chemical composition of the blood and on some cardiovascular reactions in chronic peptic ulcer throughout the year. Gastroenterology 1944; 3: 480-89. 20. Izzo JL, Larrabee PS, Sander E, Lillis LM. Haemodynamics of seasonal adaptation. Am J Hypertension 1990; 3: 405-07. 21. Pasamanick B, Dinitz S, Knobloch H. Socioeconomic and seasonal variation in birth rates. Millbank Mem Fund Q 1960; 38: 248-54. 22. Douglas AS, Russell D, Allan TM. Seasonal regional and secular variations of cardiovascular and cerebrovascular mortality in New Zealand. Aust NZ J Med 1990; 20: 669-76.
PUBLIC HEALTH Improving the cost-effectiveness of AIDS health care
in San Juan, Puerto Rico
decreasing availability of funds and increasing demand, the AIDS epidemic threatens to In
an era
of
overwhelm health-care services in some countries. We describe a comprehensive model for the treatment of AIDS in San Juan, Puerto Rico, and compare it with traditional hospital-based services. Given the existing allocation of funds, the comprehensive model emphasised prevention, education, surveillance, early detection, and outpatient care to reduce hospital care. In 1987, the last year of the traditional system, there were 95 admissions of AIDS patients to hospital, and in 1988, the first year of the comprehensive model, there were 100 admissions. The mean length of stay of AIDS inpatients was reduced from 22·3 days in 1987 to 11·3 days in 1988, a 46·8% reduction (p = 0·001). The annual mean (SE) cost of inpatient care per
patient fell from $15 118 (1699) in 1987 to $3869 (659) in 1988. Savings were used to improve services, non-hospital including outreach, and education, emergency outpatient care, laboratory and epidemiological services, and research, and to introduce an employee incentive scheme. Management strategies that reduce the length of inpatient care and provide less costly treatment alternatives can improve AIDS health care AIDS
in developing nations.
ADDRESSES: Harvard Institute for International Development, Harvard University, 1 Eliot Street, Cambridge, Massachusetts 02138, USA (Y H. Kouri, MD, DrPH, D. S. Shepard, PhD, G. A. Gellert, MDCM, MPH); and San Juan City Department of Health (F. Borras, MD), and Suan Juan AIDS Institute (J. Sotomayor, MPH), San Juan, Puerto Rico. Correspondence to DrY H. Kouri.
1398
Introduction The increasing number of patients with acquired immune deficiency syndrome (AIDS) has exacerbated the crisis in health-care financing in industrialised and developing countries.1,2 The human immunodeficiency virus (HIV) pandemic warrants reforms in health-care systems to decrease expenditures and improve the range and quality of services. Successful cost-cutting strategies include reducing inpatient hospital care,3privatisation of services, and the setting of budgets that encourage efficient management. We describe reforms in AIDS health care in San Juan, Puerto Rico, that apply management strategies from industrialised nations to a developing nation. San Juan (population about 500 000) is predicted to have 2500 AIDS cases by 1992, and by 2000 the number of cases in Puerto Rico may exceed 50 000.4 Annual expenditure on AIDS in Puerto Rico was predicted to rise to$93 million by 1992 and to$2 billion by 2000.AIDS threatened to overwhelm the health-care system of San Juan. No additional funds were available to respond to the epidemic. Inpatient care accounted for 86 % of AID S costs in San Juan and emergency care consumed the remaining resources. Outpatient, home, and hospice care were not available. To solve the problems of high costs, low productivity, lack of access to care, and lack of accountability, municipal officials decided to reform AIDS health care. The municipality contracted with a private, non-profitmaking organisation, the San Juan AIDS Institute (SJAI), to provide comprehensive AID S therapeutic and preventive services. The same funds were provided as under the previous system, but preventive services were to be emphasised and inpatient care reduced. The following reforms were proposed: (1) a shift of emphasis to preventive services, outreach, education, and early detection; (2) creation of an AIDS outpatient care centre and casemanagement system to decrease the number of inpatient days and emergency room visits; (3) provision of alternative forms of care (home, extended, and hospice care); (4) development of a new rapid diagnostic laboratory for all HIV antibody tests and contracts with private laboratories for other tests; (5) implementation of an epidemiological surveillance system; and (6) establishment of grant-funded AIDS health-care research and clinical trials to evaluate advances in AIDS therapy. Traditional AIDS health care ended in 1987, and the reformed programme started in 1988. We assessed the impact of the programme on AIDS health care and report our findings.
Methods Inpatient length of stay (LOS) was used as a measure of changes in hospital use.The LOS and inpatient costs in 1987 and 1988 were compared. Data were taken from the medical records of all AIDS patients (Centers for Disease Control definition7) admitted to the Municipal Hospital of San Juan in 1987 and 1988. Reliability of coding of hospital admission data was assessed by two independent groups of coders. There was 99% agreement on LOS and 85% agreement on use of ancillary services. Every hospital admission of an AIDS patient was assigned to a diagnostic related group (DRG)$with the ’ICD-9-CM’ computer software (Health Systems International, New Haven, USA). Each DRG is intended to reflect a similar level of consumption of hospital resources. The DRG of each patient admission is based on the primary discharge diagnosis, secondary diagnoses, age, sex, and discharge status (home, self-care, or dead). Since hospital LOS patterns are determined in part by case mix,9,10 adjustment was made for possible changes in case mix between 1987 and 1988. To control for severity of disease each
TABLE I-MEAN LENGTH OF STAY (NUMBER OF ADMISSIONS) BY DISEASE SEVERITY AND YEAR OF ADMISSION
LOS
in
days *See text for definition
admission was classified into one of three degrees of disease severity. Classification depended upon the standard LOS (as defined by the US Department of Health and Human Servicesll) for the DRG to which the admission was assigned-ie, mild disease = standard LOS 35-86days, moderate = standard LOS 87days, and severe = standard LOS 8-8-22-7 days. Case mix was also assessed by the ratio of mean actual LOS to mean standard LOS for the appropriate DRGs.
Results There were 95 admissions of AIDS patients available for analysis in 1987 and 100 in 1988 (140 patients). The number of bed days per inpatient episode averaged 17. Patients’ mean age was 31 years; 72 % were male; 91 % were adults and the remainder were children under 5 years old. 38% had Pmumocystis carinii pneumonia, 49% had other opportunistic infections, 3% had Kaposi’s sarcoma, and 11 % other diagnoses. The mean LOS for inpatients declined from 22-3 days in 1987 to 11-9 days in 1988 (p=0001, 2-tailed t test). The 1987 mean LOS was twice the US national mean (10-5 days) for equivalent DRGs, but the 1988 mean LOS was only 30% above the US national mean (8-8 days). The most common DRGs were reticuloendothelial and immune disorders with complications (75 admissions), and simple pneumonia and pleurisy with complications in a patient older than 17 (25 admissions). The decrease in LOS occurred despite an increase in the average number of care episodes per patient (including outpatient) per year from 2-11 in 1987 to 2.3 in 1988. Severity of illness accounted for variations in LOS: patients first admitted to hospital in 1988 tended to be less severely ill than those first admitted in 1987 (table I); overall reduction in LOS was 46-8%. After controlling for case mix and adjusting the 1988 mean LOS for relative frequencies of admissions by severity categories observed in 1987, the 1988 mean LOS was 12-8 days, a decline of42-9%. The ratios of standard mean LOS to actual mean LOS for appropriate DRGs showed a 36-6% reduction between 1987 and 1988. As well as reducing the length of inpatient stay the reformed programme also improved the quality of inpatient care. All services needed by San Juan’s HIV-infected patients were moved into one facility. Separate waiting, examining, and treatment rooms were created, as were an isolation area, offices for health professional, administrative, and support staff, and a laboratory, dental unit, and conference room. The range and quality of non-hospital services also improved during the first year of the reformed AIDS health-care programme. Outreach services did not exist under the traditional system, but in 1988 25 SJAI personnel contacted about 2500 individuals; 384 home-care visits were made, and 404 nursing home (extended-care) admission provided. The budget for HIV education rose from$10 000
1399
TABLE II-EXPENDITURES
(US$) ON AIDS IN SAN JUAN, PUERTO RICO
*For 1987, laboratory and pharmacy expenditures were divided equally between between inpatient and outpatient care according to estimated shares of use. Figures in parentheses are percentages of total expenditure
in 1987 to$360 000 in 1988. Educational activities included public and media presentations on AIDS, training for outpatient services, and counselling services. Outpatient contacts rose from 220 in 1987 to 1224 in 1988 (an average of 44 outpatient episodes [SD 5-8] per patient in 1988). The number of visits made by patients to emergency wards decreased from 225 in 1987 to 133 in 1988. Under the traditional system, patients’ access to doctors was restricted to daytime and patients were looked after by a different doctor during each admission. Following reform of the system, patients were assigned to a doctor or case manager who was accessible 24 hours a day and managed the patient during all admissions. The mean waiting period for results of all laboratory tests fell from 15 days (range 3-30) in 1987 to 2 days (1-7) in 1988, and the mean waiting period for results of HIV antibody testing decreased from 21 to 7 days. The reformed AIDS health-care system began a contacttracing programme and a research programme which included eight projects. Employees were offered more competitive salaries, support for continuing education, and opportunities for research. Doctors’ salaries were threefold higher than at the Municipal Hospital, and nurses’ wages increased 67%. The 1988 budget for SJAI was identical to that allocated by the Municipal Hospital for AIDS inpatient care in 1987. Table II compares expenditure on AIDS by year and activity in San Juan. Mean (SE) annual per capita cost of inpatient AIDS care fell from$15 118 (1699) in 1987 to$3869 (659) in 1988.
Several newly created services may have long-term effects. The research programme, counselling services for intravenous drug abusers and AIDS patients, and improved epidemiological surveillance may yet influence the need for clinical care. Cost savings for inpatient care could increase with earlier detection of and prevention of HIV infection. The model we describe is particularly relevant in an era of increasing AIDS expenditures and diminishing general availability of funds. The cost of AIDS health care need not be seen as prohibitive by developing nations burdened with a high incidence of HIV infection. Health officials from Brazil and the Dominican Republic are investigating whether the model can be adapted to their countries. It is important for health-care managers and policy formulators in developing nations to recognise the need to maximise cost-effectiveness in AIDS care. Our results show that even within the health infrastructure of a developing economy, strategic management of health care through appropriate resource allocation, public-private collaboration, and systematic evaluation can result in savings that can be used to increase the range and quality of services. The authors acknowledge the contribution of the following researchers: Dr J. Balling, Dr J. Garib, Ms C. Lucas, Dr J. Rivera-Dueno, Dr J. Valadez, Dr C. Myers, and Ms V. Vargas.
=
REFERENCES AA. The economic impact of AIDS in the United States. Connecticut Med 1988; 52: 727-33. 2. Scitovsky AA. AIDS: costs of care in the developed and the developing world. AIDS 1988; 2 (suppl 1): S71-81. 3. Winkelstein W Jr, Wiley JA, Padian NS, et al. The San Francisco men’s health study: continued decline in HIV seroconversion rates among homosexual/bisexual men. Am J Public Health 1988; 78: 1472-74. 4. Shepard D S. Costs of AID S in a developing area: indirect and direct costs of AIDS in Puerto Rico. In: Schwefel D, Leidl R, Rovira J, Drummond MF, eds. Economic aspects of AIDS and HIV infection. New York: Springer Verlag, 1990: 226-37. 5. Lozada Alameda J, Martinez Gonzalez A. Economic-analysis of AIDS in Puerto Rico. Vth International Conference on AIDS, Montreal 1989: 1049. 6. Arons RR. New economics of health care DRGs case mix and length of stay. New York: Prager Publishing, 1984. 7. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrom. MMWR 1989; 36 (suppl 1S): 3-15S. 8. Hsiao WC, Dunn DL. The impact of DRG payment on New Jersey hospitals. Inquiry 1987; 24: 212-20. 9. Kelly JV, Ball JK, Turner BJ. Duration and costs of AIDS hospitalizations in New York. Med Care 1989; 27: 1085-98. 10. Epstein A, Stern R, Tagnetti J, et al. The association of patients’ socioeconomic characteristics with the length of hospital stay and hospital charges within diagnosis-related groups. N Engl J Med 1988; 318: 1579-85. 11. Rules and regulations. Federal Register. 1989, 52 N 169: 33155-20. 1.
Scitovsky
Discussion The
comprehensive reformed AIDS health-care substantially decreased the mean LOS for patients and narrowed the gap between the LOS
From The Lancet
programme
AIDS under the traditional system and the US national mean. Antiviral therapy was not available to patients during the study period and thus could not have contributed to the change. The reformed programme provided better care for a larger number of AIDS patients by decreasing the average length and cost of each hospital admission. The number of outpatient visits, a far less costly alternative to inpatient care, increased, but all demands for hospital admission were met. Patients were directed to the most cost-effective care for their clinical status. Although we cannot quantify their individual contributions to decreased length of inpatient stay, the newly instituted outpatient-care, home-care, and extended-care services
were
all
important in effecting change.
Food for thought? "Solanum anthropophagorum, used with man-meat by the Feejees." Such was the somewhat startling label affixed to a very mild and harmless-looking plant exhibited at the soiree of the Pharmaceutical Society. The plant is said to be the favourite condiment of those accomplished cannibals in their moments of gastronomic indulgence... In our present state of society it may not be a very useful addition to the table; unless, indeed, it were introduced on the table of the House of Commons, and were employed by Mr Gladstone to heighten that useful feeling of terror which Mr Disraeli confessed this week to having suffered under the influence of the threatening glances and devouring wrath of the distinguished leader of the House. seem to
(May 19,1866)
