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Valerie E. Stone, MD, MPH; George R. Seage III, DSc, MPH; Thomas Hertz; Arnold M. Epstein, MD, MA

JAMA. 1992;268(19):2655-2661.

Abstract
Objective.
—To determine whether there is an association between mortality and hospital acquired immune deficiency syndrome (AIDS) experience for all AIDS-related diagnoses, and to determine whether the association is explained by differences in severity of illness, earlier discharge of terminally ill patients, or differences in resource use.

Design and Setting.
—Population-based statewide cohort study. All hospitalizations identified for a cohort of AIDS patients diagnosed during 1987 in 40 Massachusetts hospitals were included.

Patients.
—All women and all male intravenous drug users (n=151), and a random sample of all male non—intravenous drug users diagnosed with AIDS during 1987 in Massachusetts (n=149).

Main Outcome Measures.
—Primary end points studied were (1) inpatient mortality and (2) 30-day mortality. Length of stay, cost, and intensive care unit use were also examined.

Results.
—In 806 hospitalizations at 40 hospitals inpatient mortality was 13.2%. Relative risk of mortality at low AIDS experience hospitals was 2.16 (95% confidence interval, 1.43 to 3.26) compared with high AIDS experience hospitals. When logistic regression was used to control for age, sex, race, human immunodeficiency virus transmission mode, severity, payer, admission type, hospital ownership, and teaching status, low hospital experience with AIDS remained a significant predictor of inpatient mortality (relative risk, 2.92; 95% confidence interval, 1.37 to 6.22). Comparisons of 30-day mortality by hospital AIDS experience yielded similar results. Length of stay and intensive care unit use were also significantly higher at low-experience hospitals after controlling for severity of illness (P<.05).

Conclusions.
—We conclude that mortality of AIDS patients is higher at hospitals with less AIDS experience. This finding is not because of greater severity of illness, differences in discharge patterns of the terminally ill, or less intensive use of resources.

(JAMA. 1992;268:2655-2661)

Author Affiliations
From the Sections of Infectious Diseases and General Internal Medicine, Department of Medicine, Boston City Hospital, Boston University School of Medicine (Dr Stone); Institute for Urban Health Policy, Research and Education, Boston Department of Health and Hospitals (Drs Stone and Seage and Mr Hertz); Department of Health Policy and Management, Harvard School of Public Health (Drs Stone and Epstein); Department of Epidemiology and Biostatistics, Boston University School of Public Health (Dr Seage); Division of General Medicine (Section on Health Services and Policy Research), Brigham and Women's Hospital (Drs Seage and Epstein); and Department of Health Care Policy, Harvard Medical School (Dr Epstein) Boston, Mass.

Footnotes
Presented, in part, at the annual meeting of the Society of General Internal Medicine, May 1, 1991, Seattle, Wash.

Reprint requests to the Department of Health Care Policy, 25 Shattuck St, Parcel B, First Floor, Boston, MA 02115 (Dr Epstein).

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