标题：Analysis of a Population-Based Pneumocystis carinii Pneumonia Index as an Outcome Measure of Access and Quality of Care for the Treatment of HIV Disease
摘要：Objectives. A population-based Pneumocystis carinii pneumonia (PCP) Index was developed in New York City to identify geographic areas and subpopulations at increased risk for PCP. Methods. A zip code–level PCP Index was created from AIDS surveillance and hospital discharge records and defined as (number of PCP-related hospitalizations)/(number of persons living with AIDS). Results. In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City (PCP Index = .05691). PCP Index values varied widely across neighborhoods with high AIDS prevalence (West Village = .02532 vs Central Harlem = .08696). Some neighborhoods with moderate AIDS prevalence had strikingly high rates (Staten Island = .14035; northern Manhattan = .08756). Conclusions. The PCP Index highlights communities in particular need of public health interventions to improve HIV-related service delivery. (Am J Public Health. 2002;92:395–398) Despite long-standing public health guidelines and the availability of effective chemoprophylaxis for Pneumocystis carinii pneumonia (PCP), 1– 5 it remains the most common opportunistic infection at the time of AIDS diagnosis. In 1997, for example, PCP still accounted for 43% of all AIDS-defining opportunistic illnesses. 6 Although the cost-effectiveness of PCP prophylaxis has been demonstrated, 7 PCP still causes substantial morbidity, often resulting in hospitalizations and expensive therapies and decreased survival among persons with HIV infection. 8, 9 Despite declines in the incidence of PCP over the past few years, 43% of the persons who died with AIDS in 1997 had PCP diagnosed at some time during the course of their illness. 6 Several studies have reported that hospitalization for PCP is strongly associated with 2 conditions: (1) absent or substandard primary medical care and (2) patients' lack of awareness of their HIV infection status. In a study of 2174 PCP patients (in 96 hospitals in 5 cities between 1987 and 1990), we found that 67% had not received any PCP prophylaxis before admission. 10 Investigators at San Francisco General Hospital found that nearly one quarter (24.1%) of the patients hospitalized for PCP between 1996 and 1997 were unaware of their HIV infection at the time of presentation. 11 Among those patients hospitalized for PCP, most were receiving neither regular medical care (56.2%) nor PCP prophylaxis (55.6%) before admission. In a national, multistage probability sample of persons with known HIV infection who were receiving ongoing care (not necessarily in the hospital), investigators found that by late 1997, 26% had not received indicated PCP prophylaxis. 12 In an updated study at San Francisco General Hospital of 246 HIV patients diagnosed with PCP between 1996 and 1999, the vast majority had received neither PCP prophylaxis (76%) nor antiretroviral therapy (83%) before admission. 13 Because chemoprophylaxis for PCP is so effective, hospitalization for this condition should raise the possibility that one of several potentially modifiable circumstances exists (Table 1 ▶ ). TABLE 1— Potential Implications of Pneumocystis carinii Pneumonia (PCP) Hospitalizations Hospitalization Implication PCP as first indication that person is HIV positive Inadequate outreach by HIV testing and counseling programs PCP in previously diagnosed HIV-positive person Inadequate access to primary care Inadequate quality of primary care Inadequate adherence to PCP prophylaxis “Breakthrough” in a person receiving PCP prophylaxis Open in a separate window Except for true failure of chemoprophylaxis, the other reasons for PCP occurrence listed in Table 1 ▶ could in theory be diminished by specific improvements in AIDS education and medical care services. The fact that availability of highly active antiretroviral therapy—which partially restores the immune system 14– 17 —has reduced the incidence of opportunistic infections should facilitate recognition of PCP that is attributable to the causes outlined in Table 1 ▶ . If specific neighborhoods or subpopulations could be identified in which PCP incidence (measured by a rate of PCP hospitalizations) is disproportionately high, then efforts to define the defects in services particular to those communities could result in targeted improvements in HIV-related services (e.g., more widespread HIV testing, additional HIV-expert primary care services, adherence-fostering interventions). We therefore sought to create a “PCP Index” to define small geographic areas with disproportionately high PCP rates in a city with a high prevalence of HIV and AIDS. If the PCP Index could define such localities, it might serve as a useful tool to identify those communities to target for additional resources to better detect and manage HIV disease.
