Diagnosis and Treatment of Pneumocystis carinii Pneumonia: Economic Issues and Cost-Effectiveness

Abstract

Pneumocystis carinii pneumonia (PCP) has been one of the most common opportunistic infections since the beginning of the AIDS epidemic. It is associated with significant morbidity and mortality, and is costly. Because of concern over the high cost of health care for HIV-infected individuals, clinicians and policy makers have been pressed to develop economically efficient approaches to the diagnosis and treatment of PCP.

Substantial research, mainly in the form of cost-identification analyses, has focused on assessing the costs of various diagnostic strategies for PCP. These studies have suggested that definitive diagnosis of PCP is generally preferable to empiric treatment, particularly using less invasive tests such as induced sputum. Cost-effectiveness analyses have found that the optimal diagnostic strategies are most dependent on the prevalence of PCP, the diagnostic test performance, and the relative cost of sputum induction compared to bronchoscopy with broncheoalveolar lavage (BAL). No studies have found immediate BAL to be either less costly or more cost-effective than induced sputum followed by BAL if negative. Indirect tests like exercise induced oxygen desaturation (EOS) and arterial blood gas analysis, when used to stratify patients into high or low probability categories of PCP, may allow for more efficient triage to expensive BAL.

While a variety of effective treatment options are now available for PCP, trimethoprim-sulfamethoxazole (TMP-SMX) remains the first-line therapy because it is highly effective and least expensive. Cost-effectiveness analyses of second-line therapy for both mild to moderate and moderate to severe PCP have suggested that there are effective and cost-effective alternatives to pentamidine. Finally, intensive care unit (ICU) support for patients with AIDS-related PCP and severe respiratory failure has been shown to cost more per year of life saved than many commonly accepted clinical interventions.

There will continue to be a need for reliable and accurate information on the costs of AIDS-related opportunistic infections such as PCP. Future research should focus on the economic impact of PCP diagnosis and therapy in the outpatient setting, where the majority of such care now occurs.

Key Words:

Pneumocystis carinii - cost analysis - cost