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© 2002 American Public Health Association
RESEARCH AND PRACTICE |
The authors are with Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.
Correspondence: Requests for reprints should be sent to Peter S. Arno, PhD, Department of Epidemiology and Social Medicine, Montefiore Medical Center, 111 E 210 St, Bronx, NY 10467 (e-mail: parno{at}montefiore.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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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)
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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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
).
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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 system14–17—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.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Hospital discharge records and AIDS surveillance data were obtained from the New York State and New York City Departments of Health, respectively. The International Classification of Diseases, Ninth Revision (ICD-9), codes for AIDS (042.0–044.9) and PCP (136.3) were used to identify 30 217 and 2262 hospitalizations for AIDS and PCP, respectively, in 1997. Hospital discharge data were used to establish numerator estimates, identifying persons hospitalized for both AIDS and PCP in 1997.18 Discharge records include patients' race/ethnicity as well as their zip code of residence. All personal identifiers were eliminated. The number of persons living with AIDS by zip code in 1997 (AIDS prevalence) was provided by the New York City Department of Health. All income data at the zip code level were based on 1990 census data.
We defined the PCP Index as follows: (number of PCP-related hospitalizations by zip code of patients' residence)/(number of persons living with AIDS by zip code).
The PCP Index for each zip code was thus calculated, geocoded, and mapped with geographic information systems (GIS) software (Maptitude, Caliper Corp, Newton, Mass). Zip codes were stratified by tertiles of both AIDS prevalence and PCP Index values (after excluding nonresidential zip codes).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City, for a citywide PCP Index of .05691. The PCP Index varied significantly by zip codes.
We found both high and low PCP Index values for neighborhoods with high AIDS prevalence (> 580 persons living with AIDS/100 000 population). Two such neighborhoods (New York City's West Village and Central Harlem) included zip codes with PCP Index values of .02532 and .08696, respectively. In addition, zip codes in communities with low (< 234 persons/100 000, such as Staten Island) or moderate (234–580 persons/100 000, such as Inwood in northern Manhattan) AIDS prevalence had strikingly high PCP Index values (.14035 and .08756, respectively).
We observed no statistical correlation across zip codes between AIDS prevalence rates and PCP Index values (Spearman rank correlation coefficient, r = –0.118; P = .13). (We found no statistical correlation between AIDS prevalence rates and PCP Index values with either the Spearman or the Pearson correlation. However, because the denominator of the PCP Index [persons living with AIDS] is the same as the numerator in the AIDS prevalence rate, interpretation of these correlations should be viewed with caution.) Thus, the geographic distribution of PCP Index values does not simply mirror AIDS prevalence rates (Figures 1 and 2).
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The PCP Index (.076, .044, and .035) was inversely correlated with income (lowest, middle, and highest tertiles of average per capita income by zip code, respectively). Index values also were associated with race/ethnicity: they equaled .0636, .0347, and .0327 for Black, Hispanic, and White persons, respectively. The PCP Index among Blacks was higher than that among Whites (P < .001). The PCP Index was not statistically different between Whites and Hispanics. From 1993 to 1997, the PCP Index declined steadily for New York City as a whole (from .20 in 1993 to .06 in 1997), reflecting 2 trends—declining opportunistic infection incidence and increasing AIDS prevalence—that have been widely reported during this period.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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The PCP Index shows substantial variation in HIV outcomes across New York City communities, but the specific explanation for high PCP Index values may vary by locale. Thus, in some regions (e.g., Staten Island and Inwood), a high PCP Index value in the setting of low to moderate AIDS prevalence may be a sentinel indicator of pockets of formerly undetected HIV infection. In other more impoverished areas with higher AIDS prevalence (e.g., Central Harlem), high PCP Index values may indicate poor access to primary care in comparison with the low PCP Index values in financially more advantaged yet AIDS-dense neighborhoods such as the West Village.
The fact that the geographic distribution of PCP Index values did not correlate with AIDS prevalence suggests that the Index provides an additional level of information beyond that reflected by AIDS case density alone. Mapping of PCP Index values may make it possible to pinpoint specific localities and subpopulations at increased risk for PCP. Such communities could be targeted for prevention resources and improved access to and delivery of HIV-related care, thereby reducing morbidity and mortality not just from PCP but also from other HIV-associated illnesses.
Because the PCP Index measures discrete hospitalizations (not individuals), more than 1 hospitalization per person may be reflected in the numerator if PCP recurred in the same individual. However, in this project, multiple hospitalizations for the same person generally reflect a deficiency in the health care system; thus, we believe that they do not detract from—and may even enhance—the utility of the PCP Index. However, this issue may be less important than we originally assumed. After receiving an individual-level file from the New York State Department of Health, we found that the ratio of the number of hospitalizations for PCP to the number of persons hospitalized with PCP was 1.03 for the city as a whole.
The PCP Index may prove to be a reliable quality-of-care indicator for assessing the performance of health care systems serving persons with HIV. This capability may become particularly relevant as increasing numbers of impoverished persons with AIDS enroll in managed Medicaid programs.
Future work will focus on refining and validating the PCP Index to clarify its meaning and significance. Other measures associated with substandard HIV-related care will be examined for their correlation with the PCP Index, including (1) diagnosis with AIDS followed by death within 2 months, (2) diagnosis with AIDS by virtue of having an AIDS-defining opportunistic illness (vs having a CD4 cell count < 200 cells/mL), and (3) inpatient mortality. In addition, field investigations, including chart reviews, in areas with exceptionally high or otherwise surprising PCP Index values will seek to define individual patient or system-level characteristics associated with these values.
Use of the PCP Index, which is easy to generate and integrates data from 2 sources not often linked (disease surveillance and service utilization), could strengthen the current system of monitoring the effect of HIV disease, help target prevention resources, and improve the delivery of HIV-related health care.
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Acknowledgments |
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This work was supported in part by grants from the Centers for Disease Control and Prevention and the Health Resources and Services Administration.
We also would like to thank the New York City Department of Health and the Mayor's Office of AIDS Policy Coordination for facilitating access to the data in this study.
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Footnotes |
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P. S. Arno led the conception and design of the study and wrote the paper with M. N. Gourevitch. E. Drucker, K. Bonuck and E. Schoenbaum contributed to the design, analysis, and interpretation of data. J. Fang and N. Deb analyzed the data. C. Goldberg and M. Memmott gathered the data and coordinated the activities of the study staff.
Accepted for publication February 23, 2001.
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References |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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1. Centers for Disease Control. Guidelines for prophylaxis against Pneumocystis carinii pneumonia for persons infected with human immunodeficiency virus. MMWR Morb Mortal Wkly Rep.1989;38(suppl 5):1–9.
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7.
Freedberg KA, Scharfstein JA, Seage GR, et al. The cost effectiveness of preventing AIDS-related opportunistic infections. JAMA.1998;279:130–136.
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