US Hospital Care for Patients With HIV Infection and Pneumonia* The Role of Public, Private, and Veterans Affairs Hospitals in the Early Highly Active Antiretroviral Therapy Era Constance R. Uphold, PhD, ARNP, RN; Maria Deloria-Knoll, PhD; Frank J. Palella, Jr, MD; Jorge P. Parada, MD, MPH; Joan S. Chmiel, PhD; Laura Phan, MPH; and Charles L. Bennett, MD, PhD Study objectives: We evaluated differences in processes and outcomes of HIV-related pneumonia care among patients in Veterans Affairs (VA), public, and for-profit and not-for-profit private hospitals in the United States. We compared the results of our current study (1995 to 1997) with those of our previous study that included a sample of patients receiving care during the years 1987 to 1990 to determine how HIV-related pneumonia care had evolved over the last decade. Setting/patients: The sample consisted of 1,231 patients with HIV infection who received care for Pneumocystis carinii pneumonia (PCP) and 750 patients with HIV infection who received care for community-acquired pneumonia (CAP) during the years 1995 to 1997. Measurement: We conducted a retrospective medical record review and evaluated patient and hospital characteristics, HIV-related processes of care (timely use of anti-PCP medications, adjunctive corticosteroids), non–HIV-related processes of care (timely use of CAP treatment medications, diagnostic testing, ICU utilization, rates of endotracheal ventilation, placement on respiratory isolation), length of inpatient hospital stay, and inpatient mortality. Results: Rates of timely use of antibiotics and adjunctive corticosteroids for treating PCP were high and improved dramatically from the prior decade. However, compliance with consensus guidelines that recommend < 8 h as the optimal time window for initiation of antibiotics to treat CAP was lower. For both PCP and CAP, variations in processes of care and lengths of in-hospital stays, but not mortality rates, were noted at VA, public, private not-for-profit hospitals, and for-profit hospitals. Conclusions: This study provides the first overview of HIV-related pneumonia care in the early highly active antiretroviral therapy era, and contrasts current findings with those of a similarly conducted study from a decade earlier. Quality of care for patients with PCP improved, but further efforts are needed to facilitate the appropriate management of CAP. In the third decade of the epidemic, it will be important to monitor whether variations in processes of care for various HIV-related clinical diagnoses among different types of hospitals persist. (CHEST 2004; 125:548 –556) Key words: community-acquired pneumonia; HIV; Pneumocystis cariini pneumonia; quality of care Abbreviations: AMA  against medical advice; CAP  community-acquired pneumonia; DNR  do not resuscitate; HAART  highly active antiretroviral therapy; LOS  length of stay; P(A-a)O 2  alveolar-arterial oxygen gradient; PCP  Pneumocystis carinii pneumonia; VA  Veterans Affairs I n the 1980s, AIDS was predictably fatal, with Pneumocystis carinii pneumonia (PCP) being the most common opportunistic pneumonia, presenting AIDS diagnosis, and cause of death. Most medical expenditures among persons with HIV infection were for inpatient HIV-related care. Hospitalizations for PCP were typically long and costly, averaging from 12 to 20 days and $14,500 to $16,000. 1 How- ever, the duration, acuity, and quality of inpatient care for PCP varied, with Veterans Affairs (VA) hospitals having the longest mean length of stay (LOS) and highest rates of ICU use, and private hospitals most likely to utilize diagnostic bronchos- copy. 1 In the mid-1990s, marked reductions in op- portunistic diseases and AIDS-related mortality were achieved with the introduction and prevalent use of highly active antiretroviral therapy (HAART). 2 This, as well as the continued and widespread use of 548 Clinical Investigations Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/22005/ on 04/05/2017