In this study of 1,861 patients hospitalized with HIV-related PCP between the years 1995 and 1997, we found: 1) age-related differences in PCP severity of illness and an almost 2-fold higher inpatient mortality rate among older patients, and 2) while the overall timeliness of PCP medication initiation improved from 75% in the late 1980s to 90% during the years 1995 to 1997, patients ≥50 years of age continued to be less likely than younger patients to receive timely anti-PCP medications (). However, logistic regression analyses with in-hospital mortality as the outcome revealed that older age was no longer a significant predictor of inpatient mortality, after adjusting for severity of illness, timely PCP medication, and timely steroid use ().
Taken together, the results of our studies on age and PCP from the 1980s and 1990s consistently identify age-related gaps in important elements of the process of PCP care7
(). Rates of recording HIV infection in the progress notes were 10% lower for older versus younger HIV-infected PCP patients during both time periods, 1987–1990 and 1995–1997, suggesting that recognition of HIV infection was less frequent among older individuals. Older patients were more likely to present with greater severity of PCP than younger patients in both time periods, raising concern over the possibility of delayed recognition of pneumonia in older patients. Alternatively, biologic reasons may account for some of the age-related differences in severity of illness at presentation.16–18
Also, while rates of timely anti-PCP medication use increased by 20% for older and 16% for younger patients with HIV-related PCP between the late 1980s and mid-1990s, older patients were 50% to 60% as likely to have received timely anti-PCP medications. These results suggest that during both the late1980s and the mid-1990s, physicians may have overlooked the diagnosis of PCP more often when evaluating older patients. For all patients hospitalized with HIV-related PCP in both time periods, patients ≥50 years of age were almost twice as likely as younger patients to receive care in an intensive care unit and to die in-hospital.19,20
Our logistic regression models suggest that the age-related difference in in-hospital mortality may be due to variations in recognition of HIV infection, pneumonia, and/or PCP as the likely etiologic agent.
Conceptual Association of Age-related Variations in Patterns of Care with Medical Record Findings
Following publication of our finding of age-related variations in practice during the 1980s, Justice and Whalen presented physicians with a number of diagnostic and therapeutic challenges regarding age-related differences in care for individuals infected with HIV and associated opportunistic infections.21
These included recommendations to develop strategies that would increase awareness of the possibility of HIV infection in older individuals, identify how HIV management recommendations should be altered for older individuals, and conduct comparative studies of immune function of HIV-infected older versus younger individuals and with uninfected older individuals. This current study's results suggest that, while some progress has been made, additional efforts are needed to address these recommendations.
We recognize the need for caution in interpreting our findings. The data was abstracted from medical records. There may have been incompleteness in data recording. However, as in our earlier study, we employed reliable methods for ensuring the completeness and accuracy of data collection efforts and focused on clinical and laboratory information that is generally included in the overwhelming majority of medical records in HIV-related PCP cases. Another limitation is that our findings are from a period just prior to widespread use of HAART, with only 9% of our study patients having received protease inhibitors. Delays in conducting the study due to Institutional Review Board considerations at the 78 study hospitals was the main factor accounting for the extended study duration.22
Since early 1997, the rates of opportunistic infections such as PCP have declined dramatically, primarily as a result of protease inhibitor therapy.23
It is likely that even with these changes, delays in initiation of anti-PCP medications or corticosteroids will continue as physicians pursue other possible infectious causes of pulmonary findings in older individuals with pneumonia, many of whom are likely to have both unrecognized HIV-infection and unsuspected PCP infection. A third limitation is the absence of confirmed diagnoses of PCP in about one third of the patients in the study. While clinicians continue to debate the necessity of diagnostic bronchoscopy versus empiric PCP treatment for HIV-infected individuals who present with symptoms characteristic of PCP, rates of empiric treatment of PCP were almost 60% in both the 1980s and in the 1990s.7
Also, in both time periods, the results of the multivariate analyses were similar when the study sample was limited to confirmed PCP cases. Fourth, evaluations of variations in outpatient HIV care was not the primary aim of this study. Nonetheless, the finding of lower rates of HIV-recognition, PCP prophylaxis, and antiretroviral therapy among older versus younger patients in this study raises concern that age-related variations in many aspects of HIV care may exist.
In summary, the conclusions from the present study of HIV-related PCP care and outcomes in the mid-1990s are consistent with those of our earlier PCP study from the late 1980s.7
During the 2 decades of AIDS in the United States, physicians have consistently perceived AIDS as a younger persons' disease. Even in the mid-1990s, older patients with HIV-related PCP continued to have higher rates of absent notation about HIV-risk factors in the medical record, severe PCP cases at admission, intensive care unit use during the hospitalization, and in-hospital mortality, while having lower rates of use of timely anti-PCP medications. The presence of a sizeable number of older individuals with HIV infection in the third decade of the AIDS epidemic will undoubtedly present the medical profession with new challenges and opportunities.