Risk factors for chronic obstructive pulmonary disease exacerbations, quality of care, and outcomes in people with HIV

PROJECT SUMMARY AND ABSTRACT Chronic obstructive pulmonary disease (COPD) is an important public health problem in people with HIV (PWH). PWH have 3-fold the odds of COPD as uninfected people after adjusting for smoking. Acute exacerbations of COPD (AECOPD) are the principal contributor to COPD morbidity and mortality. Given the adverse effects of AECOPD, international practice guidelines for the prevention and management of AECOPD exist in the general population. Limited evidence suggests that HIV infection is associated with increased risk for AECOPD, but data on the effect of HIV infection on post-AECOPD outcomes are lacking. We also lack data on quality of COPD care or the relationship between processes of care and outcomes in PWH. Scientific aims of this K08 are to determine: 1) risk factors for AECOPD in PWH and uninfected people; 2) the effect of HIV infection on outcomes after AECOPD; 3) the effect of HIV infection on COPD treatment concordance with guidelines and the relation- ship between COPD care quality and outcomes in PWH. Hypotheses: 1) HIV infection, “traditional” AECOPD risk factors, and HIV-specific factors are associated with AECOPD with interaction effects between age, smoking, and poorly controlled HIV infection that enhance susceptibility to AECOPD; 2) HIV infection is associated with increased readmissions and mortality after AECOPD; 3) guideline-concordant tests and therapies are underpre- scribed in PWH compared to uninfected people and high-quality COPD care is associated with improved out- comes in PWH. We will test our hypotheses in a cohort study of HIV-infected and uninfected controls with ad- ministrative and electronic health record (EHR) data from health systems across the US in a causal inference framework using nested case-control sampling to randomly select controls and inverse probability treatment weighting for analysis, thus emulating a target trial with HIV infection as “treatment.” Data from this study will lay the groundwork for the candidate’s future R01 proposals to assess patient adherence to COPD therapies and to test interventions to optimize COPD care at the patient, provider, and system level. Through an integrated train- ing plan of intensive mentorship, didactic coursework, experiential research, and academic activities, the candi- date will accomplish his career development goals to develop expertise in: 1) health informatics and data science for analysis of administrative and EHR data; 2) hierarchical and longitudinal statistical modeling; 3) causal infer- ence from observational data; and 4) leadership, communication, and knowledge dissemination skills. The re- sources and experiences of the candidate’s mentors (Drs. Alison Morris, Katie Suda, and Scott Rothenberger), supportive research environment at the University of Pittsburgh, and strong institutional commitment from the Division of Pulmonary, Allergy, and Critical Care Medicine assure the successful execution of the proposed research and training activities and the candidate’s transition into an independent comparative effectiveness and health services investigator developing effective management strategies for high-quality COPD care in PWH.