Candidate: As an Assistant Professor at the Yale School of Nursing, I am ideally suited for a K01 Mentored Research Scientist Career Development Award from the National Institute of Nursing Research. My immediate goals/training needs are: 1) to develop my understanding of aging and geriatric syndromes, falls in particular;2) to develop more advanced skills in information extraction and statistical analysi;3) to gain experience in qualitative methods;and 4) To develop skills in clinical intervention research. My long-term goals are: 1) to be an independent and productive investigator in the field of geriatric syndromes and HIV, with particular expertise in falls and the use of electronic medical record-based observational cohorts;2) to develop a falls assessment and prevention intervention tailored to the HIV infected populations;and 3) to use this approach to explore other geriatric syndromes in the context of HIV infection. This project brings together mentors from multiple disciplines who are committed to my development as an independent researcher. The goal-directed training activities address my immediate goals/training needs and include didactics, intensive workshops, ongoing participation in seminars, particularly in aging and biostatistics, work on the research project itself, and preparation of an R03 that will launch the next step in my career. Environment: The facilities and resources provided by Yale and the Veterans Health Administration (VHA) Connecticut are unparalleled. The Yale School of Nursing provides extensive support to faculty conducting clinical research. The Yale Center for Medical Informatics supports resources for training and research in informatics, particularly in the area o information extraction. Much of the work that informs our understanding of falls in the elderly and falls prevention interventions comes from the Yale Program on Aging. This cross- disciplinary program provides extensive educational opportunities as well as access to individuals from a broad range of disciplines who incorporate aging as a focus of their clinical and research work. The VHA Connecticut is the home of the Veterans Aging Cohort Study (VACS) which provides the data for this project and has extensive computer resources that make the exploration of large datasets, such as VACS, feasible. Research: The research will explore serious falls (SF), falls that are serious enough to merit a visit to a health care provide, among HIV infected and uninfected individuals aged >40 years. There is evidence that falls are a problem among HIV infected individuals. However, the differences that exist between this population and the general elderly population highlight the inappropriateness of simply imposing falls prevention interventions that work in the elderly on HIV infected individuals. Orthostasis and vision loss are common in the elderly, but are not central health concerns for HIV infected individuals. HIV specific factors such as lower CD4 count, higher viral load, efavirenz use, and ritonavir use may also contribute to falls risk. I propose the following specific aims: 1) To determine the incidence, frequency, sequelae, and age of onset of SF;2) To elucidate traditional and HIV-specific risk factors for SF;3) In HIV infected individuals who have had a serious fall, to describe the factors that contributed to the fall, as well as their risk for a subsequent fall. In SA1, there are three dependent variables: first serious fall (SF), recurrent SFs, and serious fall sequelae. Serious falls will be identified using falls-related E-codes. In addition, I will use information extraction to identify serious falls in radiology reports and in outpatient progress notes. HIV status is the primary predictor variable. Sequelae of SFs will be identified by diagnostic codes. The independent variable is HIV status. I will use Poisson regression, piecewise logistic regression, and Cox regression models to test the hypotheses. In SA2, serious falls are the primary outcome and will be identified as in SA1. The primary independent variable is HIV status. In the first model that will combine HIV infected and uninfected Veterans, I will explore the contribution of traditional risk factors to the risk of a serious fall. I will test whether polysubstance abuse has a greater association with SF in HIV infected individuals by inclusion of an interaction between polysubstance abuse and HIV status and include traditional RFs. In a separate model restricted to HIV infected individuals, I will tes the contribution of HIV specific risk factors, particularly CD4 count and efavirenz use, in additio to traditional risk factors, to the risk of serious falls. I will use a longitudinal piecewise logitic regression and estimate the longitudinal average attributable fraction of each RF. SA3 will be explored from a sample of locally recruited HIV infected patients with a history of a serious fall. This is a qualitative aim that will use semi-structured, face-to-face interviews. An interpretive descriptive approach will guide data analysis. Data collected from the electronic medical record will provide specific information about the participants'medical history and about the evaluation of the fall in the emergency room or in the clinic. Together, these aims will provide me with the information necessary to develop a falls prevention intervention that is tailored to the specific risks encountered by HIV infected individuals and to begin to build a career in geriatric syndromes in the context of HIV infection.
Falls and their health consequences have never been explored among HIV infected individuals, but there is ample evidence that they are a problem. Falls prevention interventions that work in the elderly will likely not be appropriate for HIV infected populations, given the differences in the two populations and in their major falls risk factors. The information from this study will provide a foundation on which falls interventions can be developed that target the specific risk factors and needs of HIV infected populations.
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