HlV-infection and tuberculosis (TB) have had a major impact among injection and non-injection drug users, especially in New York, Chicago, Los Angeles, and Miami where nosocomial outbreaks of multidrug resistant TB among HlV-infected individuals have occurred. In this proposed competing continuation, we will build on our ongoing projects that evaluate quality of care for HlV-related Pneumocystis carinii pneumonia (PCP) and community acquired pneumonia (CAP) in several cities. In particular, we propose to assess the quality of TB care for HlV-infected individuals, both in-hospital (the majority of HlV-related TB cases are reported to Health Departments from inpatient settings) and subsequently as outpatients. Among HlV-infected inpatients with pulmonary symptoms, the differential diagnosis includes PCP, CAP, or TB. While our ongoing studies will provide important information on the quality of care that HlV-infected drug users and non-drug users receive for PCP or CAP, little is known about quality of TB care for these individuals. Our earlier studies found that PCP care varies widely, with poorer outcomes among drug users in the years 1987- 1990 and preliminary findings from 1995-1997 indicating high rates of discharge against medical advice and low rates of use of confirmatory diagnostic tests. In contrast, for HlV-related TB, our preliminary findings indicate that drug users may receive better inpatient care. Among high-risk HlV-infected individuals, rates of early suspicion for TB were higher for drug users in our 1987- 1990 data sets as well as in early looks at the 1995-1997 data from the PCP study. However, in our pilot project for HlV-related TB patients in Chicago, we found evidence of clinically relevant variations in HlV-related inpatient TB care. In particular, one Chicago hospital with few HlV-infected drug users had poor rates of TB recognition, infrequent use of isolation rooms, delayed early initiation of anti-TB therapy, and a nosocomial outbreak of MDr TB (the most recent reported outbreak), while other Chicago hospitals with larger numbers of drug users had > 80%-90% rates of TB suspicion and early isolation. We propose a 1995-1998 evaluation of quality of care, outcomes, and resource use for patients with HlV-infection and M TB to evaluate for drug users versus other HlV-infected individuals the following: in-hospital care (timing and appropriateness of initial anti-TB medications, use of resources such as isolation rooms, rapid methods for diagnosing TB, and outcomes) and outpatient care (timeliness of referral to directly observed therapy, drug therapy use, completion or not, and survival). This study, in conjunction with our already funded projects, will allow us to provide insights about the quality of care for HlV-related TB, CAP, and PCP in Chicago, New York, Los Angeles, and Miami, and will be the largest study of quality of care for HlV-related pneumonia. These issues are especially important in light of the findings that (1) poor TB care was associated with a nosocomial outbreak of MDr TB; (2) drug users may receive better inpatient TB care; (3) delayed referral to DOT has been associated with poorer survival rates; and (4) homelessness, but not drug use, was the most important predictor of incomplete outpatient TB care in one small study.

Agency
National Institute of Health (NIH)
Institute
National Institute on Drug Abuse (NIDA)
Type
Research Project (R01)
Project #
2R01DA010628-03
Application #
6017643
Study Section
Special Emphasis Panel (ZRG1-AARR-7 (01))
Program Officer
Davenny, Katherine
Project Start
1996-09-30
Project End
2001-08-31
Budget Start
1999-09-15
Budget End
2000-08-31
Support Year
3
Fiscal Year
1999
Total Cost
Indirect Cost
Name
Northwestern University at Chicago
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
005436803
City
Chicago
State
IL
Country
United States
Zip Code
60611
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Uphold, Constance R; Deloria-Knoll, Maria; Palella Jr, Frank J et al. (2004) 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. Chest 125:548-56
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Parada, Jorge P; Deloria-Knoll, Maria; Chmiel, Joan S et al. (2003) Relationship between health insurance and medical care for patients hospitalized with human immunodeficiency virus-related Pneumocystis carinii pneumonia, 1995-1997: Medicaid, bronchoscopy, and survival. Clin Infect Dis 37:1549-55
Bennett, C L; Sipler, A M; Parada, J P et al. (2001) Variations in institutional review board decisions for HIV quality of care studies: a potential source of study bias. J Acquir Immune Defic Syndr 26:390-1
Kim, B; Lyons, T M; Parada, J P et al. (2001) HIV-related Pneumocystis carinii pneumonia in older patients hospitalized in the early HAART era. J Gen Intern Med 16:583-9
Bennett, C L; Schwartz, D N; Parada, J P et al. (2000) Delays in tuberculosis isolation and suspicion among persons hospitalized with HIV-related pneumonia. Chest 117:110-6
Randall Curtis, J; Yarnold, P R; Schwartz, D N et al. (2000) Improvements in outcomes of acute respiratory failure for patients with human immunodeficiency virus-related Pneumocystis carinii pneumonia. Am J Respir Crit Care Med 162:393-8
Arozullah, A M; Yarnold, P R; Weinstein, R A et al. (2000) A new preadmission staging system for predicting inpatient mortality from HIV-associated Pneumocystis carinii pneumonia in the early highly active antiretroviral therapy (HAART) era. Am J Respir Crit Care Med 161:1081-6

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