HIV-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 HIV-infected individuals have occurred. In this proposed competing continuation, we will build on our ongoing projects that evaluate quality of care for HIV-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 HIV-infected individuals, both in-hospital (the majority of HIV-related TB cases are reported to Health Departments from inpatient settings) and subsequently as outpatients. Among HIV-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 HIV-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 HIV-related TB, our preliminary findings indicate that drug users may receive better inpatient care. Among high-risk HIV-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 HIV-related TB patients in Chicago, we found evidence of clinically relevant variations in HIV-related inpatient TB care. In particular, one Chicago hospital with few HIV-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 HIV-infection and M TB to evaluate for drug users versus other HIV-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 HIV-related TB, CAP, and PCP in Chicago, New York, Los Angeles, and Miami, and will be the largest study of quality of care for HIV-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.
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