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Principal Investigator: Barbara Ellen Jones
Organization: VA SALT LAKE CITY HEALTHCARE SYSTEM
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: The COVID-19 pandemic exposed critical failures in the management of pneumonia.
Pneumonia is the leading cause of death from infectious diseases, resulting in over 20,000 hospitalizations
and thousands of deaths across the VA system each year. For the past thirty years, the mainstays of
treatment have been antibiotics and supportive care, with little recognition of viral pathogens and the host
immune response. Our reliance on antibiotics has led not only to overuse and resistance, but also to a
stagnation in diagnostic and therapeutic research that left us ill-equipped for the viral pandemic.
Significance: The devastation of COVID19 has made it clear that our old models of disease are inadequate
for the optimal management of respiratory infection. Existing evidence surrounding empiric treatment in
pneumonia is poor, fraught with previous research that has been challenged by heterogeneity and a failure
to characterize patients with enough detail to identify beneficial treatment approaches. It is unlikely that
more of the same approach will advance care. This proposal contributes to a direction of clinical approach
toward a more complex causal model of infection that requires complex solutions.
Innovation and Impact: We will use state-of-the-art exploratory mixed methods that integrate EHR data
with survey and qualitative data to examine practice change. National analyses will allow for more inclusive
and feasible implementation solutions in diverse VA settings. This proposal breaks scientific ground in VA
informatics by leveraging variation with state-of-the-art causal inference methods. If we take the opportunity
to study new treatment approaches based on more complex clinical assessments, we will take an important
step toward developing better treatments in pneumonia and being better prepared for future pandemics.
Specific Aims: Aim 1. Describe emerging changes in the empiric use of antibiotic and steroids for
pneumonia using national practice data and qualitative interviews. Aim 2. Identify local conditions related to
emergent change in the use of empiric antibiotics and steroids using an exploratory mixed-methods design.
Aim 3. Identify and evaluate optimized, interpretable, tailored decision trees for empiric antibiotic and steroid
treatments in Veterans with pneumonia.
Methodology: Our mixed methods approach includes secondary data analyses of patient-, provider-, and
setting-level EHR data including treatment decisions and patient outcomes, combined with natural language
processing. We will apply mixed effects models to model the changes in selected treatments and outcomes
(hospitalization, deaths, secondary infection) between the pre-pandemic and later (July 2021-present)
periods, and to characterize heterogeneity in the trajectories of these variables across VA sites. To that
quantitative analysis, we will add qualitative data examining changes in VA providers’ cognitive processes
of diagnosis and management of pneumonia, including beliefs and norms surrounding treatment. We will
conduct configurational analyses and validate our analytic results with our expert advisory group for face
validity, feasibility and usefulness. We will then identify a optimized treatment regimes, in the form of
interpretable decision trees that minimize 30-day mortality, for empiric antibiotic and steroid use in Veterans
with pneumonia using machine-learning-based, causal inference algorithms, coupled with clinical expertise.
Next Steps/Implementation: Results will inform recommendations for the management of Veterans with
pneumonia that can be integrated with other evidence streams and disseminated by the national program
directors in the Advisory Group. We will produce recommendations for implementation strategies of
interventions in pneumonia care for Veterans that will be developed and tested in future work. We will also
produce recommendations for future research, including (1) pragmatic clinical trials; (2) creation of VHA-
approved living guidance for pneumonia care; and (3) decision support and other implementation strategies.
Terms: <ARDS><Acute Respiratory Distress><Acute Respiratory Distress Syndrome><Adopted><Adoption><Adult ARDS><Adult RDS><Adult Respiratory Distress Syndrome><Airway infections><Algorithms><Antibiotic Agents><Antibiotic Drugs><Antibiotics><Belief><COVID crisis><COVID epidemic><COVID pandemic><COVID-19><COVID-19 crisis><COVID-19 epidemic><COVID-19 era><COVID-19 global health crisis><COVID-19 global pandemic><COVID-19 health crisis><COVID-19 pandemic><COVID-19 period><COVID-19 public health crisis><COVID-19 years><CV-19><Caring><Causality><Cause of Death><Cessation of life><Clinical><Clinical Practice Guideline><Clinical assessments><Communicable Diseases><Complex><Coronavirus Infectious Disease 2019><Coupled><Da Nang Lung><Data><Data Analyses><Data Analysis><Death><Decision Making><Decision Trees><Diagnosis><Diagnostics Research><Etiology><Face><Failure><Future><Healthcare><Heterogeneity><Hospital Admission><Hospitalization><Immune response><Immunological response><Infection><Infectious Disease Pathway><Infectious Diseases><Infectious Disorder><Informatics><Intervention><Intervention Strategies><Interview><Investigators><Knowledge><Left><Machine Learning><Medical><Methodology><Methods><Miscellaneous Antibiotic><Modeling><Natural Language Processing><Natural experiment><Observation research><Observation study><Observational Study><Observational research><Patient outcome><Patient-Centered Outcomes><Patient-Focused Outcomes><Patients><Personalized medical approach><Pneumonia><Pragmatic clinical trial><Provider><Randomization trial><Recommendation><Research><Research Methodology><Research Methods><Research Personnel><Researchers><Resistance><Respiratory Infections><Respiratory Tract Infections><SARS-CoV-2 epidemic><SARS-CoV-2 global health crisis><SARS-CoV-2 global pandemic><SARS-CoV-2 pandemic><SARS-coronavirus-2 epidemic><SARS-coronavirus-2 pandemic><Sepsis><Severe Acute Respiratory Syndrome CoV 2 epidemic><Severe Acute Respiratory Syndrome CoV 2 pandemic><Severe acute respiratory syndrome coronavirus 2 epidemic><Severe acute respiratory syndrome coronavirus 2 pandemic><Shock Lung><Site><Steroid Compound><Steroids><Stiff lung><Stream><Supportive Therapy><Supportive care><Survey Instrument><Surveys><System><Testing><Therapeutic Research><United States><Variant><Variation><Veterans><Viral><Work><adoption by clinician><adoption by healthcare providers><adoption by physician><adoption by provider><behavior change><blood infection><bloodstream infection><causal diagram><causal model><causation><clinical care><clinical practice and guidelines><clinician adoption><cognitive process><community acquired pneumonia><community associated pneumonia><compare effectiveness><coronavirus disease 2019><coronavirus disease 2019 crisis><coronavirus disease 2019 epidemic><coronavirus disease 2019 global health crisis><coronavirus disease 2019 global pandemic><coronavirus disease 2019 health crisis><coronavirus disease 2019 pandemic><coronavirus disease 2019 public health crisis><coronavirus disease crisis><coronavirus disease epidemic><coronavirus disease pandemic><coronavirus disease-19><coronavirus disease-19 global pandemic><coronavirus disease-19 pandemic><coronavirus infectious disease-19><data interpretation><design><designing><disease causation><disease model><disorder model><evidence base><experience><faces><facial><future pandemic><health care><host response><immune system response><immunoresponse><implementation efforts><implementation strategy><individual patient><individualized approach><innovate><innovation><innovative><interventional strategy><machine based learning><mortality><natural language understanding><new approaches><new therapeutic approach><new therapeutic intervention><new therapeutic strategies><new therapy approaches><new treatment approach><new treatment strategy><next pandemic><novel approaches><novel strategies><novel strategy><novel therapeutic approach><novel therapeutic intervention><novel therapeutic strategies><novel therapy approach><pandemic><pandemic disease><pathogen><pathogenic virus><patient oriented outcomes><personalized approach><physician adoption><pre-pandemic><precision approach><programs><provider adoption><provider-level adoption><randomized trial><research and methods><resistant><response><secondary infection><severe acute respiratory syndrome coronavirus 2 global health crisis><severe acute respiratory syndrome coronavirus 2 global pandemic><standard care><standard treatment><strategies for implementation><tailored approach><therapy optimization><treatment and outcome><treatment optimization><viral pandemic><viral pathogen><virus pathogen><wet lung>