An internationally generalizable risk index for mortality after one year of antiretroviral therapy

Tate, Janet P.; Justice, Amy C.; Hughes, Michael D.; Bonnet, Fabrice; Reiss, Peter; Mocroft, Amanda; Nattermann, Jacob; Lampe, Fiona; Bucher, Heiner C.; Crane, Heidi M.; Kitahata, Mari M.; May, Margaret; Sterne, Jonathan A C

doi:10.1097/qad.0b013e32835b8c7f

Cited by 177 publications

(181 citation statements)

References 37 publications

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“…As a measure of overall severity of illness, we used the VACS Index, which incorporates age, HIV-1 RNA viral load, CD4 count, hemoglobin, FIB-4, estimated glomerular filtration rate, and hepatitis C virus. The VACS Index is a validated prognostic measure, 28,29,[37][38][39][40] which is predictive of morbidity and mortality in both HIVinfected and uninfected patients (in calculating the index, the assumption is made that uninfected patients have a CD4 count > 500 cells/μL and viral load < 20 copies/ml). 29,41 Higher scores are indicative of higher all-cause mortality risk.…”

Section: Covariatesmentioning

confidence: 99%

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

et al. 2016

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PURPOSE:For patients receiving long-term opioid therapy (LtOT), the impact of guideline-concordant care on important clinical outcomes-notably mortality-is largely unknown, even among patients with a high comorbidity and mortality burden (e.g., HIV-infected patients). Our objective was to determine the association between receipt of guideline-concordant LtOT and 1-year all-cause mortality. METHODS: Among HIV-infected and uninfected patients initiating LtOT between 2000 and 2010 through the Department of Veterans Affairs, we used Cox regression with time-updated covariates and propensity-score matched analyses to examine the association between receipt of guideline-concordant care and 1-year all-cause mortality. RESULTS: Of 17,044 patients initiating LtOT between 2000 and 2010, 1048 patients (6%) died during 1 year of follow-up. Patients receiving psychotherapeutic cointerventions (hazard ratio [HR] 0.62; 95% confidence interval [CI] 0.51-0.75; P < 0.001) or physical rehabilitative therapies (HR 0.81; 95% CI 0.67-0.98; P = 0.03) had a decreased risk of all-cause mortality compared to patients not receiving these services, whereas patients prescribed benzodiazepines concurrent with opioids had a higher risk of mortality (HR 1.39; 95% CI 1.12-1.66; P < 0.001). Among patients with a current substance use disorder (SUD), those receiving SUD treatment had a lower risk of mortality than untreated patients (HR 0.47; 95% CI 0.32-0.68; P = < 0.001). No association was found between allcause mortality and primary care visits (HR 1.12; 95% CI 0.90-1.26; P = 0.32) or urine drug testing (HR 0.96; 95% CI 0.78-1.17; P = 0.67). CONCLUSIONS: Providers should use caution in initiating LtOT in conjunction with benzodiazepines and untreated SUDs. Patients receiving LtOT may benefit from multi-modal treatment that addresses chronic pain and its associated comorbidities across multiple disciplines.

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Section: Covariatesmentioning

confidence: 99%

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

et al. 2016

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“…Notably, the Veterans Aging Cohort Study (VACS) Index incorporates HIV-specific measures (HIV-1 RNA and CD4 count), hepatitis C infection, and measures of organ system injury (anemia, renal disease, and liver disease). The Index has been shown to predict AIDS and non-AIDS morbidity and mortality in multiple settings [9][10][11][12][13][14][15][16] but has not been evaluated as a cumulative measure. Further, when studying associations between biomarkers and clinical events, mortality can act as a competing risk in which those with advanced disease die before they experience the clinical event of interest.…”

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confidence: 99%

Baseline, Time-Updated, and Cumulative HIV Care Metrics for Predicting Acute Myocardial Infarction and All-Cause Mortality

et al. 2016

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Background. After adjustment for cardiovascular risk factors and despite higher mortality, those with human immunodeficiency virus (HIV+) have a greater risk of acute myocardial infarction (AMI) than uninfected individuals.Methods. We included HIV+ individuals who started combination antiretroviral therapy (cART) in the Veterans Aging Cohort Study (VACS) from 1996 to 2012. We fit multivariable proportional hazards models for baseline, time-updated and cumulative measures of HIV-1 RNA, CD4 counts, and the VACS Index. We used the trapezoidal rule to build the following cumulative measures: viremia copy-years, CD4-years, and VACS Index score-years, captured 180 days after cART initiation until AMI, death, last clinic visit, or 30 September 2012. The primary outcomes were incident AMI (Medicaid, Medicare, and Veterans Affairs International Classification of Diseases-9 codes) and death.Results. A total of 8168 HIV+ individuals (53 861 person-years) were analyzed with 196 incident AMIs and 1710 deaths. Controlling for known cardiovascular risk factors, 6 of the 9 metrics predicted AMI and all metrics predicted mortality. Time-updated VACS Index had the lowest Akaike information criterion among all models for both outcomes. A time-updated VACS Index score of 55+ was associated with a hazard ratio (HR) of 3.31 (95% confidence interval [CI], 2.11-5.20) for AMI and a HR of 31.77 (95% CI, 26.17-38.57) for mortality.Conclusions. Time-updated VACS Index provided better AMI and mortality prediction than CD4 count and HIV-1 RNA, suggesting that current health determines risk more accurately than prior history and that risk assessment can be improved by biomarkers of organ injury.

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“…The median VACS Index was 29 in PLWH compared to [18][19][20][21][22][23][24][25][26][27] in the uninfected (p<0.001). There was a trend towards higher pack years of smoking in PLWH.…”

Section: Resultsmentioning

confidence: 99%

“…Moreover, we sought to determine whether these markers of COPD were independent of the Veterans Aging Cohort Study (VACS) Index (https://medicine.yale.edu/intmed/vacs/), a validated research and clinical tool that predicts mortality in PLWH but does not include markers of pulmonary dysfunction. [24] Methods This study utilizes the Examinations of HIV-Associated Lung Emphysema (EXHALE) Study, a pulmonary substudy of VACS described in detail elsewhere. [25,26] VACS subjects were enrolled into EXHALE at 4 Veterans Affairs (VA) Medical Centers (VAMCs) between 2009-2012.…”

Section: Introductionmentioning

confidence: 99%

“…The VACS Index was developed in Veterans and externally validated, and predicts mortality in PLWH and uninfected persons. [24,[27][28][29] The VACS Index incorporates age, CD4, viral load, hepatitis C serostatus, hemoglobin, glomerular filtration rate (eGFR) and the Fibrosis- and Nutrition Examination Survey (NHANES) III data. [30][31][32][33][34] COPD was defined as airflow obstruction (FEV1/FVC<0.7), [35] and alternatively as FEV1/FVC below lower limit of normal (LLN, <5 th percentile).…”

Section: Introductionmentioning

confidence: 99%

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Markers of chronic obstructive pulmonary disease are associated with mortality in people living with HIV

Triplette

Justice

Attia

et al. 2018

Aids

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Objective. Aging people living with HIV (PLWH) face an increased burden of comorbidities, including chronic obstructive pulmonary disease (COPD). The impact of COPD on mortality in HIV remains unclear. We examined associations between markers of COPD and mortality among PLWH and uninfected subjects.Design. Longitudinal analysis of the Examinations of HIV-Associated Lung Emphysema (EXHALE) cohort study.Methods. EXHALE includes 196 PLWH and 165 uninfected smoking-matched subjects who underwent pulmonary function testing and CT scans to define COPD and were followed. We determined associations between markers of COPD with mortality using multivariable Cox regression models, adjusted for smoking and the VACS Index, a validated predictor of mortality in HIV.Results. Median follow-up time was 6.9 years; the mortality rate was 2.7 per 100-person-years among PLWH and 1.7 per 100-person-years among uninfected subjects (p=0.11). The VACS Index was associated with mortality in both PLWH and uninfected subjects. In multivariable models, pulmonary function and CT characteristics defining COPD were associated with mortality in PLWH: those with airflow obstruction (FEV1/FVC<0.7) had 3.1 times the risk of death (HR 3.1 [95% CI 1.4-7.1]), compared to those without; those with emphysema (>10% burden) had 2.4 times the risk of death (HR 2.4 [95% CI 1.1-5.5]) compared to those with ≤10% emphysema. In uninfected subjects, pulmonary variables were not significantly associated with mortality, which may reflect fewer deaths limiting power.Conclusions. Markers of COPD were associated with greater mortality in PWLH, independent of the VACS Index. COPD is likely an important contributor to mortality in contemporary PLWH.

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An internationally generalizable risk index for mortality after one year of antiretroviral therapy

Cited by 177 publications

References 37 publications

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

The Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

Baseline, Time-Updated, and Cumulative HIV Care Metrics for Predicting Acute Myocardial Infarction and All-Cause Mortality

Markers of chronic obstructive pulmonary disease are associated with mortality in people living with HIV

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