Project Summary/Abstract Acute exacerbations of chronic obstructive pulmonary disease (COPD) increase the morbidity and mortality of the disease and are the major drivers of its high healthcare costs. Early treatment of exacerbations with systemic corticosteroids and/or antibiotics has been shown to mitigate many of their negative effects. However, prior efforts to detect exacerbations early enough to facilitate outpatient management have demonstrated mixed results. Electronic monitoring, in which patients are remotely monitored for changes in their clinical status, is a promising approach to detect exacerbations prior to presentation to care, facilitate earlier connection to outpatient management, and prevent progression to hospitalization. Electronic inhaler monitors can be attached to short-acting beta agonist (SABA) inhalers to record each actuation and transmit that data to the healthcare team. Because patients are instructed to respond to worsening symptoms by increasing use of their SABA inhalers, electronic inhaler monitors which detect this increase in use may be a potential tool to identify clinical worsening. However, there has been little research examining the use of electronic inhaler monitors in the early stages of a COPD exacerbation. To address this knowledge gap, we will conduct a secondary data analysis of an existing cohort of >250 patients with COPD enrolled into the Medication Adherence Research in COPD Patients (MARC R01 HL 128620: PI Eakin) study. As part of the MARC study, participants are monitored with weekly electronic symptom logs, electronic inhaler monitors, and monthly phone calls collecting information on recent exacerbations for a 12-month monitoring period. In Specific Aim 1, we will leverage this data to demonstrate that SABA use increases as respiratory symptoms worsen and then examine whether these increases in SABA use are associated with increased odds of a moderate or severe exacerbation. Because prior research suggests that not all patients with worsening symptoms increase their SABA use as instructed, in Specific Aim 2 we will evaluate whether patient-level risk factors, such as low cognitive functioning, are associated with this type of poor self-management. In Specific Aim 3, we will conduct a qualitative study using semi-structured interviews guided by the framework of Self-Regulation Theory to explore participants’ thought processes around their self-management during periods of worsening symptoms. This research will therefore not only evaluate the associations among respiratory symptoms, SABA use, and exacerbations but also seeks to shed light on patient subgroups that struggle to effectively self-manage their worsening symptoms. This proposal will provide the applicant with the necessary training to develop the quantitative and qualitative skills needed to pursue an independent career as a health services researcher in COPD.