Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life

BACKGROUND

COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence.

METHODS

In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention.

RESULTS

A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, P = .01), fatigue (+0.6 points, P < .001), emotional function (+0.5 points, P = .001), and mastery (+0.7 points, P < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, P = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points (P < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 (P = .045). The pharmacist reported technical issues in 64% of visits.

CONCLUSIONS

Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.

Design of the Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) AIR Study

Introduction

Population-based epidemiological evidence suggests that exposure to ambient air pollutants increases hospitalisations and mortality from chronic obstructive pulmonary disease (COPD), but less is known about the impact of exposure to air pollutants on patient-reported outcomes, morbidity and progression of COPD.

Methods and analysis

The Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) Air Pollution Study (SPIROMICS AIR) was initiated in 2013 to investigate the relation between individual-level estimates of short-term and long-term air pollution exposures, day-to-day symptom variability and disease progression in individuals with COPD. SPIROMICS AIR builds on a multicentre study of smokers with COPD, supplementing it with state-of-the-art air pollution exposure assessments of fine particulate matter, oxides of nitrogen, ozone, sulfur dioxide and black carbon. In the parent study, approximately 3000 smokers with and without airflow obstruction are being followed for up to 3 years for the identification of intermediate biomarkers which predict disease progression. Subcohorts undergo daily symptom monitoring using comprehensive daily diaries. The air monitoring and modelling methods employed in SPIROMICS AIR will provide estimates of individual exposure that incorporate residence-specific infiltration characteristics and participant-specific time-activity patterns. The overarching study aim is to understand the health effects of short-term and long-term exposures to air pollution on COPD morbidity, including exacerbation risk, patient-reported outcomes and disease progression.

Ethics and dissemination

The institutional review boards of all the participating institutions approved the study protocols. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals.

Estimating pediatric asthma prevalence in rural senegal: A cross-sectional survey

RATIONALE

In Senegal, the prevalence of childhood asthma and utilization of appropriate asthma therapies is unknown.

METHODOLOGY

We used the International Study of Asthma and Allergies in Childhood (ISAAC) survey instrument to assess childhood respiratory health in rural Senegal. We interviewed the caregivers of children aged 5 through 8 years of age in the four largest Niakhar villages in August 2012.

RESULTS

We interviewed 1,103 primary caregivers for 1,513 children, representing 91% of all age-eligible children in the study area. Overall, 206 (14%) children had wheeze at any time in the past, 130 (9%) had wheeze within the past year, and only 41 (3%) reported a clinical diagnosis of asthma. Among children with wheeze within the past year, 81 (62%) had symptoms of severe asthma. Nocturnal cough was reported in 186 (14%) children who denied any history of wheezing illness. Only four (3%) children with wheeze in the past year had ever received bronchodilator therapy. Children with wheeze in the past year were significantly more likely to seek medical care for respiratory symptoms and to be perceived as less healthy than their peers. Children of lower socioeconomic status were significantly more likely to have wheeze.

CONCLUSIONS

Nearly one in ten children in Niakhar, Senegal had symptoms suggestive of asthma; however, few children have a diagnosis of asthma or use appropriate therapies. This study highlights an opportunity to raise community awareness of asthma in rural Senegal and to increase access to appropriate medical therapies. Pediatr Pulmonol. 2017;52:303-309. © 2016 Wiley Periodicals, Inc.

Percent Emphysema and Daily Motor Activity Levels in the General Population: Multi-Ethnic Study of Atherosclerosis

BACKGROUND

COPD is associated with reduced physical capacity. However, it is unclear whether pulmonary emphysema, which can occur without COPD, is associated with reduced physical activity in daily life, particularly among people without COPD and never smokers. We hypothesized that greater percentage of emphysema-like lung on CT scan is associated with reduced physical activity assessed by actigraphy and self-report.

METHODS

The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled participants free of clinical cardiovascular disease from the general population. Percent emphysema was defined as percentage of voxels < -950 Hounsfield units on full-lung CT scans. Physical activity was measured by wrist actigraphy over 7 days and a questionnaire. Multivariable linear regression was used to adjust for age, sex, race/ethnicity, height, weight, education, smoking, pack-years, and lung function.

RESULTS

Among 1,435 participants with actigraphy and lung measures, 47% had never smoked, and 8% had COPD. Percent emphysema was associated with lower activity levels on actigraphy (P = .001), corresponding to 1.5 hour less per week of moderately paced walking for the average participant in quintile 2 vs 4 of percent emphysema. This association was significant among participants without COPD (P = .004) and among ever (P = .01) and never smokers (P = .03). It was also independent of coronary artery calcium and left ventricular ejection fraction. There was no evidence that percent emphysema was associated with self-reported activity levels.

CONCLUSIONS

Percent emphysema was associated with decreased physical activity in daily life objectively assessed by actigraphy in the general population, among participants without COPD, and nonsmokers.

Symptom profiles and inflammatory markers in moderate to severe COPD

BACKGROUND

Physical and psychological symptoms are the hallmark of patients' subjective perception of their illness. The purpose of this analysis was to determine if patients with COPD have distinctive symptom profiles and to examine the association of symptom profiles with systemic biomarkers of inflammation.

METHODS

We conducted latent class analyses of three physical (dyspnea, fatigue, and pain) and two psychological symptoms (depression and anxiety) in 302 patients with moderate to severe COPD using baseline data from a longitudinal observational study of depression in COPD. Systemic inflammatory markers included IL1, IL8, IL10, IL12, IL13, INF, GM-CSF, TNF-α (levels >75^thcentile was considered high); and CRP (levels >3 mg/L was considered high). Multinominal logistic regression models were used to examine the association between symptom classes and inflammation while adjusting for key socio-demographic and disease characteristics.

RESULTS

We found that a 4-class model best fit the data: 1) low physical and psychological symptoms (26%, Low-Phys/Low-Psych), 2) low physical but moderate psychological symptoms (18%, Low-Phys/Mod Psych), 3) high physical but moderate psychological symptoms (25%, High-Phys/Mod Psych), and 4) high physical and psychological symptoms (30%, High-Phys/High Psych). Unadjusted analyses showed associations between symptom class with high levels of IL7, IL-8 (p ≤ .10) and CRP (p < .01). In the adjusted model, those with a high CRP level were less likely to be in the High-Phys/Mod-Psych class compared to the Low-Phys/Low-Psych (OR: 0.41, 95%CI 0.19, 0.90) and Low-Phys/Mod-Psych classes (OR: 0.35, 95%CI 0.16, 0.78); elevated CRP was associated with in increased odds of being in the High-Phys/High-Psych compared to the High-Phys/Mod-Psych class (OR: 2.22, 95%CI 1.08, 4.58). Younger age, having at least a college education, oxygen use and depression history were more prominent predictors of membership in the higher symptom classes.

CONCLUSIONS

Patients with COPD can be classified into four distinct symptom classes based on five commonly co-occurring physical and psychological symptoms. Systemic biomarkers of inflammation were not associated with symptom class. Additional work to test the reliability of these symptom classes, their biological drivers and their validity for prognostication and tailoring therapy in larger and more diverse samples is needed.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT01074515 .

A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study

Background

Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.

Objective

To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.

Methods

We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants’ feedback was used to develop a family-centered self-management program called “SUCCEED: Self-management Using Couples’ Coping EnhancEment in Diseases.” The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants’ program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.

Results

Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED’s sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.

Conclusion

In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.

Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability

BACKGROUND

Overuse of short-acting beta-agonists (SABA) is described in asthma, but little is known about overuse of SABA in chronic obstructive pulmonary disease (COPD).

METHODS

Prospective 3-month cohort study of patients with moderate-to-severe COPD who were provided a portable electronic inhaler sensor to monitor daily SABA use. Subjects wore a pedometer for 3 seven-day periods and were asked to complete a daily diary of symptoms and inhaler use. Overuse was defined as >8 actuations of their SABA per day while clinically stable.

RESULTS

Among 32 participants, 15 overused their SABA inhaler at least once (mean 8.6 ± 5.0 puffs/day), and 6 overused their inhaler more than 50% of monitored days. Compared to those with no overuse, overusers had greater dyspnea (modified Medical Research Council Dyspnea Scale: 2.7 vs. 1.9, p = 0.02), were more likely to use home oxygen (67% vs. 29%, p = 0.04), and were more likely to be on maximal inhaled therapy (long-acting beta-agonist, long-acting antimuscarinic agent, and an inhaled steroid: 40% vs. 6%, p = 0.03), and most had completed pulmonary rehabilitation (67% vs. 0%, p < 0.001). However, 27% of overusers of SABA were not on guideline-concordant COPD therapy.

CONCLUSIONS

Overuse of SABA was common and associated with increased disease severity and symptoms, even though overusers were on more COPD-related inhalers and more had completed pulmonary rehabilitation. More research is needed to understand factors associated with inhaler overuse and how to improve correct inhaler use.

COPD disease severity and innate immune response to pathogen-associated molecular patterns

The airways of COPD patients are often colonized with bacteria leading to increased airway inflammation. This study sought to determine whether systemic cytokine responses to microbial pathogen-associated molecular patterns (PAMPs) are increased among subjects with severe COPD. In an observational cross-sectional study of COPD subjects, PAMP-induced cytokine responses were measured in whole blood ex vivo. We used PAMPs derived from microbial products recognized by toll-like receptors 1, 2, 4, 5, 6, 7, and 8. Patterns of cytokine response to PAMPs were assessed using hierarchical clustering. One-sided Student's t-tests were used to compare PAMP-induced cytokine levels in blood from patients with and without severe COPD, and for subjects with and without chronic bronchitis. Of 28 male patients, 12 had moderate COPD (FEV1 50%-80%) and 16 severe COPD (FEV1 <50%); 27 participants provided data on self-reported chronic bronchitis, of which 15 endorsed chronic bronchitis symptoms and 12 did not. Cytokine responses to PAMPs in severe COPD were generally lower than in subjects with milder COPD. This finding was particularly strong for PAMP-induced interleukin (IL)-10, granulocyte colony stimulating factor, and IL-1β. Subjects with chronic bronchitis showed higher PAMP-induced IL-1RA responses to most of the PAMPs evaluated. COPD patients with more severe disease demonstrated a diminished cytokine response to PAMPs, suggesting that chronic colonization with bacteria may dampen the systemic innate immune response.

Patient-centered physical activity coaching in COPD (Walk On!): A study protocol for a pragmatic randomized controlled trial

BACKGROUND

Physical inactivity is significantly associated with more frequent hospitalizations and increased mortality in COPD even after adjusting for disease severity. While practice guidelines recommend regular physical activity for all patients with COPD, health systems are challenged in operationalizing an effective and sustainable approach to assist patients in being physically active.

METHODS

A pragmatic randomized controlled trial design was used to determine the effectiveness of a 12-month home and community-based physical activity coaching intervention (Walk On!) compared to standard care for 1650 patients at high risk for COPD exacerbations from a large integrated health care system. Eligible patients with a COPD-related hospitalization, emergency department visit, or observational stay in the previous 12months were automatically identified from the electronic medical records (EMR) system and randomized to treatment arms. The Walk On! intervention included collaborative monitoring of step counts, semi-automated step goal recommendations, individualized reinforcement from a physical activity coach, and peer/family support.

RESULTS

The primary composite outcome included all-cause hospitalizations, emergency department visits, observational stays, and death in the 12months following randomization. Secondary outcomes included COPD-related utilization, cardio-metabolic markers, physical activity, symptoms, and health-related quality of life. With the exception of patient reported outcomes, all utilization and clinical variables were automatically captured from the EMR.

CONCLUSIONS

If successful, findings from this multi-stakeholder driven trial of a generalizable and scalable physical activity intervention, carefully designed with sufficient flexibility, intensity, and support for a large ethnically diverse sample could re-define the standard of care to effectively address physical inactivity in COPD.

A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs

PURPOSE

Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs.

METHODS

The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and laboratory cost per patient.

RESULTS

The baseline (n = 7824) and intervention (n = 5759) cohorts were similar in their demographics, though the distribution of primary discharge diagnosis-related groups differed. At baseline, a mean of 2.06 (standard deviation 1.40) common labs were ordered per patient-day. Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared to baseline (95% confidence interval [CI], 0.34 to 0.11; P < 0.01). There were nonsignificant reductions in hospital mortality in the intervention period compared to baseline (2.2% vs 1.8%, P = 0.1) as well as volume of blood transfused in patients who received a transfusion (127.2 mL decrease; 95% CI, -257.9 to 3.6; P = 0.06). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618).

CONCLUSION

Implementation of a multifaceted QI intervention within a community-based hospitalist group was associated with a significant, but modest, decrease in the number of ordered lab tests and hospital costs. No effect was seen on hospital length of stay, mortality, or readmission rate. This intervention suggests that a community-based hospitalist QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.

Prevalence and correlates of suicide ideation in patients with COPD: a mixed methods study

PURPOSE

The purpose of this study was to examine the prevalence and correlates of suicidal ideation (SI) in patients with stable moderate to very severe chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

We conducted an exploratory mixed methods analysis of data from participants in a longitudinal observational study of depression in COPD. We measured depression with the Patient Health Questionnaire-9 (PHQ-9), which includes an item on SI. We compared participants with and without SI in relation to sociodemographics, symptoms, anxiety, and healthcare resource use with independent t-tests and chi-square tests. Content analysis was performed on qualitative data gathered during a structured SI safety assessment.

RESULTS

Of 202 participants, 121 (60%) had depressive symptoms (PHQ ≥6); 51 (25%) had a PHQ-9 ≥10, indicating a high likelihood of current major depression; and 22 (11%) reported SI. Compared to the 99 depressed participants without SI, those with SI were more likely to be female (59% vs 27%, P=0.004); had worse dyspnea (P=0.009), depression (P<0.001), and anxiety (P=0.003); and were also more likely to have received treatment for depression and/or anxiety (82% vs 40%, P<0.001) and more hospitalizations for COPD exacerbations (P=0.03) but had similar levels of airflow obstruction and functioning than participants without SI. Themes from the qualitative analysis among those with SI included current or prior adverse life situations, untreated or partially treated complex depression, loss of a key relationship, experience of illness and disability, and poor communication with providers.

CONCLUSION

Our findings suggest that current SI is common in COPD, may occur disproportionately in women, can persist despite mental health treatment, and has complex relationships with both health and life events. Adequate management of SI in COPD may therefore require tailored, comprehensive treatment approaches that integrate medical and mental health objectives.

Disability and recovery of independent function in obstructive lung disease: the cardiovascular health study

BACKGROUND

Chronic obstructive lung disease frequently leads to disability. Older patients may experience transitions between states of disability and independence over time.

OBJECTIVE

To identify factors associated with transition between states of disability and independent function in obstructive lung disease.

METHODS

We analyzed data on 4,394 participants in the Cardiovascular Health Study who completed prebronchodilator spirometry. We calculated the 1-year probability of developing and resolving impairment in ≥1 instrumental activity of daily living (IADL) or ≥1 activity of daily living (ADL) using transition probability analysis. We identified factors associated with resolving disability using relative risk (RR) regression.

RESULTS

The prevalence of IADL impairment was higher with moderate (23.9%) and severe (36.9%) airflow obstruction compared to normal spirometry (22.5%; p < 0.001). Among participants with severe airflow obstruction, 23.5% recovered independence in IADLs and 40.5% recovered independence in ADLs. In the adjusted analyses, airflow obstruction predicted the development of IADL, but not ADL impairment. Participants with severe airflow obstruction were less likely to resolve IADL impairment [RR 0.67 and 95% confidence interval (CI) 0.49-0.94]. Compared to the most active individuals (i.e. who walked ≥28 blocks per week), walking less was associated with a decreased likelihood of resolving IADL impairment (7-27 blocks: RR 0.81 and 95% CI 0.69-0.86 and <7 blocks: RR 0.73 and 95% CI 0.61-0.86). Increased strength (RR 1.16 and 95% CI 1.05-1.29) was associated with resolving IADL impairment.

CONCLUSIONS

Disability is common in older people, especially in those with severe airflow obstruction. Increased physical activity and muscle strength are associated with recovery. Research is needed on interventions to improve these factors among patients with obstructive lung disease and disability.

Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression

OBJECTIVES

To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression.

DESIGN

Retrospective cohort study.

SETTING

Department of Veterans Affairs outpatient clinics nationwide.

PARTICIPANTS

Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups.

MEASUREMENTS

After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models.

RESULTS

Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults.

CONCLUSION

Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.

An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine

The American Board of Internal Medicine Foundation's Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated--and when they are not.

Obesity is associated with a lower resting oxygen saturation in the ambulatory elderly: results from the cardiovascular health study

BACKGROUND

The contribution of obesity to hypoxemia has not been reported in a community-based study. Our hypothesis was that increasing obesity would be independently associated with lower SpO2 in an ambulatory elderly population.

METHODS

The Cardiovascular Health Study ascertained resting SpO2 in 2,252 subjects over age 64. We used multiple linear regression to estimate the association of body mass index (BMI) with SpO2 and to adjust for potentially confounding factors. Covariates including age, sex, race, smoking, airway obstruction (based on spirometry), self reported diagnosis of emphysema, asthma, heart failure, and left ventricular function (by echocardiography) were evaluated.

RESULTS

Among 2,252 subjects the mean and median SpO2 were 97.6% and 98.0% respectively; 5% of subjects had SpO2 values below 95%. BMI was negatively correlated with SpO2 (Spearman R = -0.27, P < .001). The mean difference in SpO2 between the lowest and highest BMI categories (< 25 kg/m(2) and ≥ 35 kg/m(2)) was 1.33% (95% CI 0.89-1.78%). In multivariable linear regression analysis, SpO2 was significantly inversely associated with BMI (1.4% per 10 units of BMI, 95% CI 1.2-1.6, for whites/others, and 0.87% per 10 units of BMI, 95% CI 0.47-1.27, for African Americans).

CONCLUSIONS

We found a narrow distribution of SpO2 values in a community-based sample of ambulatory elderly. Obesity was a strong independent contributor to a low SpO2, with effects comparable to or greater than other factors clinically associated with lower SpO2.

Racial and ethnic differences in receipt of antidepressants and psychotherapy by veterans with chronic depression

OBJECTIVE

This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian-Alaska Native (AI/AN) veterans.

METHODS

Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009-2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments).

RESULTS

Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53-.82, p<.05; guideline-concordant AOR range=.59-.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant.

CONCLUSIONS

A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.

Bidirectional relationship between cognitive function and pneumonia

RATIONALE

Relationships between chronic health conditions and acute infections remain poorly understood. Preclinical studies suggest crosstalk between nervous and immune systems.

OBJECTIVES

To determine bidirectional relationships between cognition and pneumonia.

METHODS

We conducted longitudinal analyses of a population-based cohort over 10 years. We determined whether changes in cognition increase risk of pneumonia hospitalization by trajectory analyses and joint modeling. We then determined whether pneumonia hospitalization increased risk of subsequent dementia using a Cox model with pneumonia as a time-varying covariate.

MEASUREMENTS AND MAIN RESULTS

Of the 5,888 participants, 639 (10.9%) were hospitalized with pneumonia at least once. Most participants had normal cognition before pneumonia. Three cognition trajectories were identified: no, minimal, and severe rapid decline. A greater proportion of participants hospitalized with pneumonia were on trajectories of minimal or severe decline before occurrence of pneumonia compared with those never hospitalized with pneumonia (proportion with no, minimal, and severe decline were 67.1%, 22.8%, and 10.0% vs. 76.0%, 19.3%, and 4.6% for participants with and without pneumonia, respectively; P < 0.001). Small subclinical changes in cognition increased risk of pneumonia, even in those with normal cognition and physical function before pneumonia (β = -0.02; P < 0.001). Participants with pneumonia were subsequently at an increased risk of dementia (hazard ratio, 2.24 [95% confidence interval, 1.62-3.11]; P = 0.01). Associations were independent of demographics, health behaviors, other chronic conditions, and physical function. Bidirectional relationship did not vary based on severity of disease, and similar associations were noted for those with severe sepsis and other infections.

CONCLUSIONS

A bidirectional relationship exists between pneumonia and cognition and may explain how a single episode of infection in well-appearing older individuals accelerates decline in chronic health conditions and loss of functional independence.

Patients with COPD with higher levels of anxiety are more physically active

BACKGROUND

Physical activity (PA) has been found to be an excellent predictor of mortality beyond traditional measures in COPD. We aimed to determine the association between depression and anxiety with accelerometry-based PA in patients with COPD.

METHODS

We performed a cross-sectional analysis of baseline data from 148 stable patients with COPD enrolled in an ongoing, longitudinal, observational study. We measured PA (total daily step count) with a Stepwatch Activity Monitor over 7 days, depression and anxiety with the Hospital Anxiety and Depression Scales (HADSs), dyspnea with the Shortness of Breath Questionnaire, and functional capacity with the 6-min walk test.

RESULTS

Increased anxiety was associated with higher levels of PA such that for every one-point increase in the HADS-Anxiety score there was a corresponding increase of 288 step counts per day (β=288 steps, P<.001), after adjusting for all other variables. Higher levels of depressive symptoms were associated with lower PA (β=-176 steps, P=.02) only when anxiety was in the model. The interaction term for anxiety and depression approached significance (β=26, P=.10), suggesting that higher levels of anxiety mitigate the negative effects of depression on PA.

CONCLUSIONS

The increased PA associated with anxiety in COPD is, to our knowledge, a novel finding. However, it is unclear whether anxious patients with COPD are more restless, and use increased psychomotor activity as a coping mechanism, or whether those with COPD who push themselves to be more physically active experience more anxiety symptoms. Future studies should evaluate for anxiety and PA to better inform how to improve clinical outcomes.

TRIAL REGISTRY

Clinicaltrials.gov; No.: NCT01074515; URL: www.clinicaltrials.gov.

Effects of respiratory and non-respiratory factors on disability among older adults with airway obstruction: the Cardiovascular Health Study

BACKGROUND

High rates of disability associated with chronic airway obstruction may be caused by impaired pulmonary function, pulmonary symptoms, other chronic diseases, or systemic inflammation.

METHODS

We analyzed data from the Cardiovascular Health Study, a longitudinal cohort of 5888 older adults. Categories of lung function (normal; restricted; borderline, mild-moderate, and severe obstruction) were delineated by baseline spirometry (without bronchodilator). Disability-free years were calculated as total years alive and without self-report of difficulty performing &γτ;1 Instrumental Activities of Daily Living over 6 years of follow-up. Using linear regression, we compared disability-free years by lung disease category, adjusting for demographic factors, body mass index, smoking, cognition, and other chronic co-morbidities. Among participants with airflow obstruction, we examined the association of respiratory factors (FEV1 and dyspnea) and non-respiratory factors (ischemic heart disease, congestive heart failure, diabetes, muscle weakness, osteoporosis, depression and cognitive impairment) on disability-free years.

RESULTS

The average disability free years were 4.0 out of a possible 6 years. Severe obstruction was associated with 1 fewer disability-free year compared to normal spirometry in the adjusted model. For the 1,048 participants with airway obstruction, both respiratory factors (FEV1 and dyspnea) and non-respiratory factors (heart disease, coronary artery disease, diabetes, depression, osteoporosis, cognitive function, and weakness) were associated with decreased disability-free years.

CONCLUSIONS

Severe obstruction is associated with greater disability compared to patients with normal spirometery. Both respiratory and non-respiratory factors contribute to disability in older adults with abnormal spirometry.

Navigational bronchoscopy with biopsy versus computed tomography-guided biopsy for the diagnosis of a solitary pulmonary nodule: a cost-consequences analysis

BACKGROUND

Solitary pulmonary nodules (SPNs) are frequent and can be malignant. Both computed tomography-guided biopsy and electromagnetic navigational bronchoscopy (ENB) with biopsy can be used to diagnose a SPN. A nondiagnostic computed tomography (CT)-guided or ENB biopsy is often followed by video-assisted thoracoscopic surgery (VATS) biopsy. The relative costs and consequences of these strategies are not known.

METHODS

A decision tree was created with values from the literature to evaluate the clinical consequences and societal costs of a CT-guided biopsy strategy versus an ENB biopsy strategy for the diagnosis of a SPN. The serial use of ENB after nondiagnostic CT-guided biopsy and CT-guided biopsy after nondiagnostic ENB biopsy were tested as alternate strategies.

RESULTS

In a hypothetical cohort of 100 patients, use of the ENB biopsy strategy on average results in 13.4 fewer pneumothoraces, 5.9 fewer chest tubes, 0.9 fewer significant hemorrhage episodes, and 0.6 fewer respiratory failure episodes compared with a CT-guided biopsy strategy. ENB biopsy increases average costs by $3719 per case and increases VATS rates by an absolute 20%. The sequential diagnostic strategy that combines CT-guided biopsy after nondiagnostic ENB biopsy and vice versa decreases the rate of VATS procedures to 3%. A sequential approach starting with ENB decreases average per case cost relative to CT-guided biopsy followed by VATS, if needed, by $507; and a sequential approach starting with CT-guided biopsy decreases the cost relative to CT-guided biopsy followed by VATS, if needed, by $979.

CONCLUSIONS

An ENB with biopsy strategy is associated with decreased pneumothorax rate but increased costs and increased use of VATS. Combining CT-guided biopsy and ENB with biopsy serially can decrease costs and complications.

Association between hospital volume and network membership and an analgesia, sedation and delirium order set quality score: a cohort study

Introduction

Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines.

Methods

Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score.

Results

Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score.

Conclusions

Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.