Performance of valued life activities reflected asthma-specific quality of life more than general physical function

Effects of Asthma on the Performance of Activities of Daily Living: A Retrospective Study

The study aim was to identify the most problematic self--reported activities of daily living (ADLs). In a retrospective study, 1935 problematic ADLs were reported by 538 clients with 95% experiencing two or more problematic ADLs. Problematic ADLs were assessed by occupational therapists using the Canadian Occupational Performance Measure with walking (67%), household activities (41%), and climbing the stairs (41%) identified as the most prevalent problematic ADLs. Significant but weak associations were found between clinical determinants (e.g. physical, psychosocial) and problematic ADLs. The wide variety of problematic ADLs and the absence of a strong association with clinical determinants emphasizes the need for using individualized interview-based performance measures in clients with asthma.

Longitudinal mediation effects of activity meaning on the association between activity performance and quality of life among older adults with disabilities

BACKGROUND

Physical limitations may hinder older adults with physical disabilities' capability to perform various activities, which can affect their quality of life (QOL). Accomplishing meaningful activities may mitigate the impact of limited activity performance on their QOL. This longitudinal study aims to investigate how activity meaning mediates the relationship between activity performance and QOL among older adults with disabilities.

METHODS

Data for this longitudinal study was collected from 813 community-dwelling older adults aged 60 and above who had physical disabilities, over a two year interval. Path analysis was used to examine the cross-sectional and longitudinal mediation effects from activity performance, through activity meaning, to QOL.

RESULTS

At the same wave, high IADL performance or social activity performance, and high QOL was indirectly associated through high IADL meaning or social meaning. As for longitudinal association, high T1 IADL performance was associated with better T2 QOL through high T1 and T2 IADL meaning. Similarly, high T1 social activity performance also contributed to T2 QOL through high T1 and T2 social activity meaning. Additionally, social activity performance exhibited higher influence on QOL than that of IADL.

CONCLUSIONS

Both IADL and social activities have distinct impacts on the QOL of older adults with disabilities. To improve the current and future QOL of older adults with disabilities, professionals must prioritize their involvement in the most meaningful activities while being sensitive to and supportive of their preferences and valued lifestyles.

Access and Utilization of Asthma Medications Among Patients Who Receive Care in Federally Qualified Health Centers

OBJECTIVES

To describe access to and use of prescription asthma medications, and to assess factors associated with asthma exacerbation, healthcare utilization, and health status among asthma patients treated at Federally Qualified Health Centers.

METHODS

This is a retrospective cross-sectional study. We analyzed data from the 2014 National Health Center Patient Survey. This data is publicly available from the Health Resources and Services Administration. Data was collected from patients receiving face-to-face care from health centers funded under Section 330 of the Public Health Service Act. Data from patients was collected between October 8, 2014, and April 17, 2015. We included adult participants who reported having a diagnosis of asthma and confirmed that they still have asthma. Association between explanatory variables (access to prescription medications and use of asthma controller medications) and outcome variables (asthma exacerbations, asthma hospitalizations or emergency department visits, and self-rated health) was assessed using multivariable regression analyses while adjusting for demographics.

RESULTS

A total of 919 participants with asthma were included. Approximately 32% of the participants experienced delays in getting prescription medications, 26% were unable to get them, 60% experienced an asthma exacerbation last year, 48% rated their health as fair/poor, and 19% visited a hospital or an emergency department last year. Multivariable results showed that participants who were currently taking controller medications were more likely to have experienced an asthma exacerbation (OR = 4.02; 95% CI 1.91 to 8.45; P < .01), or visited a hospital or an emergency department (OR = 3.07; 95% CI 1.39 to 6.73; P < .01) in the last year compared with those who had never taken controller medications. Experiencing difficulties in accessing asthma medications was associated with lower self-rated health (β  = -.51; 95% CI -0.94 to -0.08; P = .02).

CONCLUSIONS

Future interventions should seek to improve asthma patient care and health outcomes using innovative strategies that act at multiple levels of the healthcare system (eg, individual, interpersonal, community levels).

What Matters? The Valued Life Activities of Older Adults Undergoing Elective Surgery

OBJECTIVES

Valued life activities are those activities an individual deems particularly important or meaningful. Surgery in older adults can affect their ability to perform valued activities, but data are lacking. We characterized these activities and assessed performance of them following surgery.

DESIGN

Retrospective observational study.

SETTING

Preoperative program for older adults undergoing elective surgery at an academic hospital.

PARTICIPANTS

Older adults (N = 194) in the program from February 2015 to February 2018.

MEASUREMENTS

A preoperative written questionnaire asked, "What are the activities that are most important to you to be able to do when you return home from surgery?" Participants could list up to three activities. Content analysis was used to develop domains of valued life activities and categorize responses. Postoperative questionnaires and medical records were used to determine ability to perform activities 6 months after surgery.

RESULTS

Of 194 participants (mean age = 74.9 ± 9.1 y), 57.7% were female; 33.5% had more than two comorbid conditions. We elicited 510 valued activities, with a mean of 2.6 (± .7) activities per participant. Content analysis revealed five categories: (1) recreational activities (28.9%); (2) mobility (24.9%); (3) activities of daily living (ADLs; 17.5%); (4) instrumental activities of daily living (IADLs; 16.9%); and (5) social activities (12.0%). Ultimately, 154 participants had surgery, of which 27.3% were unable to perform one of their valued activities at 6 months. Performance varied between activity categories; 91.9% of mobility activities, 90.8% of ADLs, 80.3% of IADLs, 77.3% of social activities, and 65.5% of recreational activities were able to be performed after surgery.

CONCLUSION

Older adults expressed a wide range of valued life activities. More than one-quarter were unable to engage in at least one valued life activity after surgery, with recreation the most commonly affected. Assessment of valued life activities should be incorporated into the perioperative management of older adults. J Am Geriatr Soc 67:2305-2310, 2019.

How does patient-provider communication influence adherence to asthma medications?

OBJECTIVE

To assess hypothesized pathways through which patient-provider communication impacts asthma medication adherence.

METHODS

A national sample of 452 adults with asthma reported assessments of patient-provider communication, proximal outcomes (understanding of asthma self-management, patient-provider agreement, trust in the clinician, involvement in care, motivation), and adherence to asthma medications. Structural equation modeling was used to examine hypothesized pathways.

RESULTS

Significantly positive direct pathways were found between patient-provider communication and all proximal outcomes. Only positive indirect pathways, operating through trust and motivation, were found between patient-provider communication and medication adherence.

CONCLUSION

Patient-provider communication influences many desirable proximal outcomes, but only influences adherence through trust and motivation.

PRACTICE IMPLICATIONS

To promote better adherence to asthma medication regimens and, ultimately positive asthma outcomes, healthcare providers can focus on implementing communication strategies that strengthen patients' trust and increase patient motivation to use asthma medications.

Values, Coping Strategies, and Psychopathological Symptoms Among Adolescents With Asthma

Values are related to coping strategies. However, little is known about the relationship between values and coping strategies among people suffering from chronic illnesses. This study investigates the mediating role of coping strategies specific to asthma on the relationship between the value of health, the value of an exciting life, and anxiety/depression symptoms among Russian and French adolescents with asthma. Adolescents aged 14 to 16 years with moderate and severe asthma ( N = 100, 58 males) were recruited in Russia and France and completed the Rokeach Value Survey, the Asthma-Specific Coping Scale, the Beck Depression Inventory, and the State-Trait Anxiety Inventory. Among Russian adolescents, the coping strategy of hiding asthma mediated the relationship between the value of health and depression symptoms. Among French adolescents, the coping strategies of ignoring asthma and adopting a restricted lifestyle mediated the relationship between the value of an exciting life and depression/anxiety symptoms. Among Russian and French girls, the coping strategy of ignoring asthma mediated the relationship between the value of health and anxiety/depression symptoms. Valuing an exciting life, French adolescents used coping strategies that led them to ignore asthma more, and as a result, experienced greater levels of anxiety and depression. Valuing health, Russian adolescents used coping strategies in which they hid their asthma less, but experienced more symptoms of depression. Valuing health, Russian and French girls used coping strategies in which they ignored their asthma less and experienced symptoms of anxiety and depression less.

Relationship between CD4 count and quality of life over time among HIV patients in Uganda: a cohort study

BACKGROUND

Immunological markers (CD4 count) are used in developing countries to decide on initiation of antiretroviral therapy and monitor HIV/AIDS disease progression. HIV is an incurable chronic illness, making quality of life paramount. The direct relationship between quality of life and CD4 count is unclear. The purpose of this study is to determine the relationship between change in CD4 count and quality of life measures in a Ugandan cohort of people living with HIV.

METHODS

We prospectively assessed quality of life among 1274 HIV patients attending an HIV clinic within a national referral hospital over a period of 6 months. Quality of life was measured using an objective measure, the Medical Outcomes Study HIV health survey summarized as Physical Health Score and Mental Health Score and a subjective measure, the Global Person Generated Index. Generalized estimating equations were used to analyze the data. The primary predictor variable was change in CD4 count, and the outcome was quality of life scores. We controlled for sociodemographic characteristics, clinical factors and behavioral factors. Twenty in-depth interviews were conducted to assess patient perception of quality of life and factors influencing quality of life.

RESULTS

Of the 1274 patients enrolled 1159 had CD4 count at baseline and six months and 586 (51%) received antiretroviral therapy. There was no association found between change in CD4 count and quality of life scores at univariate and multivariate analysis among the study participants whether on or not on antiretroviral therapy. Participants perceived quality of life as happiness and well-being, influenced by economic status, psychosocial factors, and health status.

CONCLUSIONS

Clinicians and policy makers cannot rely on change in immunological markers to predict quality of life in this era of initiating antiretroviral therapy among relatively healthy patients. In addition to monitoring immunological markers, socioeconomic and psychosocial factors should be underscored in management of HIV patients.

Correspondence between the RAND-Negative Impact of Asthma on Quality of Life item bank and the Marks Asthma Quality of Life Questionnaire

BACKGROUND

In many research and clinical settings in which patient-reported outcome (PRO) measures are used, it is often desirable to link scores across disparate measures or to use scores from 1 measure to describe scores on a separate measure. However, PRO measures are scored by using a variety of metrics, making such comparisons difficult.

OBJECTIVE

The objective of this article was to provide an example of how to transform scores across disparate measures (the Marks Asthma Quality of Life Questionnaire [AQLQ-Marks] and the newly developed RAND-Negative Impact of Asthma on Quality of Life item bank [RAND-IAQL-Bank]) by using an item response theory (IRT)-based linking method.

METHODS

Our sample of adults with asthma (N = 2032) completed 2 measures of asthma-specific quality of life: the AQLQ-Marks and the RAND-IAQL-Bank. We use IRT-based co-calibration of the 2 measures to provide a linkage, or a common metric, between the 2 measures. Co-calibration refers to the process of using IRT to estimate item parameters that describe the responses to the scales' items according to a common metric; in this case, a normal distribution transformed to a T scale with a mean of 50 and an SD of 10.

RESULTS

Respondents had an average age of 43 (15), were 60% female, and predominantly non-Hispanic White (56%), with 19% African American, 14% Hispanic, and 11% Asian. Most had at least some college education (83%), and 90% had experienced an asthma attack during the last 12 months. Our results indicate that the AQLQ-Marks and RAND-IAQL-Bank scales measured highly similar constructs and were sufficiently unidimensional for IRT co-calibration. Once linked, scores from the 2 measures were invariant across subgroups. A crosswalk is provided that allows researchers and clinicians using AQLQ-Marks to crosswalk to the RAND-IAQL toolkit.

CONCLUSIONS

The ability to translate scores from the RAND-IAQL toolkit to other "legacy" (ie, commonly used) measures increases the value of the new toolkit, aids in interpretation, and will hopefully facilitate adoption by asthma researchers and clinicians. More generally, the techniques we illustrate can be applied to other newly developed or existing measures in the PRO research field to obtain crosswalks with widely used traditional legacy instruments.

Development and validation of a lung transplant-specific disability questionnaire

BACKGROUND

Lung transplant (LT) aims to extend survival and improve patient-centred outcomes (PCOs) by reducing disability and improving health-related quality of life (HRQL). Few PCO instruments have been validated in LT populations. We aimed to develop and validate a shortened version of the valued life activities (VLA) disability scale specific to LT.

METHODS

We used data from 140 subjects participating in an ongoing cohort study of LT. Subjects completed a survey battery, including VLA items, and physical assessments before LT. To develop a shortened LT-specific VLA (LT-VLA), we iteratively deleted items from a longer 32-item VLA battery, retaining the instrument's conceptual framework, scoring and performance characteristics. We evaluated LT-VLA validity by testing correlations with a HRQL measure (Short Form-12 Physical Function (SF-12 PF) subscale), forced vital capacity % (FVC%) predicted and 6 minute walk distance (6MWD). Responsiveness was evaluated in 84 subjects who completed assessments before and after LT.

RESULTS

The 15-item LT-VLA scoring closely matched the longer VLA (correlations ≥0.96) and had excellent internal consistency (Cronbach's α 0.92). The LT-VLA required only 3 min or less to administer. The LT-VLA, measured as mean difficulty in performing each of the 15 activities queried, correlated with FVC% predicted (r=-0.30), 6MWD (r=-0.38) and SF-12 PF (r=-0.47) (all p<0.01). The LT-VLA mean difficulty was responsive to change from before to after LT (63% improvement; effect size=1.60).

CONCLUSIONS

The LT-VLA is a short, easy to administer, valid and responsive disease-specific PCO instrument that may be useful in clinical and research applications for lung transplantation.

Determinants of quality of life in children with asthma

BACKGROUND

HRQoL in children with asthma depends on multiple factors, among which asthma severity and level of control are believed to play a vital role. The determinants of the connection between asthma severity and asthma control with quality of life remain unclear.

AIMS

Primary aim of the study was to evaluate the HRQoL in children with asthma and to determine the factors that affect it.

MATERIALS AND METHODS

In total 504 children and one of their parents were recruited during a regular follow up visit in an outpatient asthma clinic. The measures used were the DISABKIDS smiley measure (DSmM), chronic generic measure-long form (DCGM-37) and the Condition-specific modules for asthma along with a special form for collecting demographic and clinical characteristics.

RESULTS

Three hundred fifteen children with mean age 5.35 years (Group A) and 189 with mean age 10.79 years (Group B), were recruited. Children with controlled asthma had significant higher mean score than the other asthma control groups (P < 0.001). Corticosteroid use, asthma severity, number of visits in doctor's office and lack of asthma control were significantly associated with the DCGM-37 scores as well as Impact Scale and Worry Scale. Lack of Asthma Control was the only factor that was associated with negative HRQoL in all the multiple regression models, controlling for the effect of the other covariates, in both age groups.

CONCLUSIONS

In conclusion, the evaluation of asthma HRQoL independently reflects the asthma control state and a dimension of its severity. These results highlight the need to modify asthma management strategy.

Comparison of the health-related quality of life, CD4 count and viral load of AIDS patients and people with HIV who have been on treatment for 12 months in rural South Africa

This study compared the level of CD4 count, viral load and health-related quality of life (HRQOL) between treatment-naïve AIDS patients and a cohort of people living with HIV who have been on treatment for 12 months. This study is based on a secondary data analysis of the records of 642 people with HIV consisting of 311 treatment-naïve AIDS patients and 331 people with HIV who have been on treatment for 12 months. The study findings are mostly presented in tables and analysed using the t-test to compare HRQOL scores, CD4 count and viral load in the two groups. The study generally noted poor financial capacity and low activity tolerance among the participants. Significant changes were noted in all the domains of HRQOL compared between the treatment-naïve patients and the 12 months treatment cohort. In the same manner, the median CD4 cell count and viral load differed significantly between both groups. The treatment-naïve and the 12 months treatment cohorts consistently reported much lower quality of life scores in the level of dependence domain which includes the measures of mobility, activity of daily living, dependence on medication and work capacity. There were little or no associations between the biomedical markers (CD4 count and viral load) and HRQOL indicators. However, the quality of life tended to increase with increase in the CD4 cell count. The poor to no association between the biomedical markers and HRQOL indicators show that these cannot be direct proxies of each other and that the CD4 cell count and viral load alone may be inadequate eligibility criteria for social support.

Differences in sleep quality and health-related quality of life in young adults with allergies and asthma and their healthy peers

OBJECTIVE

The current study examined the relationship between sleep quality and health-related quality of life (HRQOL).

PARTICIPANTS

Participants were 501 undergraduate students with allergies (167), asthma + allergies (167), or with no history of a chronic illness (167) completed study measures from August 2011 to April 2012.

METHODS

The undergraduate students completed questionnaires online as part of a larger study of psychosocial adjustment of young adults.

RESULTS

Young adults with allergies and asthma + allergies reported significantly worse sleep quality and HRQOL than healthy peers. Additionally, those with allergies and asthma + allergies had significantly more sleep disturbances and used sleeping medication significantly more often in the previous month than healthy peers.

CONCLUSIONS

These results highlight concerns regarding quality of life and sleep problems in an often-overlooked population. Importantly, sleep difficulties can result in difficulties in daily living and impairment in academic functioning.

Asthma outcomes: quality of life

BACKGROUND

"Asthma-related quality of life" (QOL) refers to the perceived impact that asthma has on the patient's QOL.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures of the impact of asthma on QOL for use in future asthma clinical research.

METHODS

We reviewed published documentation regarding the development and psychometric evaluation; clinical research use since 2000; and extent to which the content of each existing QOL instrument provides a unique, reliable, and valid assessment of the intended construct. We classified instruments as core (required in future studies), supplemental (used according to the study's aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011.

RESULTS

Eleven instruments for adults and 6 for children were identified for review. None qualified as core instruments because they predominantly measured indicators of asthma control (symptoms and/or functional status); failed to provide a distinct, reliable score measuring all key dimensions of the intended construct; and/or lacked adequate psychometric data.

CONCLUSIONS

In the absence of existing instruments that meet the stated criteria, currently available instruments are classified as either supplemental or emerging. Research is strongly recommended to develop and evaluate instruments that provide a distinct, reliable measure of the patient's perception of the impact of asthma on all of the key dimensions of QOL, an important outcome that is not captured in other outcome measures.

Disability in valued life activities among individuals with COPD and other respiratory conditions

PURPOSE

The purpose of this study was to delineate the effect of chronic obstructive pulmonary disease (COPD) on a broad range of valued life activities (VLAs) and make comparisons to effects of other airways conditions.

METHODS

We used cross-sectional data from a population-based, longitudinal study of US adults with airways disease. Data were collected by telephone interview. VLA disability was compared among 3 groups defined by reported physician diagnoses: COPD/emphysema, chronic bronchitis, and asthma. Multiple regression analyses were conducted to identify independent predictors of VLA disability.

RESULTS

About half of individuals with COPD were unable to perform at least 1 VLA; almost all reported at least 1 VLA affected. The impact among individuals with chronic bronchitis and asthma was less but still notable: 74%-84% reported at least 1 activity affected, and about 15% were unable to perform at least 1 activity. In general, obligatory activities were the least affected. Symptom measures and functional limitations were the strongest predictors of disability, independent of respiratory condition.

CONCLUSION

VLA disability is common among individuals with COPD. Obligatory activities are less affected than committed and discretionary activities. A focus on obligatory activities, as is common in disability studies, would miss a great deal of the impact of these conditions. Because individuals are often referred to pulmonary rehabilitation as a result of dissatisfaction with ability to perform daily activities, VLA disability may be an especially relevant outcome for rehabilitation.

Onset of depressive symptoms among adults with asthma: results from a longitudinal observational cohort

AIMS

Individuals with asthma may be at increased risk of depression, but few studies have identified precursors to the onset of depression. The study goal was to identify risk factors for depression onset among a community-based sample of adults with asthma.

METHODS

Data were obtained from three telephone interviews conducted at 2-yearly intervals on a longitudinal cohort of adults with asthma (n=439). The Center for Epidemiologic Studies Depression scale (CESD) was used to measure depressive symptoms. Multiple regression analyses tested associations of sociodemographic and health-related variables with depression prevalence (cross-sectional analyses) and incident depression (longitudinal analyses).

RESULTS

15% of subjects were classified as "depressed" (CESD> or =23) at each interview. Individuals depressed at baseline were more likely to drop out (OR=1.76 [95% CI 1.05, 2.96]). Low perceived control of asthma (measured with the Perceived Control of Asthma Questionnaire [PCAQ]) exhibited the most consistent association with depression. Lower PCAQ was cross-sectionally associated with depression (OR=0.51 per 0.5 SD difference in PCAQ [0.35, 0.75]). Onset of depression was noted in 38 individuals. Decrease in perceived control at follow-up was associated with depression onset (OR=7.47 [2.15, 26.01]).

CONCLUSIONS

Low perceived control of asthma predicted depression onset among adults with asthma. This risk factor may respond to self-management education.

Patient And phaRmacist Telephonic Encounters (PARTE) in an underserved rural population with asthma: methods and rationale

PURPOSE

Methods used to deliver and test a pharmacy-based asthma care telephonic service for an underserved, rural patient population are described.

SUMMARY

In a randomized controlled trial (RCT), the Patient And phaRmacist Telephonic Encounters (PARTE) project is assessing the feasibility, acceptability, and preliminary impact of providing pharmacy-based asthma care service telephonically. The target audience is a low income patient population across a large geographic area served by a federally qualified community health center. Ninety-eight participants have been randomized to either standard care or the intervention group who received consultation and direct feedback from pharmacists via telephone regarding their asthma self-management and medication use. Pharmacists used a counseling framework that incorporates the Indian Health Services 3 Prime Questions and the RIM Technique (Recognition, Identification, and Management) for managing medication use problems. Pharmacists encouraged patients to be active partners in the decision-making process to identify and address the underlying cause of medication use problems. Uniquely, this trial collected process and summative data using qualitative and quantitative approaches. Pharmacists' training, the fidelity and quality of pharmacists' service delivery, and short term patient outcomes are being evaluated. This evaluation will improve our ability to address research challenges and intervention barriers, refine staff training, explore patient perspectives, and evaluate measures' power to provide preliminary patient outcome findings.

CONCLUSION

A mixed method evaluation of a structured pharmacist intervention has the potential to offer insights regarding staff training, service fidelity and short term outcomes using quantitative and qualitative data in an RCT. Results will provide evidence regarding the feasibility and quality of carrying out the study and service delivery from the multiple perspectives of participants, clinicians, and researchers.

Development of disability in chronic obstructive pulmonary disease: beyond lung function

BACKGROUND

COPD is a major cause of disability, but little is known about how disability develops in this condition.

METHODS

The authors analysed data from the Function, Living, Outcomes and Work (FLOW) Study which enrolled 1202 Kaiser Permanente Northern California members with COPD at baseline and re-evaluated 1051 subjects at 2-year follow-up. The authors tested the specific hypothesis that the development of specific non-respiratory impairments (abnormal body composition and muscle strength) and functional limitations (decreased lower extremity function, poor balance, mobility-related dyspnoea, reduced exercise performance and decreased cognitive function) will determine the risk of disability in COPD, after controlling for respiratory impairment (FEV(1) and oxygen saturation). The Valued Life Activities Scale was used to assess disability in terms of a broad range of daily activities. The primary disability outcome measure was defined as an increase in the proportion of activities that cannot be performed of 3.3% or greater from baseline to 2-year follow-up (the estimated minimal important difference). Multivariable logistic regression was used for analysis.

RESULTS

Respiratory impairment measures were related to an increased prospective risk of disability (multivariate OR 1.75; 95% CI 1.26 to 2.44 for 1 litre decrement of FEV(1) and OR 1.57 per 5% decrement in oxygen saturation; 95% CI 1.13 to 2.18). Non-respiratory impairment (body composition and lower extremity muscle strength) and functional limitations (lower extremity function, exercise performance, and mobility-related dyspnoea) were all associated with an increased longitudinal risk of disability after controlling for respiratory impairment (p<0.05 in all cases). Non-respiratory impairment and functional limitations were predictive of prospective disability, above-and-beyond sociodemographic characteristics, smoking status and respiratory impairment (area under the receiver operating characteristic curve increased from 0.65 to 0.75; p<0.001).

CONCLUSIONS

Development of non-respiratory impairment and functional limitations, which reflect the systemic nature of COPD, appear to be critical determinants of disablement. Prevention and treatment of disability require a comprehensive approach to the COPD patient.

The impact of disability on depression among individuals with COPD

BACKGROUND

Both disability and depression are common in COPD, but limited information is available on the time-ordered relationship between increases in disability and depression onset.

METHODS

Subjects were members of a longitudinal cohort with self-reported physician-diagnosed COPD, emphysema, or chronic bronchitis. Data were collected through three annual structured telephone interviews (T1, T2, and T3). Depression was defined as a score >/= 4 on the Geriatric Depression Scale Short Form (S-GDS). Disability was measured with the Valued Life Activities (VLA) scale; three disability scores were calculated: percent of VLAs unable to perform, percent of VLAs affected (unable to perform or with some degree of difficulty), and mean VLA difficulty rating. Disability increases were defined as a 0.5 SD increase in disability score between T1 and T2. Multiple logistic regression analyses estimated the risk of T3 depression following a T1 to T2 disability increase for the total cohort and then excluding individuals who met the depression criterion at T1 or T2.

RESULTS

Approximately 30% of subjects met the depression criterion each year. Eight percent to 19% experienced a T1 to T2 disability increase, depending on the disability measure. Including all cohort members and controlling for baseline S-GDS scores, T1 to T2 increases in disability yielded a significantly elevated risk of T3 depression (% affected odds ratio [OR] =3.6; 95% CI, [1.7, 7.7]; % unable OR = 6.1 [17, 21.8]; mean difficulty OR= 3.6 [1.7, 8.0]). Omitting individuals depressed at T1 or T2 yielded even stronger risk estimates for % unable (OR = 13.4 [2.0, 91.4]) and mean difficulty (OR = 3.9 [1.3, 11.8]).

CONCLUSIONS

Increases in VLA disability are strongly predictive of the onset of depression.

Patient-reported outcomes among omalizumab and salmeterol/fluticasone combination therapy patients

BACKGROUND

Some asthma patients remain poorly controlled despite receiving care consistent with treatment guidelines.

OBJECTIVE

This study compared the ability to sleep, work, and participate in leisure activities among subjects with immunoglobulin E-mediated (allergic) asthma initiating omalizumab (omalizumab start group) with subjects receiving moderate-to-high doses of salmeterol/fluticasone combination therapy, who continued on salmeterol/fluticasone combination therapy for at least a year without adding omalizumab (salmeterol/fluticasone combination continuation group).

METHODS

Subjects completed an Internet-based screener and, if eligible, an Internet-based questionnaire. A propensity score model was utilized in the analysis. Group differences were assessed through logistic and linear regression models. Analyses were adjusted for propensity score quintile, how subjects heard about the study, and responses to retrospective single-item questions.

RESULTS

The analysis population included 86 omalizumab start group subjects and 436 salmeterol/fluticasone combination continuation subjects, recruited from June to November 2006. In the adjusted analyses, the omalizumab start group was more than twice as likely to have controlled asthma as measured by the Asthma Control Test (odds ratio, 2.62; p = 0.005). The omalizumab start group had significantly fewer sleep disturbances as measured by the Jenkins Sleep Evaluation Questionnaire (least-square means difference, -1.65;p = 0.004), less activity impairment as measured by the Work Productivity Activity Impairment-Asthma Scale (least-square means difference, -13.36;p < 0.001), and less difficulty in activities as measured by the Valued Life Activities Questionnaire (least-square means difference, -0.24; p < 0.001).

CONCLUSION

Asthma subjects who started taking omalizumab reported more improvement in asthma control, fewer sleep problems, less activity impairment, and less difficulty with activities than a similar cohort of subjects who continued taking salmeterol/fluticasone combination therapy.

Measures of asthma control and quality of life: longitudinal data provide practical insights into their relative usefulness in different research contexts

PURPOSE

To further our understanding of the relationships between asthma control and health-related quality of life (HRQOL) and provide insights into the relative usefulness of various measures in different research contexts. We present a conceptual model and test it with longitudinal survey data.

METHODS

Participants recruited via population sampling and hospital Emergency Departments completed questionnaires every 6 months for up to 3 years. Measures included: sleep disturbance, use of short-acting beta agonists (SABA), activity limitation, urgent medical visits, hospital use, Marks' Asthma Quality of Life Questionnaire (AQLQ-M) and the SF-36 Health Survey. Correlation analysis and multi-level models tested predictions from the conceptual model.

RESULTS

A total of 213 people with asthma aged 16-75 years provided 967 observations. Correlations between asthma control and asthma-specific HRQOL were stronger than those between asthma control and generic HRQOL. The asthma control variables explained 54-58% of the variance in asthma-specific HRQOL and 8-25% of the variance in generic HRQOL. Activity limitation was the main contributor to between-person variation, while sleep disturbance and SABA use were the main contributors to within-person variation.

CONCLUSIONS

Sleep disturbance and SABA use may be most useful in evaluating treatment effectiveness, while activity limitation may be better when monitoring the impact of asthma in populations.

Predictors of asthma medication nonadherence

BACKGROUND

The purpose of this study was to describe asthma medication adherence behavior and to identify predictors of inhaled corticosteroid (ICS) underuse and inhaled beta-agonist (IBA) overuse.

METHODS

Self-reported medication adherence, spirometry, various measures of status, and blood for immunoglobulin E measurement were collected on 158 subjects from a larger cohort of adults with asthma and rhinitis who were prescribed an ICS, an IBA, or both.

RESULTS

There was a positive association between ICS underuse and higher forced expiratory volume in one second percent (FEV1%) predicted (P = .01) and a negative association with lower income (P = 0.04). IBA overuse was positively associated with greater perceived severity of asthma (P = 0.004) and negatively with higher education level (P = 0.02).

CONCLUSIONS

Nonadherence to prescribed asthma therapy seems to be influenced by socioeconomic factors and by perceived and actual severity of disease. These factors are important to assess when trying to estimate the degree of medication adherence and its relationship to clinical presentation.

Disability in valued life activities among individuals with systemic lupus erythematosus

OBJECTIVE

To identify the prevalence of disability in a wide range of valued life activities (VLAs) among individuals with systemic lupus erythematosus (SLE), 1-year changes in such disability, and predictors of and changes in VLA disability.

METHODS

Data were from 2 waves of a cohort of 829 individuals with SLE interviewed annually by telephone. VLA disability was assessed using a scale rating the difficulty of performing 21 activities. Scores were also calculated for subscales corresponding to obligatory, committed, and discretionary activities. Changes in VLA disability from baseline to 1-year followup were assessed. Sociodemographic and disease status measures were examined as predictors of and changes in VLA disability using multiple regression analyses.

RESULTS

Almost half of the subjects were unable to perform > or =1 VLA at baseline. Almost all (91%) reported > or =1 VLA affected by SLE. One-quarter of the subjects experienced a significant increase in the number of activities they were unable to perform; approximately half experienced significant increases in the number of activities affected and in difficulty scores. Proportions of individuals whose disability increased and whose disability decreased were roughly equivalent. Disease status measures accounted for 62-72% of the variation in VLA difficulty. More severe disease status was predictive of increases in VLA difficulty; few predictors of improvements were identified.

CONCLUSION

VLA disability was common, with more disability noted in committed and discretionary activities than in obligatory activities. Because VLA disability has been linked to psychological well-being in previous studies, identification of factors that may protect against such disability is important.

Time use patterns among women with rheumatoid arthritis: association with functional limitations and psychological status

OBJECTIVES

This study assessed time use patterns among 375 women with rheumatoid arthritis (RA). We hypothesized that (i) as functional limitations increased, time use imbalances would occur (i.e. time needed for obligatory activities would conflict with time needed for productive and free-time activities) and (ii) time use imbalances would be associated with psychological distress.

METHODS

Time use estimates were obtained from written questionnaires; other study data were collected from annual telephone interviews. Activities were categorized as obligatory, committed or discretionary, as defined by Verbrugge. Time use estimates were aggregated to define number of obligatory (e.g. self-care) activities requiring >2 h/day and a number of committed and discretionary activities in which no time was spent each day.

RESULTS

After adjusting for age, education, marital status and pain severity, women with more functional limitations were significantly more likely to spend >2 h/day in obligatory activities. As functional limitations increased, the proportion spending no time in each committed activity and many discretionary activities increased. Spending >2 h/day in obligatory activities was not significantly associated with poor psychological status, but spending no time in a greater number of committed and discretionary activities was associated with lower life satisfaction and higher levels of depressive symptoms.

CONCLUSIONS

Having more severe functional limitations appears to shift time use patterns towards more time spent in obligatory activities and less time spent in committed and discretionary activities. These imbalances in time use were associated with psychological distress, highlighting the need for women with RA to maintain important productive, social and discretionary activities.

Asthma and activities of daily living

The provider's ability to judge the severity of a patient's illness is a vital part of the care of chronic disorders. In the treatment of asthma, it should extend beyond the objectively quantifiable measures of obstruction or inflammation. "Interference with activities of daily living" is a highly subjective assessment that may not allow quantitative comparisons, but it matters to the patient. Interventions aimed at lessening the burden of asthma on the daily life of the patient and his or her family may hold the key to improvement in a broader range of outcome measures.

Functioning and Psychological Status among Individuals with COPD

BACKGROUND

We examined the link between functioning and psychological status among persons with chronic obstructive pulmonary disease (COPD), using measures of both general functional status and performance of life activities.

METHODS

334 persons with COPD were interviewed by telephone. Functioning was assessed with two measures of difficulty with specific types of activities (self-care, recreational activities/hobbies) and a general measure of functional status (SF-12 Physical Component Score (PCS)).

RESULTS

About 16.2% of the sample had SF-12 Mental Component Score (MCS) scores indicative of psychological distress (MCS < 35). In separate regression models, difficulty with self-care and recreational activities was associated with an increased likelihood of distress (self-care: OR=2.9, 95%CI 1.3, 6.6; recreation: OR=7.5 [2.4, 23.7]), while PCS scores were not. In a model including all three predictors, difficulty with recreation was strongly associated with distress (OR=7.7 [2.1, 29.2]), difficulty with self-care was less strongly associated with distress (OR=2.1 [0.8, 5.5]), and PCS did not contribute significantly to the predictive ability of the model. However, low functioning as measured by the PCS was a significant risk factor for difficulty performing activities.

CONCLUSIONS

Measures of activity difficulty were independent predictors of psychological distress, while general physical function was not. Poor general physical function was a risk factor for activity difficulties, suggesting an indirect relationship between low PCS and psychological distress, with activity difficulties as the intermediate variable.

Effect of high dose inhaled glucocorticoids on quality of life in patients with moderate to severe asthma

Asthma is a chronic disorder that can place considerable restrictions on the physical, emotional, and social aspects of the lives of patients. Inhaled glucocorticoids (GCs) are the most effective controller therapy. The purpose of this study was to evaluate the effect of inhaled GCs on quality of life in patients with moderate to severe asthma. Patients completed the asthma quality of life questionnaire (AQLQ) and pulmonary function test at baseline and after 4 wks treatment of GCs. We enrolled 60 patients who had reversibility in FEV1 after 200 microgram of albuterol of 15% or more and/or positive methacholine provocation test, and initial FEV1% predicted less than 80%. All patients received inhaled GCs (fluticasone propionate 1,000 microgram/day) for 4 wks. The score of AQLQ was significantly improved following inhaled GCs (overall 51.9+/-14.3 vs. 67.5+/-12.1, p<0.05). The change from day 1 to day 28 in FEV1 following inhaled GCs was diversely ranged from -21.0% to 126.8%. The improvement of score of AQLQ was not different between at baseline and after treatment of GCs according to asthma severity and GCs responsiveness. Quality of life was improved after inhaled GCs regardless of asthma severity and GCs responsiveness in patients with moderate to severe asthma.

Impact of the home indoor environment on adult asthma and rhinitis

OBJECTIVE

We sought to study the combined effects of multiple home indoor environmental exposures in adult asthma and rhinitis.

METHODS

We studied 226 adults with asthma and rhinitis by structured interviews and home assessments. Environmental factors included dust allergen, endotoxin and glucan concentrations, and indoor air quality (IAQ) variables. Outcomes included forced expiratory volume in 1 second (FEV1) percent predicted, Severity of Asthma Score (SAS), Short-Form (SF)-12 Physical Component Scale (PCS), and asthma Quality of Life (QOL) score.

RESULTS

House dust-associated exposures together with limited IAQ variables were related to FEV1 % predicted (R = 0.24; P = 0.0001) and SAS (R = 0.18; P = 0.007). IAQ and limited dust variables were associated with SF-12 PCS (R = 0.15; P = 0.02), but not QOL (R = 0.13; P = 0.16).

CONCLUSIONS

The home environment is strongly linked to lung function, health status, and disease severity in adult asthma and rhinitis.