Functional status, health problems, age and comorbidity in primary care patients

The Impact of Dupilumab on Work Productivity and Emotional Health in CRSwNP: A Multicentric Study in Northeast Italy

Chronic rhinosinusitis with nasal polyps (CRSwNP) in the severe forms is associated with a poor quality of life. Dupilumab has been suggested as an add-on treatment option for severe CRSwNP. Severe CRSwNP patients treated with Dupilumab in different rhinological units were considered for this study via their evaluation at the baseline at first and the consequential follow-up at 6-, 12-, and 24 months from the first administration. At baseline (T0) and at each follow-up, patients underwent NPS, Sinonasal Outcome Test (SNOT)-22, Visual Analogue Scale (VAS) for smell, and Sniffin' sticks identification test (SSIT). The SNOT-22 domains for function and emotion were also analysed separately. Two hundred and seventeen patients with at least 6 months of follow-up were included. All parameters have improved during treatment (p < 0.0001). Noticeably, both the function and emotion SNOT-22 domains have improved within 6 months of treatment and have continued to progress during every interval within 12 months from the baseline, positively influencing patients' emotivity and augmenting their social and economic performances. Dupilumab improves the QoL of CRSwNP patients with good effects on the reported productivity and emotional health. Clinicians should pay attention to these two aspects when dealing with patients affected by severe CRSwNP.

Nasal polyp syndrome: a patient-centred term for CRSwNP by EUFOREA

Chronic Rhinosinusitis with Nasal Polyps (CRSwNP) is a chronic inflammatory disease of the nose and paranasal sinus cavities that significantly affects well-being and social function, particularly in young adults and middle-aged populations. CRSwNP is a common health condition in the Western world, with an estimated prevalence of 3%. Despite worldwide evidence-based treatment guidelines such as the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) 2020 and the European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA) chronic rhinosinusitis (CRS) pocket guide, a significant number of patients remain undiagnosed and/or uncontrolled with repeated oral corticosteroids (OCS) treatments and/or (multiple) endoscopic sinus surgeries (ESS).

Mepolizumab Reduces Systemic Corticosteroid Use in Chronic Rhinosinusitis With Nasal Polyps

BACKGROUND

Systemic corticosteroids (SCSs) are associated with short- and long-term adverse effects.

OBJECTIVE

To assess mepolizumab efficacy according to prior SCS use and characterize mepolizumab's SCS-sparing capabilities, in patients with severe chronic rhinosinusitis with nasal polyps.

METHODS

In the randomized, double-blind, phase III SYNAPSE trial (NCT03085797), adults with severe chronic rhinosinusitis with nasal polyps eligible for repeat sinus surgery despite standard of care treatment received mepolizumab (100 mg subcutaneously) or placebo every 4 weeks for 52 weeks. The impact of prior SCS courses (0/1/>1) on mepolizumab versus placebo treatment responses (changes from baseline in total endoscopic nasal polyp [week 52], nasal obstruction visual analog scale [weeks 49-52], and 22-item Sino-Nasal Outcome Test total [week 52] scores) was analyzed post hoc. To characterize mepolizumab's SCS-sparing capabilities, time-to-first SCS course for nasal polyps (prespecified) and total prednisolone-equivalent oral corticosteroid dose by patient baseline characteristics (post hoc, in patients with ≥1 SCS course during SYNAPSE) were assessed up to week 52.

RESULTS

Mepolizumab versus placebo improved treatment responses, irrespective of prior SCS use. By week 52, the probability of requiring SCSs for nasal polyps (Kaplan-Meier estimate [95% CI]) was lower with mepolizumab (25.4% [20.0-32.1]) versus placebo (37.5% [31.1-44.6]). In patients requiring 1 or more dose of SCSs, total (mean ± SD mg/y) prednisolone-equivalent oral corticosteroid dose was lower with mepolizumab (438.9 ± 350.40) versus placebo (505.2 ± 455.091), overall and irrespective of prior sinus surgeries, blood eosinophil count, or comorbidities.

CONCLUSIONS

Mepolizumab is associated with clinical benefits in patients with severe chronic rhinosinusitis with nasal polyps regardless of prior SCS use and has an SCS-sparing effect.

The Effects of Health Anxiety and Litigation Potential on Symptom Endorsement, Cognitive Performance, and Physiological Functioning in the Context of a Food and Drug Administration Drug Recall Announcement

Drug recalls and lawsuits against pharmaceutical manufacturers are accompanied by announcements emphasizing harmful drug side-effects. Those with elevated health anxiety may be more reactive to such announcements. We evaluated whether health anxiety and financial incentives affect subjective symptom endorsement, and objective outcomes of cognitive and physiological functioning during a mock drug recall. Hundred and sixty-one participants reported use of over-the-counter pain medications and presented with a fictitious medication recall via a mock Food and Drug Administration (FDA) website. The opportunity to join a class-action lawsuit was manipulated. We assessed health anxiety, recalled drug usage, blood pressure, heart rate, and performance on a computerized Trail Making Test (TMT). Symptom endorsement was strongly predicted by health anxiety. When combined, three health anxiety measures explained 28.5% variance (Cohen’s d = 1.26). These effects remain strong after controlling for depression and anxiety. Litigation condition did not predict symptom endorsement. Blood pressure and heart rate were modestly predicted by health anxiety, but not by litigation condition. TMT performance was consistently predicted by health anxiety, with higher scores associated with poorer performance. Although there were no main effects for litigation, interactions consistently emerged for the TMT, with generally poorer performance for those with higher health anxiety in the non-litigation condition; whereas health anxiety was unrelated to performance for the litigation condition. All but one participant joined the litigation when given the opportunity, despite a healthy sample and minimal use of pain medication. Subsequent data from 67 individuals with no mention of the FDA scenario or litigation showed that health anxiety still significantly predicts symptom endorsement (12.6% variance), but the explained variance is less than half that obtained in the FDA scenario. The findings suggest that health anxiety plays a significant role in adverse symptom reporting, beyond anxiety or depression, and this effect is independent of the presence of the FDA recall. The lack of differences for health anxiety and symptom endorsement between litigation and non-litigation conditions rules out malingering. Although it is general practice in drug recalls to list potential adverse side effects caused by medications, this may elicit unintended symptom experiences and health anxious individuals may be more susceptible.

Functional Decline in the Cancer Patient: A Review

A decline in functional status, an individual's ability to perform the normal activities required to maintain adequate health and meet basic needs, is part of normal ageing. Functional decline, however, appears to be accelerated in older patients with cancer. Such decline can occur as a result of a cancer itself, cancer treatment-related factors, or a combination of the two. The accelerated decline in function seen in older patients with cancer can be slowed, or even partly mitigated through routine assessments of functional status and timely interventions where appropriate. This is particularly important given the link between functional decline and impaired quality of life, increased mortality, comorbidity burden, and carer dependency. However, a routine assessment of and the use of interventions for functional decline do not typically feature in the long-term care of cancer survivors. This review outlines the link between cancer and subsequent functional decline, as well as potential underlying mechanisms, the tools that can be used to assess functional status, and strategies for its prevention and management in older patients with cancer.

Patients Unmet Needs in Chronic Rhinosinusitis With Nasal Polyps Care: A Patient Advisory Board Statement of EUFOREA

Background: European patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have had only limited occasions to unite to have their voices heard, hence missing the opportunity to contribute to the improvement of CRSwNP care.

Aims: To identify unmet needs in CRSwNP from the perspective of CRSwNP patients from the Patient Advisory Board (PAB) of the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA).

Methodology: Semi-structured interviews were conducted individually with 15 European patients with CRSwNP and with a disease history of more than 2 years. Patients shared their burden of the disease and frustrations related to CRSwNP care, experiences with key pillars of current treatment options, shortcomings of the current care pathways and recommendations for improvement of care. A panel of 30 members of the Patient Advisory Board reviewed the interview report and provided further input during 2 virtual meetings.

Results: CRSwNP patients indicated the need for greater awareness from society and physicians of the disease burden with impact on social function and well-being. Along with a loss of ability to smell and the continuous presence of secretions in the nose, most patients reported poor sleep quality and psychological impact as the most bothersome symptoms. Patients' frustrations relate primarily to the underestimation of the disease burden, the lack of coordination of care and the limited treatment options available to them. Treatment options with oral corticosteroids and/or sinus surgery both have positive and negative aspects, including the lack of long-lasting efficacy. Better coordination of care, more patient-centered care, greater public awareness, increases in research on the disease mechanisms and better therapeutic options would be warmly welcomed by CRSwNP patients.

Conclusions: This statement of the EUFOREA Patient Advisory Board on CRSwNP provides novel insights on the underestimation of the burden of CRSwNP and shortcomings of current care. Multiple recommendations made by the patients can underpin action plans for implementation of better care for CRSwNP among all physicians treating patients with this disabling disease.

Factors Associated With Health-Related Quality of Life Among Older People Exposed to the Jeju 4·3 Incident

OBJECTIVE

We explored factors associated with health-related quality of life (HRQOL), including socio-demographic and clinical characteristics, in among older people exposed to the Jeju 4·3 incident, and aimed to determine the effects of depression, posttraumatic stress disorder (PTSD) and perceived social support on HRQOL.

METHODS

We obtained data from 110 survivors and 1,011 immediate family members of the victims of the Jeju April 3 incident (mean age, 75.1 years), and evaluated the relationships of HRQOL with sociodemographic and clinical characteristics including posttraumatic and depressive symptoms, and perceived social support.

RESULTS

Poorer physical health, psychological health, social relationships, and environment HRQOL domain scores were strongly associated with older age, being a woman, poor socioeconomic status, and symptoms of depression and PTSD. The regression analyses indicated that, when relevant factors were controlled for, perceived social support moderated the negative association between HRQOL and psychiatric symptoms.

CONCLUSION

Our results suggest the importance of sociodemographic characteristics, in addition to psychiatric symptoms, for understanding HRQOL in older people exposed to the Jeju 4·3 incident. These results have important implications for interventions aiming to improve the HRQOL of the victims of the Jeju 4·3 incident.

Cross-sectional study evaluating the association between integrated care and health-related quality of life (HRQOL) in Dutch primary care

OBJECTIVES

The aim of this study was to evaluate the association between integrated care and health-related quality of life (HRQOL) in a primary care practice population.

DESIGN

A cross-sectional survey study.

SETTING

Primary care practice population.

PARTICIPANTS

A sample (n=5562) of patients in two general practitioner practices in the Netherlands.

PRIMARY OUTCOME MEASURES

The Rainbow Model of Integrated Care Measurement Tool patient version and EQ-5D was used to assess integrated service delivery and HRQOL. The association between integrated care and HRQOL groups was analysed using multivariate logistic regression.

RESULTS

Overall, 933 respondents with a mean age of 62 participated (20% response rate) in this study. The multivariate analysis revealed that positive organisational coordination experiences were linked to better HRQOL (OR=1.87, 95% CI 1.18 to 2.95), and less anxiety and depression problems (OR=0.36, 95% CI 0.20 to 0.63). Unemployment was associated with a poor HRQOL (OR=0.15, 95% CI 0.08 to 0.28). Ageing was associated with more mobility (OR=1.06, 95% CI 1.04 to 1.09), self-care (OR=1.06, 95% CI 1.02 to 1.11), usual activity (OR=1.03, 95% CI 1.01 to 1.05) and pain problems (OR=1.02, 95% CI 1.01 to 1.04). Being married improved the overall HRQOL (OR=1.60, 95% CI 1.13 to 2.26) and decreased anxiety and depression (OR=0.47, 95% CI 0.31 to 0.72). Finally, females had a poor overall HRQOL (OR=1.67, 95% CI 0.48 to 0.93) and more pain and discomfort problems (OR=1.47, 95% CI 1.11 to 1.95).

CONCLUSION

This study shows for the first time that organisational coordination activities are positively associated with HROQL of adult patients in a primary care context, adding to the evidence of an association between integrated care and HRQOL. Also, unemployment, ageing and being female are accumulating risk factors that should be considered when designing integrated primary care programmes. Further research is needed to explore how various integration types relate to HRQOL for people in local communities.

Burden of Disease in Chronic Rhinosinusitis with Nasal Polyps

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a predominantly type 2 inflammation-mediated disease of the nasal mucosa and paranasal sinuses with an under-recognized clinical, humanistic, and economic burden. Patients with CRSwNP experience a high symptom burden, including nasal congestion, loss of smell, and rhinorrhea, which has a negative impact on physical and mental health-related quality of life, including sleep quality. Existing medical and surgical interventions, including local and systemic corticosteroids and endoscopic sinus surgery, may be associated with recurrence of nasal polyps and associated symptoms and with an increased risk of short- and long-term adverse effects, especially with repeated or long-term use. Because type 2 inflammation is implicated in the pathogenesis of several coexisting diseases, patients with CRSwNP often have comorbid asthma and/or nonsteroidal anti-inflammatory drug-exacerbated respiratory disease. These patients, as well as those with high corticosteroid use and/or sinonasal surgical history, have more severe disease and associated symptom burden and represent a difficult-to-treat population under the existing management paradigm. This article reviews the clinical, humanistic, and economic burden of CRSwNP; it highlights the unmet need for effective and safe CRSwNP therapies that effectively control symptoms and minimize recurrence by targeting the underlying type 2 inflammatory disease pathophysiology.

The acceleration of ageing in older patients with cancer

Older cancer survivors may experience ageing at an accelerated rate when compared to their similar-aged, cancer-free counterparts. Ageing is undoubtedly a significant risk factor for cancer. There is evidence to suggest, however, that this relationship may in fact be bidirectional, with cancer and its treatments contributing to the ageing process. In this review, we outline the current literature linking cancer and anti-cancer therapy to adverse ageing outcomes and explore what additional research is needed in order to conclusively define cancer and its treatment as an accelerator of ageing.

Multimorbidity and functional limitation: the role of social relationships

OBJECTIVES

To examine the relationship between multimorbidity and functional limitation, and how social relationships alter that association.

METHODS

This cross-sectional study used data collected by self-reported questionnaires from adults aged 65 years and older living in a rural area in Japan in 2017. This analysis included complete data from 570 residents. Multimorbidity status was defined as having two chronic diseases exist simultaneously in one individual, and the function status was measured by their long-term care needs. Social relationships were assessed by the Index of Social Interaction and divided into high and low levels. Multiple logistic regression analysis was used to examine the association between social relationships and functional limitation and to assess the role of social relationships in this association.

RESULTS

The logistic regression model indicated that the risk of functional limitation was higher in multimorbidity participants than free-of-multimorbidity participants (OR = 2.55, 95% CI = 1.56-4.16). Compared with participants with no multimorbidity and a high level of social relationships, low level of social relationships increased the risk of functional limitation among participants both with and without multimorbidity, with the OR = 7.71, 95% CI = 3.03-19.69 and OR = 3.28, 95% CI = 1.30-8.27, respectively. However, no significant result was found in participants with multimorbidity and a high level of social relationships (P = 0.365).

CONCLUSIONS

Multimorbidity was associated with functional limitations. However, this association could be increased by a low level of social relationships and decreased by a high level of social relationships.

Chronic rhinosinusitis: a qualitative study of patient views and experiences of current management in primary and secondary care

OBJECTIVES

To explore patient views and perspectives of current management of chronic rhinosinusitis (CRS) in primary and secondary care.

DESIGN

Semistructured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic RhinOsinusitis).

SETTING

Primary care and secondary care ear, nose and throat outpatient clinics in the UK.

PARTICIPANTS

Twenty-five patients consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.

RESULTS

CRS has a significant impact on patients' quality of life, affecting their ability to work effectively, their social interactions and daily living. Patients seek help when symptoms become unmanageable, but can become frustrated with the primary care system with difficulties obtaining an appointment, and lack of continuity of care. Patients perceive that general practitioners can be dismissive of CRS symptoms, and patients often prioritise other concerns when they consult. Health system barriers and poor communication can result in delays in accessing appropriate treatment and referral. Adherence to intranasal steroids is a problem and patients are uncertain about correct technique. Nasal irrigation can be time-consuming and difficult for patients to use. Secondary care consultations can appear rushed, and patients would like specialists to take a more 'holistic' approach to their management. Surgery is often considered a temporary solution, appropriate when medical options have been explored.

CONCLUSIONS

Patients are frustrated with the management of their CRS, and poor communication can result in delays in receiving appropriate treatment and timely referral. Patients seek better understanding of their condition and guidance to support treatments decisions in light of uncertainties around the different medical and surgical options. Better coordinated care between general practice and specialist settings and consistency of advice has the potential to increase patient satisfaction and improve outcomes.

Expert panel process to optimise the design of a randomised controlled trial in chronic rhinosinusitis (the MACRO programme)

BACKGROUND

MACRO (Defining best Management for Adults with Chronic RhinOsinusitis) is an NIHR-funded programme of work designed to establish best practice for adults with chronic rhinosinusitis (CRS). The 7-year programme comprises three consecutive workstreams, designed to explore NHS care pathways through analysis of primary and secondary data sources, and to undertake a randomised controlled trial to evaluate a longer-term course of macrolide antibiotics and endoscopic sinus surgery for patients with CRS. A number of outstanding elements still required clarification at the funding stage. This paper reports an expert panel review process designed to agree and finalise the MACRO trial design, ensuring relevance to patients and clinicians whilst maximising trial recruitment and retention.

METHODS

An expert panel, consisting of the MACRO Programme Management Group, independent advisors, and patient contributors, was convened to review current evidence and the mixed-method data collected as part of the programme, and reach agreement on MACRO trial design. Specifically, agreement was sought for selection of macrolide antibiotic, use of orally administered steroids, inclusion of CRS phenotypes (with/without nasal polyps), and overall trial design.

RESULTS

A 12-week course of clarithromycin was agreed as the main trial comparator due to its increasing use as a first- and second-line treatment for patients with CRS, and the perceived need to establish its role in CRS management. Orally administered steroids will be used as a rescue medication during the trial, rather than routinely either pre or post trial randomisation, to limit any potential effects on surgical outcomes and better reflect current UK prescribing habits. Both CRS phenotypes will be included in a single trial to ensure that the MACRO trial is both pragmatic and generalisable to primary care. A modified, three-arm trial design was agreed after intense discussions and further exploratory work. Inclusion criteria were amended to ensure that the patients recruited would be considered eligible for the treatment offered in the trial due to having already received appropriate medical therapy as deemed suitable by their ENT surgeon. A proposed 6-week run-in period prior to randomisation was removed due to the new criteria prior to randomisation.

CONCLUSION

The expert panel review process resulted in agreement on key elements and an optimal design for the MACRO trial, considered most likely to be successful in terms of both recruitment potential and ability to establish best management of patients with CRS.

Management strategies for chronic rhinosinusitis: a qualitative study of GP and ENT specialist views of current practice in the UK

OBJECTIVES

To explore general practitioner (GP) and ears, nose and throat (ENT) specialist perspectives of current treatment strategies for chronic rhinosinusitis (CRS) and care pathways through primary and secondary care.

DESIGN

Semi-structured qualitative telephone interviews as part of the MACRO programme (Defining best Management for Adults with Chronic Rhinosinusitis) SETTING: Primary care and secondary care ENT outpatient clinics in the UK.

PARTICIPANTS

Twelve GPs and 9 ENT specialists consented to in-depth telephone interviews. Transcribed recordings were managed using NVivo software and analysed using inductive thematic analysis.

MAIN OUTCOME MEASURES

Healthcare professional views of management options and care pathways for CRS.

RESULTS

GPs describe themselves as confident in recognising CRS, with the exception of assessing nasal polyps. In contrast, specialists report common missed diagnoses (eg, allergy; chronic headache) when patients are referred to ENT clinics, and attribute this to the limited ENT training of GPs. Steroid nasal sprays provide the foundation of treatment in primary care, although local prescribing restrictions can affect treatment choice and poor adherence is perceived to be the causes of inadequate symptom control. Symptom severity, poor response to medical treatment and patient pressure drive referral, although there is uncertainty about optimal timing. Treatment decisions in secondary care are based on disease severity, polyp status, prior medical treatment and patient choice, but there is major uncertainty about the place of longer courses of antibiotics and the use of oral steroids. Surgery is regarded as an important treatment option for patients with severe symptoms or with nasal polyps, although timing of surgery remains unclear, and the uncertainty about net long-term benefits of surgery makes balancing of benefits and risks more difficult.

CONCLUSIONS

Clinicians are uncertain about best management of patients with CRS in both primary and secondary care and practice is varied. An integrated care pathway for CRS is needed to improve patient management and timely referral.

The SUMMIT ambulatory-ICU primary care model for medically and socially complex patients in an urban federally qualified health center: study design and rationale

BACKGROUND

Medically complex urban patients experiencing homelessness comprise a disproportionate number of high-cost, high-need patients. There are few studies of interventions to improve care for these populations; their social complexity makes them difficult to study and requires clinical and research collaboration. We present a protocol for a trial of the streamlined unified meaningfully managed interdisciplinary team (SUMMIT) team, an ambulatory ICU (A-ICU) intervention to improve utilization and patient experience that uses control populations to address limitations of prior research.

METHODS/DESIGN

Participants are patients at a Federally Qualified Health Center in Portland, Oregon that serves patients experiencing homelessness or who have substance use disorders. Participants meet at least one of the following criteria: > 1 hospitalization over past 6 months; at least one medical co-morbidity including uncontrolled diabetes, heart failure, chronic obstructive pulmonary disease, liver disease, soft-tissue infection; and 1 mental health diagnosis or substance use disorder. We exclude patients if they have < 6 months to live, have cognitive impairment preventing consent, or are non-English speaking. Following consent and baseline assessment, we randomize participants to immediate SUMMIT intervention or wait-list control group. Participants receiving the SUMMIT intervention transfer care to a clinic-based team of physician, complex care nurse, care coordinator, social worker, and pharmacist with reduced panel size and flexible scheduling with emphasis on motivational interviewing, patient goal setting and advanced care planning. Wait-listed participants continue usual care plus engagement with community health worker intervention for 6 months prior to joining SUMMIT. The primary outcome is hospital utilization at 6 months; secondary outcomes include emergency department utilization, patient activation, and patient experience measures. We follow participants for 12 months after intervention initiation.

DISCUSSION

The SUMMIT A-ICU is an intensive primary care intervention for high-utilizers impacted by homelessness. Use of a wait-list control design balances community and staff stakeholder needs, who felt all participants should have access to the intervention, while addressing research needs to include control populations. Design limitations include prolonged follow-up period that increases risk for attrition, and conflict between practice and research; including partner stakeholders and embedded researchers familiar with the population in study planning can mitigate these barriers. Trial registration ClinicalTrials.gov NCT03224858, Registered 7/21/17 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT03224858.

The association between different domains of quality of life and symptoms in primary care patients with emotional disorders

Despite the importance of quality of life (QoL) in primary care patients with emotional disorders, the specific influence of the symptoms of these disorders and the sociodemographic characteristics of patients on the various QoL domains has received scant attention. The aim of the present study of primary care patients with emotional disorders was to analyse the associations between four different QoL domains and the most prevalent clinical symptoms (i.e., depression, anxiety and somatization), while controlling for sociodemographic variables. A total of 1241 participants from 28 primary care centres in Spain were assessed with the following instruments: the Patient Health Questionnaire (PHQ)-9 to evaluate depression; the Generalized Anxiety Disorder Scale (GAD)-7 for anxiety; PHQ-15 for somatization; and the World Health Organization Quality of Life Instrument-Short Form (WHOQOL-Bref) to assess four broad QoL domains: physical health, psychological health, social relationships, and environment. The associations between the symptoms and QoL domains were examined using hierarchical regression analyses. Adjusted QoL mean values as a function of the number of overlapping diagnoses were calculated. The contribution of sociodemographic variables to most QoL domains was modest, explaining anywhere from 2% to 11% of the variance. However, adding the clinical variables increased the variance explained by 12% to 40% depending on the specific QoL domain. Depression was the strongest predictor for all domains. The number of overlapping diagnoses adversely affected all QoL domains, with each additional diagnosis reducing the main QoL subscales by 5 to 10 points. In primary care patients with a diagnostic impression of an emotional disorders as identified by their treating GP, clinical symptoms explained more of the variance in QoL than sociodemographic factors such as age, sex, level of education, marital status, work status, and income. Given the strong relationship between depressive symptoms and QoL, treatment of depression may constitute a key therapeutic target to improve QoL in people with emotional disorders in primary care.

The Affordable Care Act and Changes in Insurance Coverage and Source of Health Care among High-risk Rural, Substance-using, Female Offenders Transitioning to the Community

PURPOSE

This study examines health care coverage and health care among rural, drug-involved female offenders under the Affordable Care Act (ACA) compared with pre-ACA and whether being insured is associated with having a usual source of care.

METHODS

This study involved random selection, screening, and face-to-face interviews with drug-using women in three rural Appalachian jails. Analyses focused on participants who had completed a three-month follow-up interview after release from jail (N=371).

RESULTS

Analyses indicated that women released after ACA implementation were more likely than those released pre-implementation to be insured. A multivariate logistic regression model showed that being insured was significantly related to having a usual health care source during community re-entry.

CONCLUSIONS

Results demonstrate the benefits of the ACA, signaling important implications for public health in rural communities and the criminal justice system, including targeting underserved groups during incarceration and providing information about and resources for health care enrollment.

Sensitivity of alternative measures of functioning and wellbeing for adults with sickle cell disease: comparison of PROMIS® to ASCQ-Me℠

BACKGROUND

Sickle Cell Disease (SCD) causes profound suffering and decrements in daily functioning. Demand is growing for valid and reliable measures to systematically document these effects, particularly in adults. The Adult Sickle Cell Quality of Life Measurement System, ASCQ-Me℠, was developed for this purpose. ASCQ-Me℠ is one of four measurement systems housed within the Person-Centered Assessment Resource (PCAR), funded by the National Institutes of Health, to support clinical research. To help users select the best of these measures for adults with SCD, we evaluated and compared two PCAR systems: one designed to be "universally applicable" (the Patient-Reported Outcome Measurement Information System, PROMIS®) and one designed specifically for SCD (ASCQ-Me℠).

METHODS

Respondents to PROMIS and ASCQ-Me questions were 490 adults with SCD from seven geographically-disbursed clinics within the US. Data were collected for six ASCQ-Me measures (Emotional Impact, Sleep Impact, Social Impact, Stiffness Impact, Pain Impact, SCD Pain Episode Frequency and Severity) and ten PROMIS measures (Pain Impact, Pain Behavior, Physical Functioning, Anxiety, Depression, Fatigue, Satisfaction with Discretionary Social Activities, Satisfaction with Social Roles, Sleep Disturbance, and Sleep-Related Impairment). Statistical analyses, including analysis of variance and multiple linear regression, were conducted to determine the sensitivity of measures to SCD severity. SCD severity was assessed via a checklist of associated treatments and conditions.

RESULTS

For those with the most severe SCD, PROMIS scores showed worse health compared to the general population for nine of ten health domains: the magnitude of the difference ranged 0.5 to 1.1 standard deviation units. The PROMIS domains most severely affected were Physical Functioning and Pain (Impact and Behavior). Significant differences by tertile of the SCD-MHC were shown for most PROMIS short forms and all ASCQ-Me short and fixed forms. In most models, ASCQ-Me measures explained statistically significant unique variance in SCD-MHC scores complementary to that explained by corresponding PROMIS measures.

CONCLUSIONS

Study results supported the validity of both PROMIS and ASCQ-Me measures for use in adults with SCD. Compared to comparable PROMIS scores, most ASCQ-Me scores were better predictors of SCD disease severity, as measured by a medical history checklist. The clinical implications of these results require further investigation.

Relationship between health-related quality of life, perceived family support and unmet health needs in adult patients with multimorbidity attending primary care in Portugal: a multicentre cross-sectional study

BACKGROUND

Multimorbidity has a high prevalence in the primary care context and it is frequently associated with worse health-related quality of life (HRQoL). Few studies evaluated the variables that could have a potential effect on HRQoL of primary care patients with multimorbidity. The purpose of this study, the first of its kind ever undertaken in Portugal, is to analyse the relationship between multimorbidity, health-related quality of life, perceived family support and unmet health needs in adult patients attending primary care.

METHODS

Multicentre, cross-sectional survey conducted among primary care patients with multimorbidity. It included 521 participants (64.1 % females) who met the inclusion criteria. HRQoL was evaluated using the Portuguese Short Form-12 Health Status Questionnaire. The Portuguese Family APGAR was used to measure the perceived family support. A patients' unmet health needs questionnaire was used. The unmet needs for medical, surgical and dental care; prescription medications; mental healthcare or counselling; and eyeglasses or other technical aid was assessed. Descriptive and multivariate analyses were performed.

RESULTS

The sample had an overall average of 4.5 chronic health problems. Increased multimorbidity levels were linked to worse health-related quality of life, particularly the physical health. Some variables were confirmed as playing a role on health-related quality of life. Male patients with high monthly incomes and highly functional families had better physical and mental health. High levels of education and the presence of asthma were also associated with better physical health. Contrariwise, elderly patients with high levels of multimorbidity and with osteoarthritis had lower physical health. The majority of the patients did not have unmet health needs. When health needs were stated they were mostly for generalist medical care, dental care, and eyeglasses/other technical aid. Financial insufficiency was the primary reason for not fulfilling their health needs.

CONCLUSION

To improve the quality of life of multimorbid patients, within primary care practices and health delivery systems, one should take into special account the sex of the patient, the perceived family support and the self-perceived economic status because of their relationship with both physical and mental health. Limitations and recommendations are discussed.

Disease burden morbidity assessment by self-report: Psychometric properties in older adults in Spain

AIM

To carry out an analysis of the psychometric properties of the Disease Burden Morbidity Assessment (DBMA) according to the assumptions of the Classical Test Theory.

METHODS

A sample of 707 community-dwelling adults aged 65 years and older, living in Spain, completed the DBMA. Psychometric properties of the scale (feasibility, acceptability, scaling assumptions, reliability and construct validity) were analyzed.

RESULTS

The mean DBMA score was 6.8. Feasibility and acceptability were satisfactory, except for large floor effects (>50%), as well as a skewed distribution (1.8). Item-total corrected correlation ranged 0.10-0.49, item homogeneity index was 0.09 and Cronbach's alpha was 0.72. Disease burden correlated strongly with physical functioning (r = -0.56) and perceived health (r = -0.56), and moderately with depression (r = 0.41) and the Personal Wellbeing Index (r = -0.41). Exploratory factor analysis extracted five factors, explaining 44% of the variance.

CONCLUSIONS

The DBMA is an acceptable and valid instrument for measuring disease burden in older adults. Future studies should include Rasch analysis to further assess dimensionality and explore other measurement properties. Geriatr Gerontol 2017; 17: 1102-1108.

Comorbidities of asthma and the unified airway

BACKGROUND

Asthma is a comorbid condition that may be seen by otolaryngic allergists when treating their patients with allergic rhinitis (AR). Often asthma is overlooked when aggressive treatment could prevent the development or progression of early disease.

METHODS

This article is a retrospective review of the current literature on asthma as a comorbidity of the unified airway. The unified airway and asthma are clearly defined. The epidemiology, morbidity, mortality, pathophysiologic mechanisms, and the chronicity of asthma are reviewed.

RESULTS

The otolaryngic allergist will become familiar the unified airway concept and the close relationships between AR, chronic rhinosinusitis, and asthma.

CONCLUSION

Otolaryngologists should be aware of the unified airway in order to most effectively treat their patients with AR. Knowledge of the close relationships between asthma and AR will help prevent progression of disease, identify early asthma, and improve the outcomes and quality of life for our patients.

Impact of the AYA HOPE Comorbidity Index on Assessing Health Care Service Needs and Health Status among Adolescents and Young Adults with Cancer

BACKGROUND

Existing comorbidity indices were not developed for adolescent and young adults (AYA) 15 to 39 years of age. The aim of this study was to assess impact of comorbidities on health care service needs and health status among AYA cancer survivors using the newly developed AYA HOPE comorbidity index in comparison with the existing indices.

METHODS

Data on comorbid conditions were obtained from medical records and service needs and health status were from a survey of AYA cancer survivors. Prevalence of comorbidities was based on the AYA HOPE index. Charlson and NCI indices were compared. Multivariable logistic regression was used.

RESULTS

Of the 485 patients, 14.6% had ≥2 comorbidities based on the AYA HOPE Index. Prevalence of mental illness and obesity/overweight, which were not included in existing indices, were 8.2% and 5.8%, respectively. Prevalence of cardiovascular, endocrine, gastrointestinal, and neurologic conditions were higher with the AYA HOPE Index than the other two indices. Forty percent of AYA patients reported service needs, particularly for mental health services (25.2%) and support groups (17.7%). Having ≥2 comorbidities on the AYA index was associated with higher mental health service needs [OR, 2.05; 95% confidence interval (CI), 1.10-3.82] adjusting for demographic and clinical factors. Comorbidities were associated with fair/poor self-reported health status.

CONCLUSION

The AYA HOPE Index is a more comprehensive comorbidity index for AYA cancer patients than existing indices, and the number of comorbidities is associated with service needs and health status.

IMPACT

The AYA HOPE index could identify patients' additional service needs early in therapy.

Multimorbidity and functional decline in community-dwelling adults: a systematic review

BACKGROUND

Multimorbidity affects up to one quarter of primary care populations. It is associated with reduced quality of life, an increased risk of mental health difficulties and increased healthcare utilisation. Functional decline is defined as developing difficulties with activities of daily living and is independently associated with poorer health outcomes. The aim of this systematic review was to examine the association between multimorbidity and functional decline and to what extent multimorbidity predicts future functional decline.

METHODS

A systematic literature search (1990-2014) and narrative analysis was conducted.

INCLUSION CRITERIA

Population; Community-dwelling adults (≥18 years), Risk; Multimorbidity defined as the presence of ≥2 chronic medical conditions in an individual, Primary outcome; Physical functional decline measured using a validated instrument, Study design; cross-sectional or cohort studies. The following databases were included: PubMed, EMBASE, CINAHL, the Cochrane Library and the International Research Community on Multimorbidity (IRCMo) publication list. Methodological quality assessment of included studies was conducted with a suitable risk of bias tool.

RESULTS

A total of 37 studies were eligible for inclusion (28 cross-sectional studies and 9 cohort studies). The majority of cross-sectional studies (n = 24/28) demonstrated a consistent association between multimorbidity and functional decline. Twelve of these studies reported that increasing numbers of chronic condition counts were associated with worsening functional decline. Nine cohort studies included 14,133 study participants with follow-up periods ranging from one to six years. The majority (n = 5) found that multimorbidity predicted functional decline. Of the five studies that reported the impact of increasing numbers of conditions, all reported greater functional decline with increasing numbers of conditions. One study examined disease severity and found that this also predicted greater functional decline. Overall, cohort studies were of good methodological quality but were mixed in terms of participants, multimorbidity definitions, follow-up duration, and outcome measures.

CONCLUSIONS

The available evidence indicates that multimorbidity predicts future functional decline, with greater decline in patients with higher numbers of conditions and greater disease severity. This review highlights the importance of considering physical functioning when designing interventions and systems of care for patients with multimorbidity, particularly for patients with higher numbers of conditions and greater disease severity.

Multimorbidity and functional decline in community-dwelling adults: a systematic review

BACKGROUND

Multimorbidity affects up to one quarter of primary care populations. It is associated with reduced quality of life, an increased risk of mental health difficulties and increased healthcare utilisation. Functional decline is defined as developing difficulties with activities of daily living and is independently associated with poorer health outcomes. The aim of this systematic review was to examine the association between multimorbidity and functional decline and to what extent multimorbidity predicts future functional decline.

METHODS

A systematic literature search (1990-2014) and narrative analysis was conducted.

INCLUSION CRITERIA

Population; Community-dwelling adults (≥18 years), Risk; Multimorbidity defined as the presence of ≥2 chronic medical conditions in an individual, Primary outcome; Physical functional decline measured using a validated instrument, Study design; cross-sectional or cohort studies. The following databases were included: PubMed, EMBASE, CINAHL, the Cochrane Library and the International Research Community on Multimorbidity (IRCMo) publication list. Methodological quality assessment of included studies was conducted with a suitable risk of bias tool.

RESULTS

A total of 37 studies were eligible for inclusion (28 cross-sectional studies and 9 cohort studies). The majority of cross-sectional studies (n = 24/28) demonstrated a consistent association between multimorbidity and functional decline. Twelve of these studies reported that increasing numbers of chronic condition counts were associated with worsening functional decline. Nine cohort studies included 14,133 study participants with follow-up periods ranging from one to six years. The majority (n = 5) found that multimorbidity predicted functional decline. Of the five studies that reported the impact of increasing numbers of conditions, all reported greater functional decline with increasing numbers of conditions. One study examined disease severity and found that this also predicted greater functional decline. Overall, cohort studies were of good methodological quality but were mixed in terms of participants, multimorbidity definitions, follow-up duration, and outcome measures.

CONCLUSIONS

The available evidence indicates that multimorbidity predicts future functional decline, with greater decline in patients with higher numbers of conditions and greater disease severity. This review highlights the importance of considering physical functioning when designing interventions and systems of care for patients with multimorbidity, particularly for patients with higher numbers of conditions and greater disease severity.

[Economic evaluation of a program of coordination between levels for complex chronic patients' management]

OBJECTIVE

The complex chronic patient program (CCP) of the Alt Penedès aims to improve the coordination of care. The objective was to evaluate the relationship between the costs associated with the program, and its results in the form of avoided admissions.

DESIGN

Dost-effectiveness analysis from the perspective of the health System based on a before-after study.

LOCATION

Alt Penedès.

MAIN MEASUREMENTS

Health services utilisation (hospital [admissions, emergency visits, day-care hospital] and primary care visits). CCP Program results were compared with those prior to its implementation. The cost assigned to each resource corresponded to the hospital CatSalut's concert and ICS fees for primary care. A sensitivity analysis using boot strapping was performed. The intervention was considered cost-effective if the incremental cost-effectiveness ratio (ICER) did not exceed the cost of admission (€ 1,742.01).

RESULTS

149 patients were included. Admissions dropped from 212 to 145. The ICER was €1,416.3 (94,892.9€/67). Sensitivity analysis showed that in 95% of cases the cost might vary between €70,847.3 and €121,882.5 and avoided admissions between 30 and 102. In 72.4% of the simulations the program was cost-effective.

CONCLUSIONS

Sensitivity analysis showed that in most situations the PCC Program would be cost-effective, although in a percentage of cases the program could raise overall cost of care, despite always reducing the number of admissions.

Multimorbidity and functional status in community-dwelling older adults

BACKGROUND

Multimorbidity is common in older people and may contribute to many adverse health events, such as disability. The aim of the study was to investigate how chronic health conditions (single, paired, and grouped) affect functional independence.

METHOD

We used two samples (a one-time, convenience sample and a nationally representative cross-sectional survey) of community-dwelling people of 65 years old or over, with a total of 2818 subjects in Spain. To assess functional independence, we used the Barthel index, administered as an interview. Information about the presence of 11 chronic health problems was collected by interview or review of their medical chart. Explanatory factor analysis was performed to assess associations between chronic health conditions.

RESULTS

Diabetes mellitus and hypertension emerged as the pair of chronic health conditions that most affected functional status [OR 1.98; 95% CI (1.51-2.60)], followed by visual and hearing impairment. A synergistic effect was found (p<0.05) for the cardiovascular disease and hypertension pair. Four multimorbidity groups emerged from the factor analysis: sensory and bone; cancer, lung and gastrointestinal; cardiovascular and metabolic; neuropsychiatric disorders. The neuropsychiatric disorders group was the most strongly associated with physical impairment [OR 4.94; 95% CI (2.71-8.99)], followed by the sensory and bones group [OR 1.90; 95% CI (1.56-2.31)].

CONCLUSION

Despite its low prevalence, the neuropsychiatric disorders group was most strongly associated with lower functional status. Analysis of the relationship between chronic medical conditions and functional status could be useful to develop primary health care strategies to improve functional independence in older people with comorbidities.

Patient reports of health outcome for adults living with sickle cell disease: development and testing of the ASCQ-Me item banks

Background

Providers and patients have called for improved understanding of the health care requirements of adults with sickle cell disease (SCD) and have identified the need for a systematic, reliable and valid method to document the patient-reported outcomes (PRO) of adult SCD care. To address this need, the Adult Sickle Cell Quality of Life Measurement System (ASCQ-Me) was designed to complement the Patient Reported Outcome Measurement Information System (PROMIS®). Here we describe methods and results of the psychometric evaluation of ASCQ-Me item banks (IBs).

Methods

At seven geographically-disbursed clinics within the US, 556 patients responded to questions generated to assess cognitive, emotional, physical and social impacts of SCD. We evaluated the construct validity of the hypothesized domains using exploratory factor analysis (EFA), parallel analysis (PA), and bi-factor analysis (Item Response Theory Graded Response Model, IRT-GRM). We used IRT-GRM and the Wald method to identify bias in responses across gender and age. We used IRT and Cronbach’s alpha coefficient to evaluate the reliability of the IBs and then tested the ability of summary scores based on IRT calibrations to discriminate among tertiles of respondents defined by SCD severity.

Results

Of the original 140 questions tested, we eliminated 48 that either did not form clean factors or provided biased measurement across subgroups defined by age and gender. Via EFA and PA, we identified three subfactors within physical impact: sleep, pain and stiffness impacts. Analysis of the resulting six item sets (sleep, pain, stiffness, cognitive, emotional and social impacts of SCD) supported their essential unidimensionality. With the exception of the cognitive impact IB, these item sets also were highly reliable across a broad range of values and highly significantly related to SCD disease severity.

Conclusion

ASCQ-Me pain, sleep, stiffness, emotional and social SCD impact IBs demonstrated exceptional measurement properties using modern and classical psychometric methods of evaluation. Further development of the cognitive impact IB is required to improve its sensitivity to differences in SCD disease severity. Future research will evaluate the sensitivity of the ASCQ-Me IBs to change in SCD disease severity over time due to health interventions.

Health related quality of life in patients with chronic gastritis and peptic ulcer and factors with impact: a longitudinal study

BACKGROUND

The assessment of Health Related Quality of Life (HRQOL) has been applied as a significant outcome indicator for patients with chronic diseases. No HRQOL study, however, has looked at HRQOL in patients with chronic gastritis and peptic ulcers. This paper focuses on comparing HRQOL in patients with chronic gastritis and peptic ulcers and examining the factors that influence the HRQOL of such patients. Results can be used for making decisions in clinical trials as well as aiding individual management and preventive care of these diseases.

METHODS

The Chinese version of the SF-36 (CSF-36) was administered twice to 244 patients with chronic gastritis and peptic ulcers. Mean scores across the two disease groups were compared using t-tests, change over time was analyzed with paired samples t-tests, and factors predicting HRQOL were investigated using the univariate general linear model.

RESULTS

The mean domain scores of patients with chronic gastritis were lower than those for patients with peptic ulcers, with the exception of physical functioning. Both groups had lower HRQOL compared with population norms. Mean domain scores increased after treatment in both groups. HRQOL in patients with these two chronic diseases differed by age, education level, marriage, income, and gender, but their explanatory power was relatively low.

CONCLUSION

Quality of life of patients with chronic gastritis was lower than that of patients with peptic ulcers, which was lower than population norms. Quality of life in both patients groups was associated with socio-demographic risk factors.

The role of rhinosinusitis in severe asthma

The prevalence of asthma is approximately 5% to 10% in the general population. Of these, approximately 5% to 10% are severe asthmatics who respond poorly to asthmatic drugs, including high-dose inhaled steroids. Severe asthmatics have persistent symptoms, frequent symptom exacerbation, and severe airway obstruction even when taking high-dose inhaled steroids. The medical costs of treating severe asthmatics represent ~50% of the total healthcare costs for asthma. Risk factors for severe asthma are genetic and environmental, including many kinds of aeroallergens, β-blockers, and anti-inflammatory drugs. Gastroesophageal reflux disease and factors such as denial, anxiety, fear, depression, socioeconomic status, and alcohol consumption can exacerbate asthma. Rhinitis and asthma usually occur together. There is increasing evidence that allergic rhinitis and rhinosinusitis may influence the clinical course of asthma. This review discusses the role of rhinosinusitis in severe asthma.

Comorbidity and disease burden in the National Comorbidity Survey Replication (NCS-R)

BACKGROUND

Disease burden estimates rarely consider comorbidity. Using a recently developed methodology for integrating information about comorbidity into disease burden estimates, we examined the comparative burdens of nine mental and 10 chronic physical disorders in the National Comorbidity Survey Replication (NCS-R).

METHODS

Face-to-face interviews in a national household sample (n = 5,692) assessed associations of disorders with scores on a visual analog scale (VAS) of perceived health. Multiple regression analysis with interactions for comorbidity was used to estimate these associations. Simulation was used to estimate incremental disorder-specific effects adjusting for comorbidity.

RESULTS

The majority of respondents (74.9%) reported one or more disorders. Of respondents with disorders, 73.8-98.2% reported having at least one other disorder. The best-fitting model to predict VAS scores included disorder main effects and interactions for number of disorders. Adjustment for comorbidity reduced individual-level disorder-specific burden estimates substantially, but with considerable between-disorder variation (0.07-0.69 ratios of disorder-specific estimates with and without adjustment for comorbidity). Four of the five most burdensome disorders at the individual level were mental disorders based on bivariate analyses (panic/agoraphobia, bipolar disorder, posttraumatic stress disorder, major depression) but only two based on multivariate analyses, adjusting for comorbidity (panic/agoraphobia, major depression). Neurological disorders, chronic pain conditions, and diabetes were the other most burdensome individual-level disorders. Chronic pain conditions, cardiovascular disorders, arthritis, insomnia, and major depression were the most burdensome societal-level disorders.

CONCLUSIONS

Adjustments for comorbidity substantially influence estimates of disease burden, especially those of mental disorders, underlining the importance of including information about comorbidity in studies of mental disorders.

Anticholinergic drugs and functional outcomes in older patients undergoing orthopaedic rehabilitation

BACKGROUND

Medications with anticholinergic (antimuscarinic) effects negatively affect physical and cognitive function in community-dwelling older patients. However, it is unknown if anticholinergic drugs exert detrimental effects in older patients undergoing rehabilitation.

OBJECTIVE

The purpose of our study was to assess the effect of anticholinergic drug exposure on functional outcomes in older patients undergoing rehabilitation. We speculated that higher anticholinergic drug exposure would be associated with reduced functional outcomes in this group.

METHODS

Data on clinical characteristics, full medication, anticholinergic drug exposure (total number of anticholinergic drugs [tAD] and Anticholinergic Risk Scale [ARS] score), and Barthel index (BI) score were collected on admission and discharge in a consecutive series of 117 older patients (age 79 [7] years) admitted to the orthopaedic rehabilitation unit of a teaching hospital between July 2010 and March 2011. Outcome measures were BI changes (BI on discharge - BI on admission) during rehabilitation (primary outcome) and length of stay (secondary outcome).

RESULTS

Anticholinergic drugs were prescribed in 38 patients (32.5%). Median and interquartile range for tAD = 0 (0-1); for ARS = 0 (0-1). Poisson regression showed that higher tAD (incidence rate ratio [IRR] = 0.92; 95% CI, 0.88-0.97; P = 0.003) and ARS scores (IRR = 0.97; 95% CI, 0.95-0.99; P = 0.008) on admission independently predicted lower BI changes. Being a woman (IRR = 0.87; 95% CI, 0.78-0.97; P = 0.01), lower Abbreviated Mental Test scores (IRR = 0.94; 95% CI, 0.91-0.97; P < 0.001), and lower BI on admission (IRR = 0.98; 95% CI, 0.97-0.98; P < 0.001), but not tAD or ARS scores, independently predicted increasing length of stay.

CONCLUSIONS

Higher anticholinergic drug exposure on admission independently predicts reduced functional outcomes, but not length of stay, in older patients undergoing orthopaedic rehabilitation.

A randomized, clinical trial of education or motivational-interviewing-based coaching compared to usual care to improve cancer pain management

PURPOSE/OBJECTIVES

To test the effectiveness of two interventions compared to usual care in decreasing attitudinal barriers to cancer pain management, decreasing pain intensity, and improving functional status and quality of life (QOL).

DESIGN

Randomized clinical trial.

SETTING

Six outpatient oncology clinics (three Veterans Affairs [VA] facilities, one county hospital, and one community-based practice in California, and one VA clinic in New Jersey)Sample: 318 adults with various types of cancer-related pain.

METHODS

Patients were randomly assigned to one of three groups: control, standardized education, or coaching. Patients in the education and coaching groups viewed a video and received a pamphlet on managing cancer pain. In addition, patients in the coaching group participated in four telephone sessions with an advanced practice nurse interventionist using motivational interviewing techniques to decrease attitudinal barriers to cancer pain management. Questionnaires were completed at baseline and six weeks after the final telephone calls. Analysis of covariance was used to evaluate for differences in study outcomes among the three groups.

MAIN RESEARCH VARIABLES

Pain intensity, pain relief, pain interference, attitudinal barriers, functional status, and QOL.

FINDINGS

Attitudinal barrier scores did not change over time among groups. Patients randomized to the coaching group reported significant improvement in their ratings of pain-related interference with function, as well as general health, vitality, and mental health.

CONCLUSIONS

Although additional evaluation is needed, coaching may be a useful strategy to help patients decrease attitudinal barriers toward cancer pain management and to better manage their cancer pain.

IMPLICATIONS FOR NURSING

By using motivational interviewing techniques, advanced practice oncology nurses can help patients develop an appropriate plan of care to decrease pain and other symptoms.

Chronic rhinosinusitis in Europe--an underestimated disease. A GA²LEN study

BACKGROUND

Chronic rhinosinusitis (CRS) is a common health problem, with significant medical costs and impact on general health. Even so, prevalence figures for Europe are unavailable. In this study, conducted by the GA²LEN network of excellence, the European Position Paper on Rhinosinusitis and nasal Polyps (EP³OS) diagnostic criteria are applied to estimate variation in the prevalence of Chronic rhinosinusitis (CRS) for Europe.

METHOD

A postal questionnaire was sent to a random sample of adults aged 15-75 years in 19 centres in Europe. Participants reported symptoms of CRS, and doctor diagnosed CRS, allergic rhinitis, age, gender and smoking history. Definition of CRS was based on the EP³OS diagnostic criteria: the presence of more than two of the symptoms: (i) nasal blockage, (ii) nasal discharge, (iii) facial pain/pressure or (iv) reduction in sense of smell, for >12 weeks in the past year--with at least one symptom being nasal blockage or discharge.

RESULTS

Information was obtained from 57,128 responders living in 19 centres in 12 countries. The overall prevalence of CRS by EP³OS criteria was 10.9% (range 6.9-27.1). CRS was more common in smokers than in nonsmokers (OR 1.7: 95% CI 1.6-1.9). The prevalence of self-reported physician-diagnosed CRS within centres was highly correlated with the prevalence of EP³OS-diagnosed CRS.

CONCLUSION

This is the first European international multicentre prevalence study of CRS. In this multicentre survey of adults in Europe, about one in ten participants had CRS with marked geographical variation. Smoking was associated with having CRS in all parts of Europe.

Construct validation of a knee-specific functional status measure: a comparative study between the United States and Israel

BACKGROUND

Comparative effectiveness research (CER) requires valid outcome measures that discriminate patients by risk factors in similar ways across settings. Standardized functional status (FS) measures in physical therapy are used routinely in multiple countries, creating the potential for CER among countries.

OBJECTIVE

The purpose of this study was to assess known-groups construct validity of a knee-specific FS measure within and between 2 countries for patients receiving outpatient physical therapy due to knee impairments.

DESIGN

This was a longitudinal, observational cohort study.

METHODS

The participants were 4,972 and 2,964 adult (age ≥18 years) patients with knee impairments from Israel and the United States, respectively. Differences in patient characteristics between the 2 countries were assessed using chi-square statistics and 2-sample t tests, as appropriate. Known-groups validity within and between the countries was assessed using 2-way analysis of covariance predicting FS at discharge, with sex, age, symptom acuity, surgical and exercise history, intake medication use, and country as risk-adjustment factors. Intake FS was the covariate. To compare how FS discriminated patient groups between countries, each factor was tested separately with models including an interaction term between the factor and country.

RESULTS

Patients were different between countries but had similar discharge FS trends, including: higher outcomes in patients who were male, were younger, had acute conditions, had one surgical procedure related to their knee impairment, were more physically active, and did not use related medication at admission. Interactions were not significant for sex, symptom acuity, and exercise history but were significant for age, surgical history, and medication use. Limitations Although strict patient selection criteria were set, some patient selection bias still might have existed.

CONCLUSIONS

The results demonstrated the knee FS measures would be valid for use in CER between Hebrew-speaking patients (Israel) and English-speaking patients (United States).

Primary care practice-based care management for chronically ill patients (PraCMan): study protocol for a cluster randomized controlled trial [ISRCTN56104508]

BACKGROUND

Care management programmes are an effective approach to care for high risk patients with complex care needs resulting from multiple co-occurring medical and non-medical conditions. These patients are likely to be hospitalized for a potentially "avoidable" cause. Nurse-led care management programmes for high risk elderly patients showed promising results. Care management programmes based on health care assistants (HCAs) targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need.

METHODS/DESIGN

PraCMan is a cluster randomized controlled trial with primary care practices as unit of randomisation. The study evaluates a complex primary care practice-based care management of patients at high risk for future hospitalizations. Eligible patients either suffer from type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure or any combination. Patients with a high likelihood of hospitalization within the following 12 months (based on insurance data) will be included in the trial. During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and resources as well as regular structured monitoring of symptoms. Assessment and monitoring will be performed by trained HCAs from the participating practices. Additionally, patients will receive written information, symptom diaries, action plans and a medication plan to improve self-management capabilities. This intervention is addition to usual care. Patients from the control group receive usual care. Primary outcome is the number of all-cause hospitalizations at 12 months follow-up, assessed by insurance claims data. Secondary outcomes are health-related quality of life (SF12, EQ5D), quality of chronic illness care (PACIC), health care utilisation and costs, medication adherence (MARS), depression status and severity (PHQ-9), self-management capabilities and clinical parameters. Data collection will be performed at baseline, 12 and 24 months (12 months post-intervention).

DISCUSSION

Practice-based care management for high risk individuals involving trained HCAs appears to be a promising approach to face the needs of an aging population with increasing care demands.

Development and validation of a quality of life instrument for patients with drug dependence: comparisons with SF-36 and WHOQOL-100

AIM

Our goal was to develop a self-administered quality of life scale for patients with drug addiction/dependence (QOL-DA) and compare it with the SF-36 and the WHOQOL-100.

METHODS

Employing theory and methodology of rating scale construction, a self-administered quality of life instrument for individuals with drug dependence QOL-DA was developed and evaluated utilizing responses from 212 drug-dependent subjects at the Kunming Municipal Mandatory Detoxification and Rehabilitation Center in China. Quality of life was measured using the SF-36, WHOQOL-100 and QOL-DA three times during the detoxification.

RESULTS

Test-retest reliability in the domains of physical function, psychological function, social function and toxicity were 0.82, 0.64, 0.78, and 0.76, respectively. Cronbach's coefficient α for the 4 domains was 0.87, 0.89, 0.93 and 0.86, respectively. Correlations and factor analysis showed good construct validity. Criterion-related and convergent validity was confirmed by using the SF-36 and the WHOQOL-100 simultaneously. The instrument does show the change in QOL after two weeks of detoxification with higher standardized response mean higher than that of SF-36 and WHOQOL-100.

CONCLUSION

The instrument developed has good validity, reliability and better responsiveness than instruments currently used, and can be employed effectively to measure the quality of life of individuals with drug dependence.

Benchmarking the burden of 100 diseases: results of a nationwide representative survey within general practices

Objective To assess the burden of diseases and quality of life (QOL) of patients for a large variety of diseases within general practice. Design In a representative nationwide cross-sectional study, a total of 825 general practitioners (GPs) were randomly selected from across France. Independent investigators recruited 8559 patients attending the GPs' practices. Data on QOL (12-Item Short Form questionnaire) and other individual characteristics were documented by the independent investigators for all participants in the waiting room. Medical information was recorded by GPs. Sampling was calibrated to national standards using the CALMAR (CALage sur MARges) weighting procedure. Associations of lower scores (ie, below vs above the first quartile) of physical and mental component scores (physical component summary score (PCS) and mental component summary score (MCS), respectively) with main diseases and patients characteristics were estimated using multivariate logistic regression. Weighted morbidity rates, PCS and MCS were computed for 100 diagnoses using the International Classification of Diseases (9th version). Results Overall mental impairment was observed among patients in primary care with an average MCS of 41.5 (SD 8.6), ranging from 33.0 for depressive disorders to 45.3 for patients exhibiting fractures or sprains. Musculoskeletal diseases were found to have the most pronounced effect on impaired physical health (OR=2.31; 95% CI 2.08 to 2.57) with the lowest PCS (45.6 (SD 8.8)) and ranked first (29.0%) among main diagnoses experienced by patients followed by cardiovascular diseases (26.7%) and psychological disorders (22.0%). When combining both prevalence and QOL, musculoskeletal diseases represented the heaviest burden in general practice. Conclusions Etude épidémiologique de l'Impact de santé public sur 3 groupes de pathologies (EPI3) is the first study to provide reference figures for burden of disease in general practice across a wide range of morbidities, particularly valuable for health-economics and healthcare-system evaluation.

Assessing enablement in clinical practice: a systematic review of available instruments

RATIONALE, AIMS AND OBJECTIVES

Enablement is an intervention by which the health care provider recognizes, promotes and enhances patients' ability to control their health and life. An abundant health literature suggests that enablement is associated with good outcomes. In this review, we aimed at identifying and comparing instruments that assess enablement in the health care context.

METHOD

We conducted a systematic literature review using Medline, Embase, Cochrane, Cinahl and PsycINFO databases, 1980 through March 2009, with specific search strategy for each database. Citations were included if they reported: (1) development and/or validation of an instrument; (2) evaluation of enablement in a health care context; and (3) quantitative results following administration of the instrument. The quality of each main retained citation was assessed using a modified version of the Standards for Reporting of Diagnostic Accuracy.

RESULTS

Of 3135 citations identified, 53 were retrieved for detailed evaluation. Four articles were included. Two instruments were found: the Patient Empowerment Scale (PES) and the Empowering Speech Practices Scale (ESPS). Both instruments assessed enablement in hospital setting, one from the inpatient's perspective (PES) and the other from both perspectives (ESPS).

CONCLUSION

Two instruments assess enablement in hospital setting. No instrument is currently available to assess enablement in an ambulatory care context.

Development and validation of a quality of life instrument for patients with liver cancer QOL-LC

OBJECTIVE

To develop a self-administered quality of life instrument for patients with liver cancer.

METHODS

The programmed decision procedure, the theory and methodology in developing rating scale were used to establish the instrument. On the basis of the data from 105 liver cancer patients, the psychometric properties of the scale were evaluated by indicators of validity, reliability coefficients, and statistical methods like structural equation modeling.

RESULTS

The test-retest coefficients for physical, psychological, symptom/side effects, social domains, and the overall scale are 0.76, 0.86, 0.71, 0.80, and 0.84, respectively. The α coefficients for the above 4 domains are 0.78, 0.81, 0.75, and 0.68, respectively. The correlation analysis and the structural equation model showed good construct validity. The criterion-related was confirmed by using the functional living index-cancer simultaneously. The scale can reflect the changes of patients' quality of life after treatment.

CONCLUSIONS

The instrument is of good validity, reliability, and responsiveness and has been broadly used in China.

Development of a primary care-based complex care management intervention for chronically ill patients at high risk for hospitalization: a study protocol

BACKGROUND

Complex care management is seen as an approach to face the challenges of an ageing society with increasing numbers of patients with complex care needs. The Medical Research Council in the United Kingdom has proposed a framework for the development and evaluation of complex interventions that will be used to develop and evaluate a primary care-based complex care management program for chronically ill patients at high risk for future hospitalization in Germany.

METHODS AND DESIGN

We present a multi-method procedure to develop a complex care management program to implement interventions aimed at reducing potentially avoidable hospitalizations for primary care patients with type 2 diabetes mellitus, chronic obstructive pulmonary disease, or chronic heart failure and a high likelihood of hospitalization. The procedure will start with reflection about underlying precipitating factors of hospitalizations and how they may be targeted by the planned intervention (pre-clinical phase). An intervention model will then be developed (phase I) based on theory, literature, and exploratory studies (phase II). Exploratory studies are planned that entail the recruitment of 200 patients from 10 general practices. Eligible patients will be identified using two ways of 'case finding': software based predictive modelling and physicians' proposal of patients based on clinical experience. The resulting subpopulations will be compared regarding healthcare utilization, care needs and resources using insurance claims data, a patient survey, and chart review. Qualitative studies with healthcare professionals and patients will be undertaken to identify potential barriers and enablers for optimal performance of the complex care management program.

DISCUSSION

This multi-method procedure will support the development of a primary care-based care management program enabling the implementation of interventions that will potentially reduce avoidable hospitalizations.

[The comorbidity in primary care]

As patients live longer, and more illnesses become chronic, comorbidity rates increase. This increase shows in attended morbidity registers, and its importance is revealed by the use of services, treatments, the survival rates and the patients life quality. A frequent coexistence of illnesses, such as diabetes and depression, increases the cost of primary care and emergency treatments and the number of hospital admissions; increases the probability of cardiovascular risk and non-adherence to treatment and diet; causes a perception of poor physical and mental health and, on the whole, increases global costs. The annual mortality rate shoots up when anemia and cardiovascular or kidney failure occur. Mental comorbidity has a greater effect on the patients perception of their life quality than physical comorbidity. Comorbidity increases the number of hospital admissions which could have been prevented, as well as the avoidable complications related to them. Suicidal thoughts occur more frequently in patients suffering from chronic obstructive pulmonary disease (COPD) than in those suffering from other chronic organic illnesses. In patients suffering from atrial fibrillation, the risk of acute coronary crisis increases as they age and the comorbidity increases the use of angiotensin-converting enzymes (ICAE), antidepressant drugs and the visits to the psychiatrist.

Defining comorbidity: implications for understanding health and health services

Comorbidity is associated with worse health outcomes, more complex clinical management, and increased health care costs. There is no agreement, however, on the meaning of the term, and related constructs, such as multimorbidity, morbidity burden, and patient complexity, are not well conceptualized. In this article, we review definitions of comorbidity and their relationship to related constructs. We show that the value of a given construct lies in its ability to explain a particular phenomenon of interest within the domains of (1) clinical care, (2) epidemiology, or (3) health services planning and financing. Mechanisms that may underlie the coexistence of 2 or more conditions in a patient (direct causation, associated risk factors, heterogeneity, independence) are examined, and the implications for clinical care considered. We conclude that the more precise use of constructs, as proposed in this article, would lead to improved research into the phenomenon of ill health in clinical care, epidemiology, and health services.

Additional impact of concomitant hypertension and osteoarthritis on quality of life among patients with type 2 diabetes in primary care in Germany - a cross-sectional survey

Background

Patients with type 2 diabetes are likely to have comorbid conditions which represent a high burden for patients and a challenge for primary care physicians. The aim of this cross-sectional survey was to assess the impact of additional comorbidities on quality of life within a large sample of patients with type 2 diabetes in primary care.

Methods

A cross-sectional survey within a large sample (3.546) of patients with type 2 diabetes in primary care was conducted. Quality of life (QoL) was assessed by means of the Medical Outcome Study Short Form (SF-36), self reported presence of comorbid conditions was assessed and groups with single comorbidities were selected. QoL subscales of these groups were compared to diabetes patients with no comorbidities. Group comparisons were made by ANCOVA adjusting for sociodemographic covariates and the presence of depressive disorder.

Results

Of 3546 questionnaires, 1532 were returned, thereof 1399 could be analysed. The mean number of comorbid conditions was 2.1. 235 patients declared to have only hypertension as comorbid condition, 97 patients declared to have osteoarthritis only. Patients suffering from diabetes and hypertension reached similar scores like diabetic patients with no comorbidities. Patients with diabetes and osteoarthritis reached remarkable lower scores in all subscales. Compared to patients with diabetes alone these differences were statistically significant in the subscales representing pain and physical impairment.

Conclusion

The impact of osteoarthritis as an often disabling and painful condition on QoL in patients with type 2 diabetes is higher than the impact of hypertension as common but often asymptomatic comorbidity. Individual care of patients with chronic conditions should aim at both improving QoL and controlling risk factors for severe complications.

Assessing the impact of behavioral risk factors and known-groups validity of the SF-12 in a US Chinese immigrant population

BACKGROUND

Health status measures are being used in increasingly diverse populations. However, there are no known studies to date that examine the SF-12 in US Chinese populations. This study reports on the performance and validity of the SF-12 among Chinese immigrants residing in New York City, and evaluates the impact of multiple behavioral risk factors on physical and mental health status.

METHODS

We used cross-sectional survey data from a multistage probability sample of 2537 Chinese adults. SF-12 scores were examined according to sociodemographic, cultural, and clinical characteristics. Regression analyses were used to examine associations between health status and co-occurring behavioral risk factors of smoking, risky drinking, physical inactivity, and overweight/obesity.

RESULTS

SF-12 scores were significantly lower among women, those with less education, lower incomes, and more health problems (P < 0.001). Older adults had worse physical but better mental health (P < 0.05). Individuals with 1, 2, 3, and 4 behavioral risk factors reported decreases of 1.91, 2.92, 4.86, and 9.21 points on the PCS-12, respectively, in comparison with the reference group having zero risk factors (P < 0.01). Similar trends up to 2 co-occurring risks were observed with MCS-12 scores (P < 0.01).

CONCLUSIONS

The SF-12 exhibited known-groups validity in a US Chinese immigrant population. Co-occurring behavioral risk factors were associated with progressive declines in physical health, independent of sociodemographic and clinical characteristics traditionally associated with impairments in health status. Targeting patients with multiple risks for behavior change may be effective in improving health across diverse populations.