0696 The O2VERLAP Study: High Cpap Use Levels Found In Overlap Syndrome (OSA And COPD) Patients

Introduction

CPAP therapy is prescribed to help manage disordered breathing during sleep time periods. Most users, especially those with non-severe obstructive sleep apnea (OSA), use it only for some portion of their sleep period. Patients with Overlap Syndrome have both OSA and chronic obstructive pulmonary disease (COPD). While there has been some research on CPAP use levels in this patient population, there has been little indication that they use CPAP any differently than those with OSA only.

Methods

The O2VERLAP Study was a large comparative effectiveness trial enrolling people with COPD and OSA and using two different methods of providing information and support to current users of CPAP therapy. The study utilized an electronic national recruitment strategy and 332 participants were enrolled. CPAP data from the 12-week study period was analyzed. The Pittsburgh Sleep Quality Index was used to determine both estimated total sleep period (TSP) and total sleep time (TST). Because participants were all current users of CPAP, data from the total sample was combined and used. The percentage of TST and TSP that CPAP was used was calculated as CPAP use divided by either TST or TSP.

Results

The mean TST was 6.8 hours, TSP was 8.1 hours, and CPAP use was 6.7 hours. CPAP was used during 98.5% of the TST and during 82.7% of the TSP. Over 35% of the sample used CPAP at a level that was equal to or greater than their total sleep period.

Conclusion

Most OSA study populations use CPAP for some fraction of their night’s sleep. This COPD/OSA study population used CPAP to a markedly high level, including over one-third of the sample (n=~100) who used CPAP more than their self-reported sleep period. Further research on the extent and reasons for non-sleep period (i.e., daytime) CPAP use in COPD patients is warranted.

Support

PPRND #1507-31666.

The epidemiology of herpes zoster in patients with invasive cancer

9562

Background: Given the limited available data, the aim of this study was to estimate the incidence of Herpes Zoster (HZ) in cancer patients. Methods: In this retrospective cohort study, we used the Kaiser Permanente Northern California cancer registry to identify adult health plan members diagnosed with an invasive hematologic malignancy (HM) or solid tumor malignancy (STM) during 2001–2005. Potential episodes of HZ were ascertained from time of cancer diagnosis through 2006 from electronic databases using inpatient and outpatient diagnoses, laboratory tests, and prescriptions for antivirals. HZ diagnoses were confirmed by abstraction and clinical review of information from patients' inpatient and outpatient medical records. Incidence rates were calculated as the number of new occurrences of HZ per person-time of follow-up. Age-standardized incidence ratios (SIRs) were computed to compare HZ rates in cancer patients to reported rates in the general population (Yawn et al, 2007). Results: Among the 4,728 STM patients (mean age 66 years, range 18–102), the rate of HZ was 12/1000 person years (py) of follow-up (total 9170 py). Among the 1504 HM patients (mean age 67 years, range 18–97), the rate of HZ was 33/1000 py (total 2355 py). The SIRs and 95% confidence intervals for STM and HM were 1.7 (1.4–2.1) and 4.5 (3.5–5.6), respectively. Among patients with HM, incidence rates were highest in the first year after cancer diagnosis (40/1000 py); rates did not appear to vary markedly over time among patients with STM. For either cancer type, HZ rates were similar for males and females and did not increase consistently with increasing age. Conclusions: Compared to the general population, the incidence of HZ was nearly 2 times higher in patients with STM and over 4 times higher in patients with HM. HZ rates did not differ markedly by age or gender.

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Pharmacologic and anti-IgE treatment of allergic rhinitis ARIA update (in collaboration with GA2LEN)

The pharmacologic treatment of allergic rhinitis proposed by ARIA is an evidence-based and step-wise approach based on the classification of the symptoms. The ARIA workshop, held in December 1999, published a report in 2001 and new information has subsequently been published. The initial ARIA document lacked some important information on several issues. This document updates the ARIA sections on the pharmacologic and anti-IgE treatments of allergic rhinitis. Literature published between January 2000 and December 2004 has been included. Only a few studies assessing nasal and non-nasal symptoms are presented as these will be discussed in a separate document.

Is diabetes treated as an acute or chronic illness in community family practice?

OBJECTIVE

Poor quality of diabetes care has been ascribed to the acute care focus of primary care practice. A better understanding of how time is spent during outpatient visits for diabetes compared with visits for acute conditions and other chronic diseases may facilitate the design of programs to enhance diabetes care.

RESEARCH DESIGN AND METHODS

Research nurses directly observed consecutive outpatient visits during two separate days in 138 community family physician offices. Time use was categorized into 20 different behaviors using the Davis Observation Code (DOC). Time use was compared for visits for diabetes, other chronic conditions, and acute illnesses during 1,867 visits by patients > or =40 years of age.

RESULTS

Of 20 DOC behavioral categories, 10 exhibited differences among the three groups. Discriminant analysis identified two distinct factors that distinguished visits for chronic disease from visits for acute illness and visits for diabetes from those for other chronic diseases. Compared with visits for other chronic diseases, visits for diabetes devoted a greater proportion of time to nutrition counseling, health education, and feedback on results and less time to chatting. Compared with visits for acute illness, visits for diabetes were longer and involved a higher proportion of dietary advice, negotiation, and assessment of compliance.

CONCLUSIONS

Visits for diabetes are distinct from visits for other chronic diseases and acute illnesses in ways that may facilitate patient self-management. Novel quality-improvement interventions could support and expand existing differences between family physicians' current approaches to care of diabetes and other chronic and acute illnesses.

Availability of rural Minnesota obstetric services: is it a problem?

In the late 1980s several published articles predicted a crisis in the availability of obstetric care due to declining numbers of rural obstetrical providers. Several state and national studies documented the adverse impact of malpractice and time demands on both urban and rural physicians. But only limited information is available to document current trends in rural obstetrical practice and assess whether or not the predicted crisis occurred. This study sought to provide that updated information for rural Minnesota. A telephone survey of all rural Minnesota obstetrical providers was used to document the number, location, and specialty of rural obstetrical providers, their practice limitations, and plans for future practice. This data was combined with state perinatal statistics for each county to further assess obstetrical care availability and perinatal outcomes. All rural Minnesota obstetricians and certified nurse midwives provide obstetrical care as did 69 percent of all rural family physicians. Only 27 percent of rural obstetrical providers put any type of restrictions on their obstetrical practices. During the past year, 67 currently practicing rural physicians have stopped providing obstetrical care while 55 new obstetrical providers have begun rural practice. Two to 3 percent of current rural providers plan to retire or discontinue obstetrical services during the next five years. The provider demographics from the survey identified eight counties with no prenatal providers, and 12 additional communities of decreased provider availability. However, only two of the counties with no prenatal providers and five of the counties with areas of limited providers had increased percentages of adverse prenatal outcomes such as low birthweight or late prenatal care. This study concluded that Minnesota does not have a serious statewide problem with availability of rural obstetrical providers. However, a few isolated regions of the state have limited provider availability, including limited availability of local high-risk services and consultants.

Rural radiology: who is producing images and who is reading them?

The purpose of this study is to identify the local availability and trends in local availability of imaging technology and interpretation services in rural hospitals in the northwestern United States during the period between 1991 to 1994. Another objective is to describe hospital and community factors associated with the diffusion of image production and interpretation services. The information for this study was gathered through telephone surveys of rural hospital administrators in eight northwestern states in 1991 and 1994. The availability of magnetic resonance imaging (MRI) equipment, computed tomography (CT) scanners, ultrasonography equipment, and dedicated mammography equipment increased between 1991 and 1994. The increases in MRI units were primarily in mobile equipment, while ultrasonography and mammography equipment increases were primarily fixed hospital-based units. In 1994, image interpretation in the rural hospitals was provided by both primary care and radiology physicians. Forty-six (11.5%) of the rural hospitals had no on-site radiology services and only 73 (18%) had daily radiology services. Between 1991 and 1994, 12 hospitals gained at least once-a-week radiology services, but 24 lost all radiology services. Teleradiology availability more than doubled during the three years. Radiology technology has diffused widely into rural communities in this region of the United States at differing rates for large and small hospitals. Radiologists are available to these hospitals only 46 percent of the days each year, with more days of availability in the larger hospitals and fewer days in the smaller hospitals. Teleradiology capability is increasing more rapidly in the larger hospitals that have radiologists more readily available.

Understanding integrated rural health networks

In an era of constraints on public and private sector health care budgets, organizational restructuring of hospital and physician practice, and the shifting of financial risk to patients and providers, rural health professionals and communities are grappling with the issue of how to assure access to a comprehensive and affordable set of health care services. In recent years, rural health providers have turned to the strategy of developing voluntary network relations as an alternative to system or diversification strategies that entail ownership and management by one entity. A systematic analysis of the cooperative efforts of selected providers results in a proposed definition of integrated rural health networks and highlights critical aspects of their formation and development.

Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL)

We report the development and validation of an osteoporosis-targeted quality of life questionnaire to measure the impact of the disease in the general population. From multiple focus groups with women with osteoporosis, healthy women at risk for osteoporosis, spouses and relatives of women with osteoporosis, and health care providers, we identified over 300 potential items related to the disease. A lengthy questionnaire incorporated these items and was administered to a second large study cohort of 222 women with clinical osteoporosis (history of fracture, significant height loss, and/or kyphosis); 101 women with known low bone mineral density levels that would categorize them as osteoporotic but who had not yet shown obvious physical manifestations of the disease; and 142 women with other conditions (such as arthritis, cancer, depression) expected to also have an impact on quality of life. Final items from among the original 300 were chosen for their demonstrated relationship with osteoporosis as measured by clinical manifestations and low bone density and with quality of life measured by a standard generic questionnaire, the SF-36. The final questionnaire contains 26 scored items in three domains-physical activity, adaptations, and fears- and six nonscored questions relating to osteoporotic changes and diagnosis. This instrument is unique among osteoporosis-targeted questionnaires in that it attempts to measure the total impact of the disease on quality of life within a population at a single point in time.

Impact of fears on quality of life in patients with a silent disease: osteoporosis

Fears and apprehensions are often cited as contributing to decreased quality of life; however, questions relating to worry over the future are rarely included in generic quality-of-life questionnaires. We report an effort to quantify the effect of fear on quality-of-life domains as measured by using the Short-Form 36 (SF-36) Health Survey. In the course of developing an osteoporosis-targeted quality-of-life (OPTQoL) questionnaire, we asked participants to complete the SF-36 Health Survey and another questionnaire containing items that women with osteoporosis could be expected to find difficult or worrisome. Two hundred twenty-two women with established osteoporosis (loss of height, kyphosis, history of fractures); 101 women with known low bone mineral density (BMD) but without established osteoporosis; and 142 women with no known osteoporosis completed both the osteoporosis questionnaire and the SF-36 Health Survey. This test version of the OPTQoL contained two domains for fears of osteoporosis and the consequent fractures and deformities; these domains were termed fears now and fears future. After adjusting for age and selected comorbidities, we estimated the additional contribution of the two fears domains on the domain scores of the SF-36 Health Survey. For women with established osteoporosis, the fears now domain explained 4% to 8% of the variance within each domain of the survey. For women with low BMD only, fears now had a significant effect only on the physical functioning domain of the survey and explained 4% of the variance of that domain. Fears future had a significant role in explaining the SF-36 Health Survey score on all domains except physical functioning among women with established osteoporosis; however, the fears future domain explained less of the variance (2% to 5%) among these women than did the fears now domain. For women with low BMD only, fears future had a significant impact only on the mental health and the general health domains (4% and 5% of the variance, respectively). Osteoporosis-related fears appear to explain a small but significant percentage of the variation in quality of life for women in midlife.

Preventing cervical cancer

Primary physicians should be sure their women patients of all ages are being screened for cervical cancer. Underinsured women with low incomes may be referred to the Minnesota Breast and Cervical Cancer Control Program for free exams.