1
|
Locke ER, Thomas RM, Simpson TL, Fortney JC, Battaglia C, Trivedi RB, Gylys-Colwell J, Swenson ER, Edelman JD, Fan VS. Cognitive and Emotional Responses to Chronic Obstructive Pulmonary Disease Exacerbations and Patterns of Care Seeking. Ann Am Thorac Soc 2024; 21:559-567. [PMID: 37966313 DOI: 10.1513/annalsats.202303-287oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/15/2023] [Indexed: 11/16/2023] Open
Abstract
Rationale: Cognitive and emotional responses associated with care seeking for chronic obstructive pulmonary disease (COPD) exacerbations are not well understood.Objectives: We sought to define care-seeking profiles based on whether and when U.S. veterans seek care for COPD exacerbations and compare cognitive and emotional responses with exacerbation symptoms across the profiles.Methods: This study analyzes data from a 1-year prospective observational cohort study of individuals with COPD. Cognitive and emotional responses to worsening symptoms were measured with the Response to Symptoms Questionnaire, adapted for COPD. Seeking care was defined as contacting or visiting a healthcare provider or going to the emergency department. Participants were categorized into four care-seeking profiles based on the greatest delay in care seeking for exacerbations when care was sought: 0-3 days (early), 4-7 days (short delay), >7 days (long delay), or never sought care for any exacerbation. The proportion of exacerbations for which participants reported cognitive and emotional responses was estimated for each care-seeking profile, stratified by the timing of when care was sought.Results: There were 1,052 exacerbations among 350 participants with Response to Symptoms Questionnaire responses. Participants were predominantly male (96%), and the mean age was 69.3 ± 7.2 years. For the 409 (39%) exacerbations for which care was sought, the median delay was 3 days. Those who sought care had significantly more severe COPD (forced expiratory volume in 1 s, modified Medical Research Council dyspnea scale) than those who never sought care. Regardless of the degree of delay until seeking care at one exacerbation, participants consistently reported experiencing serious symptoms if they sought care compared with events for which participants did not seek care (e.g., among early care seekers when care was sought, 36%; when care was not sought, 25%). Similar findings were seen in participants' assessment of the importance of getting care (e.g., among early care seekers when care was sought, 90%; when care was not sought, 52%) and their assessment of anxiety about the symptoms (e.g., among early care seekers when care was sought, 33%; when care was not sought, 17%).Conclusions: Delaying or not seeking care for COPD exacerbations was common. Regardless of care-seeking profile, cognitive and emotional responses to symptoms when care was sought differed from responses when care was not sought. Emotional and cognitive response to COPD exacerbations should be considered when developing individualized strategies to encourage seeking care for exacerbations.Clinical trial registered with www.clinicaltrials.gov (NCT02725294).
Collapse
Affiliation(s)
- Emily R Locke
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Rachel M Thomas
- Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Tracy L Simpson
- Center of Excellence in Substance Addiction Treatment and Education, and
- Department of Psychiatry and Behavioral Sciences and
| | - John C Fortney
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Department of Psychiatry and Behavioral Sciences and
| | - Catherine Battaglia
- Veterans Affairs Eastern Colorado Health Care System, U.S. Department of Veterans Affairs, Aurora, Colorado
- Department of Health Systems, Management & Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ranak B Trivedi
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, U.S. Department of Veterans Affairs, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | | | - Erik R Swenson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jeffrey D Edelman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, U.S. Department of Veterans Affairs, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Vincent S Fan
- Center of Innovation for Veteran-Centered and Value-Driven Care
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
2
|
Crothers K, Adams SV, Turner AP, Batten L, Nikzad R, Kundzins JR, Fan VS. COVID-19 Severity and Mortality in Veterans with Chronic Lung Disease. Ann Am Thorac Soc 2024. [PMID: 38530061 DOI: 10.1513/annalsats.202311-974oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/21/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Chronic lung disease (CLD) has been associated with risk for more severe manifestations and death with COVID-19. However, few studies have evaluated the risk overall and by type of CLD for severity of COVID-19 outcomes in a US national cohort. METHODS Using data from the Veterans Health Administration, we determined the risk associated with CLDs including COPD (mild/severe), asthma (mild/active/severe), idiopathic pulmonary fibrosis (IPF), sarcoidosis and other interstitial lung diseases (ILDs) for outcomes among veterans with SARS-CoV-2 positive tests between 3/1/2020-4/30/2021. We used multinomial regression to estimate risk of four mutually exclusive COVID-19 outcomes within 30-days: outpatient management, hospitalization, hospitalization with indicators of critical illness, or death. We calculated the overall proportion with each outcome, the absolute risk difference and risk ratios for each outcome between those with and without CLD. We also describe clinical and laboratory abnormalities by CLD in those hospitalized. RESULTS We included 208,283 veterans with COVID-19; 35,587 (17%) had CLD. Compared to no CLD, veterans with CLD were older and had more comorbidities. Hospitalized veterans with CLD were more likely to have low temperature, mean arterial pressure, oxygen saturation, leukopenia and thrombocytopenia, and more likely to receive oxygen, mechanical ventilation and vasopressors. Veterans with CLD were significantly less likely to have mild COVID-19 (-4.5%, adjusted risk ratio [aRR] 0.94, 95% confidence interval [CI] 0.94-0.95), and more likely to have a moderate (+2.5%, aRR 1.21, 95% CI 1.18-1.24), critical (+1.4%, aRR 1.38, 95% CI 1.32-1.45) or fatal (+0.7%, aRR 1.15, 95% CI 1.10-1.20) outcome. IPF was most strongly associated with COVID-19 severity, especially mortality (+3.2%, aRR 1.69, 95% CI 1.46-1.96), followed by other ILDs and COPD, whereas asthma was less likely to be associated with severity of COVID-19. In veterans under age 65, worse COVID-19 outcomes were generally more likely with IPF, sarcoidosis, and other ILDs. CONCLUSIONS Veterans who had CLD, particularly IPF, other ILDs and COPD, had an increased probability of more severe 30-day outcomes with COVID-19. These results provide insight into the absolute and relative risk of different CLDs with severity of COVID-19 outcomes and can help inform considerations of healthcare utilization and prognosis.
Collapse
Affiliation(s)
- Kristina Crothers
- University of Washington, Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, Washington, United States
- Seattle, United States;
| | - Scott V Adams
- VA Puget Sound Health Care System Seattle Division, 20128, Seattle, Washington, United States
| | - Aaron P Turner
- VA Puget Sound Health Care System Seattle Division, 20128, Seattle, Washington, United States
- University of Washington, Department of Rehabilitation Medicine, Seattle, Washington, United States
| | - Lisa Batten
- VA Puget Sound Health Care System Seattle Division, 20128, Seattle, Washington, United States
| | - Reyhaneh Nikzad
- VA Puget Sound Health Care System Seattle Division, 20128, Seattle, Washington, United States
| | - John R Kundzins
- VA Puget Sound Health Care System Seattle Division, 20128, Seattle, Washington, United States
| | - Vincent S Fan
- University of Washington, Seattle, Washington, United States
- VA Puget Sound Health Care System Seattle Division, 20128, Seattle, Washington, United States
| |
Collapse
|
3
|
Pattock AM, Locke ER, Hebert PL, Simpson T, Battaglia C, Trivedi RB, Swenson ER, Edelman J, Fan VS. Predictors of Patient-reported and Pharmacy Refill Measures of Maintenance Inhaler Adherence in Veterans with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2024; 21:384-392. [PMID: 37774091 DOI: 10.1513/annalsats.202211-975oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 09/29/2023] [Indexed: 10/01/2023] Open
Abstract
Rationale: Suboptimal adherence to inhaled medications in patients with chronic obstructive pulmonary disease (COPD) remains a challenge. Objectives: To examine the sociodemographic and clinical characteristics and medication beliefs associated with adherence measured by self-report and pharmacy data. Methods: A cross-sectional analysis of data from a prospective observational cohort study of patients with COPD was completed. Participants underwent spirometry and completed questionnaires regarding sociodemographic data, inhaler use, dyspnea, social support, psychological and medical comorbidities, and medication beliefs (Beliefs about Medicines Questionnaire [BMQ]). Self-reported adherence to inhaled medications was measured with the Adherence to Refills and Medications Scale (ARMS), and pharmacy-based adherence was calculated from administrative data using the ReComp score. Multivariable linear regression was used to examine the sociodemographic, clinical, and medication-belief factors associated with both adherence measures. Results: Among 269 participants with ARMS and ReComp data, adherence was the same for each measure (38.3%), but only 18% of participants were adherent by both measures. In multivariable adjusted analysis, a 10-year increase in age (β = 0.54; 95% confidence interval, 0.14-0.94) and the number of maintenance inhalers used (β = 0.53; 0.04-1.02) were associated with increased adherence by self-report. Improved ReComp adherence was associated with chronic prednisone use (β = 0.18; 0.04-0.31) and the number of maintenance inhalers used (β = 0.11; 0.05-0.17). In adjusted analyses examining patient beliefs about medications, increases in the COPD-specific BMQ concerns score (β = -0.10; -0.17 to -0.02) were associated with reduced self-reported adherence. No significant associations between ReComp adherence and BMQ score were found in adjusted analyses. Conclusions: Adherence to inhaled COPD medications was poor as measured by self-report or pharmacy refill data. There were notable differences in factors associated with adherence based on the method of adherence measurement. Older age, chronic prednisone use, the number of prescribed maintenance inhalers used, and patient beliefs about medication safety were associated with adherence. Overall, fewer variables were associated with adherence as measured based on pharmacy refills. Pharmacy refill-based and self-reported adherence may measure distinct aspects of adherence and may be affected by different factors. These results also underscore the importance of addressing patient beliefs when developing interventions to improve medication adherence.
Collapse
Affiliation(s)
| | - Emily R Locke
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Paul L Hebert
- Department of Health Systems and Population Health, University of Washington, Seattle, Washington
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Tracy Simpson
- Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry, University of Washington School of Medicine, Seattle, Washington
| | - Catherine Battaglia
- Center of Innovation for Veteran-Centered and Value-Driven Care, Eastern Colorado VA Health Care System, Aurora, Colorado
- Department of Health System Management and Policy, Colorado School of Public Health, Aurora, Colorado
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California; and
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
| | - Erik R Swenson
- Department of Medicine and
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Jeff Edelman
- Department of Medicine and
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| | - Vincent S Fan
- Department of Medicine and
- Center of Innovation for Veteran-Centered and Value-Driven Care and
| |
Collapse
|
4
|
Garshick E, Redlich CA, Korpak A, Timmons AK, Smith NL, Nakayama K, Baird CP, Ciminera P, Kheradmand F, Fan VS, Hart JE, Koutrakis P, Kuschner W, Ioachimescu O, Jerrett M, Montgrain PR, Proctor SP, Wan ES, Wendt CH, Wongtrakool C, Blanc PD. Chronic respiratory symptoms following deployment-related occupational and environmental exposures among US veterans. Occup Environ Med 2024; 81:59-65. [PMID: 37968126 PMCID: PMC10872566 DOI: 10.1136/oemed-2023-109146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/30/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Characterise inhalational exposures during deployment to Afghanistan and Southwest Asia and associations with postdeployment respiratory symptoms. METHODS Participants (n=1960) in this cross-sectional study of US Veterans (Veterans Affairs Cooperative Study 'Service and Health Among Deployed Veterans') completed an interviewer-administered questionnaire regarding 32 deployment exposures, grouped a priori into six categories: burn pit smoke; other combustion sources; engine exhaust; mechanical and desert dusts; toxicants; and military job-related vapours gas, dusts or fumes (VGDF). Responses were scored ordinally (0, 1, 2) according to exposure frequency. Factor analysis supported item reduction and category consolidation yielding 28 exposure items in 5 categories. Generalised linear models with a logit link tested associations with symptoms (by respiratory health questionnaire) adjusting for other covariates. OR were scaled per 20-point score increment (normalised maximum=100). RESULTS The cohort mean age was 40.7 years with a median deployment duration of 11.7 months. Heavy exposures to multiple inhalational exposures were commonly reported, including burn pit smoke (72.7%) and VGDF (72.0%). The prevalence of dyspnoea, chronic bronchitis and wheeze in the past 12 months was 7.3%, 8.2% and 15.6%, respectively. Burn pit smoke exposure was associated with dyspnoea (OR 1.22; 95% CI 1.06 to 1.47) and chronic bronchitis (OR 1.22; 95% CI 1.13 to 1.44). Exposure to VGDF was associated with dyspnoea (OR 1.29; 95% CI 1.14 to 1.58) and wheeze (OR 1.18; 95% CI 1.02 to 1.35). CONCLUSION Exposures to burn pit smoke and military occupational VGDF during deployment were associated with an increased odds of chronic respiratory symptoms among US Veterans.
Collapse
Affiliation(s)
- Eric Garshick
- Pulmonary, Allergy, Sleep, and Critical Care Medicine Section, Medical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
| | - Carrie A Redlich
- Occupational and Environmental Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Andrew K Timmons
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | - Nicholas L Smith
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Karen Nakayama
- Seattle Epidemiologic Research and Information Center, Department of Veteran Affairs Office of Research and Development, VA Puget Sound Health Care System Seattle Division, Seattle, Washington, USA
| | | | - Paul Ciminera
- Health Services Policy and Oversight, Office of the Assistant Secretary of Defense for Health Affairs, Washington, District of Columbia, USA
| | - Farrah Kheradmand
- Department of Medicine, Michael E DeBakey VA Medical Center, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
| | - Vincent S Fan
- VA Puget Sound HCS Seattle Division, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jaime E Hart
- Harvard Medical School, Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Petros Koutrakis
- Department of Environmental Health, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Ware Kuschner
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Octavian Ioachimescu
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin, USA
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Jerrett
- University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, California, USA
| | - Phillipe R Montgrain
- VA San Diego Healthcare System, San Diego, California, USA
- Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Susan P Proctor
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA
| | - Emily S Wan
- Pulmonary, Allergy, Sleep, and Critical Care Medicine Section, Medical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Brigham and Women's Hospital Channing Division of Network Medicine, Boston, Massachusetts, USA
| | - Christine H Wendt
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, Minneapolis VA Medical Center, Minneapolis, Minnesota, USA
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Cherry Wongtrakool
- Atlanta VA Medical Center, Decatur, Georgia, USA
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Paul D Blanc
- San Francisco VA Health Care System, San Francisco, California, USA
- Division of Occupational, Environmental, and Climate Medicine, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| |
Collapse
|
5
|
Lee JE, Nguyen HQ, Fan VS. Inflammatory Markers and Fatigue in Individuals With Moderate to Severe Chronic Obstructive Pulmonary Disease. Nurs Res 2024; 73:54-61. [PMID: 38064303 PMCID: PMC10751060 DOI: 10.1097/nnr.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Fatigue, a prevalent complex symptom among patients with chronic obstructive pulmonary disease (COPD), is considered an important clinical indicator of disease severity. However, the underlying mechanisms of COPD-related fatigue are not fully understood. OBJECTIVES This analysis explored the relationships between peripheral inflammatory markers and COPD-related fatigue in people with moderate to severe COPD. METHODS This is a secondary analysis of a longitudinal observational study of individuals with COPD examining the biological causes and functional consequences of depression. The data used in this study were collected at baseline. Systemic inflammation markers included C-reactive protein (CRP) and three pro-inflammatory cytokines consisting of interleukin-6 (IL-6), IL-8, and tumor necrosis factor-α. COPD-related fatigue was self-reported using the Chronic Respiratory Questionnaire. Covariates included age; gender; smoking status; disease severity; symptoms of depression, anxiety, and pain; and social support. Multivariable linear regression analyses were conducted. RESULTS The sample included 300 adults living with COPD; 80% were male, and the average age was 67.6 years. Modest correlations were found between two systemic inflammatory markers (CRP and IL-8) and COPD-related fatigue. CRP was the only inflammatory marker significantly associated with fatigue symptoms after adjusting for covariates in multivariable analyses. Depression, pain, and education level were also significant predictors of COPD-related fatigue. DISCUSSION The findings suggest that altered immune response based on CRP may contribute to COPD-related fatigue. Management of depression and pain may work as an effective treatment strategy for COPD-related fatigue. Further longitudinal studies with a broader range of inflammatory markers and multidimensional measures of fatigue symptoms are warranted.
Collapse
|
6
|
Ritchey KC, Yohannes AM, Locke ER, Chen S, Simpson T, Battaglia C, Trivedi RB, Swenson ER, Edelman J, Fan VS. Association between self-reported falling risk and risk of hospitalization for patients with chronic obstructive pulmonary disease. Respir Med 2023; 220:107466. [PMID: 37981244 DOI: 10.1016/j.rmed.2023.107466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 11/21/2023]
Abstract
RATIONALE The association between self-report falling risk in persons with COPD and hospitalization has not been previously explored. OBJECTIVE To examine whether self-reported risk is associated with hospitalizations in patients with COPD. METHODS A secondary analysis from a prospective observational cohort study of veterans with COPD. Participants completed questions from the Stopping Elderly Accidents, Deaths and Injuries (STEADI) tool kit at either baseline or at the end of the 12-month study. A prospective or cross-sectional analysis examined the association between responses to the STEADI questions and risk of all-cause or COPD hospitalizations. RESULTS Participants (N = 388) had a mean age of 69.6 ± 7.5 years, predominately male (96 %), and 144 (37.1 %) reported having fallen in the last year. More than half reported feeling unsteady with walking (52.6 %) or needing to use their arms to stand up from a chair (61.1 %). A third were concerned about falling (33.3 %). Three questions were associated with all-cause (not COPD) hospitalization in both unadjusted and adjusted cross-sectional analysis (N = 213): "fallen in the past year" (IRR 1.77, 95 % CI 1.10 to 2.86); "unsteady when walking" (IRR 1.88, 95 % CI 1.14 to 3.10); "advised to use a cane or walker" (IRR 1.89, 95 % CI 1.16 to 3.08). CONCLUSIONS The prevalence of self-reported falling risk was high in this sample of veterans with COPD. The association between falling risk and all-cause hospitalization suggests that non-COPD hospitalizations can negatively impact intrinsic risk factors for falling. Further research is needed to clarify the effects of all-cause hospitalization on falling risk in persons with COPD.
Collapse
Affiliation(s)
- Katherine C Ritchey
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA; Division of Geriatrics and Gerontology, Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Box 359755, Seattle, WA, 98104-2499, USA.
| | - Abebaw M Yohannes
- Department of Physical Therapy, School of Health Professions Building, University of Alabama at Birmingham, 1716 9th Avenue South, Birmingham, AL, 35233, USA.
| | - Emily R Locke
- Center of Innovation for Veteran-Centered and Value-Driven Care VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA.
| | - Sunny Chen
- Geriatric Research Education and Clinical Center (GRECC), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, USA
| | - Tracy Simpson
- Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA; Department of Psychiatry, University of Washington School of Medicine, 959 NE Pacific Street Box 356560, Seattle, WA, 98195-6560, USA.
| | - Catherine Battaglia
- Eastern Colorado VA Health Care System, 1700 N. Wheeling, Aurora, CO, 80045, USA; University of Colorado Anschutz Medical Campus, 13001 E. 17th Pl, Aurora, CO, 80045, USA.
| | - Ranak B Trivedi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795. Willow Road, Menlo Park, CA, 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, 401 Quarry Road, Stanford, CA, 94305, USA
| | - Erik R Swenson
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA 1959 NE Pacific Street, Seattle, WA, 98159, USA; Pulmonary and Critical Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
| | - Jeff Edelman
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA 1959 NE Pacific Street, Seattle, WA, 98159, USA; Pulmonary and Critical Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
| | - Vincent S Fan
- Division of Pulmonary and Critical Care, Department of Medicine, University of Washington School of Medicine, Seattle, WA 1959 NE Pacific Street, Seattle, WA, 98159, USA; Pulmonary and Critical Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA, 98108, USA.
| |
Collapse
|
7
|
Fan VS, Dominitz JA, Eastment MC, Locke E, Green P, Berry K, O’Hare AM, Shah JA, Crothers K, Ioannou GN. Risk Factors for Testing Positive for Severe Acute Respiratory Syndrome Coronavirus 2 in a National United States Healthcare System. Clin Infect Dis 2021; 73:e3085-e3094. [PMID: 33105485 PMCID: PMC7665412 DOI: 10.1093/cid/ciaa1624] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Identifying risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection could help health systems improve testing and screening strategies. The aim of this study was to identify demographic factors, comorbid conditions, and symptoms independently associated with testing positive for SARS-CoV-2. METHODS This was an observational cross-sectional study at the Veterans Health Administration, including persons tested for SARS-CoV-2 nucleic acid by polymerase chain reaction (PCR) between 28 February and 14 May 2020. Associations between demographic characteristics, diagnosed comorbid conditions, and documented symptoms with testing positive for SARS-CoV-2 were measured. RESULTS Of 88 747 persons tested, 10 131 (11.4%) were SARS-CoV-2 PCR positive. Positivity was associated with older age (≥80 vs <50 years: adjusted odds ratio [aOR], 2.16 [95% confidence interval {CI}, 1.97-2.37]), male sex (aOR, 1.45 [95% CI, 1.34-1.57]), regional SARS-CoV-2 burden (≥2000 vs <400 cases/million: aOR, 5.43 [95% CI, 4.97-5.93]), urban residence (aOR, 1.78 [95% CI, 1.70-1.87]), black (aOR, 2.15 [95% CI, 2.05-2.26]) or American Indian/Alaska Native Hawaiian/Pacific Islander (aOR, 1.26 [95% CI, 1.05-1.52]) vs white race, and Hispanic ethnicity (aOR, 1.52 [95% CI, 1.40-1.65]). Obesity and diabetes were the only 2 medical conditions associated with testing positive. Documented fevers, chills, cough, and diarrhea were also associated with testing positive. The population attributable fraction of positive tests was highest for geographic location (35.3%), followed by demographic variables (27.1%), symptoms (12.0%), obesity (10.5%), and diabetes (0.4%). CONCLUSIONS The majority of positive SARS-CoV-2 tests were attributed to geographic location, demographic characteristics, and obesity, with a minor contribution of chronic comorbid conditions.
Collapse
Affiliation(s)
- Vincent S Fan
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
| | - Jason A Dominitz
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - McKenna C Eastment
- Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA
| | - Emily Locke
- Division of Research and Development, University of Washington, Seattle, WA, USA
| | - Pamela Green
- Division of Research and Development, University of Washington, Seattle, WA, USA
| | - Kristin Berry
- Division of Research and Development, University of Washington, Seattle, WA, USA
| | - Ann M O’Hare
- Division of Nephrology at the Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Javeed A Shah
- Division of Allergy and Infectious Disease, University of Washington, Seattle, WA, USA
| | - Kristina Crothers
- Division of Pulmonary and Critical Care, University of Washington, Seattle, WA, USA
| | - George N Ioannou
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| |
Collapse
|
8
|
O'Hare AM, Berry K, Fan VS, Crothers K, Eastment MC, Dominitz JA, Shah JA, Green P, Locke E, Ioannou GN. Age differences in the association of comorbid burden with adverse outcomes in SARS-CoV-2. BMC Geriatr 2021; 21:415. [PMID: 34229623 PMCID: PMC8258273 DOI: 10.1186/s12877-021-02340-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 06/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background Older age and comorbid burden are both associated with adverse outcomes in SARS-CoV-2, but it is not known whether the association between comorbid burden and adverse outcomes differs in older and younger adults. Objective To compare the relationship between comorbid burden and adverse outcomes in adults with SARS-CoV-2 of different ages (18–64, 65–79 and ≥ 80 years). Design, setting, and participants Observational longitudinal cohort study of 170,528 patients who tested positive for SARS-CoV-2 in the US Department of Veterans Affairs (VA) Health Care System between 2/28/20 and 12/31/2020 who were followed through 01/31/2021. Measurements Charlson Comorbidity Index (CCI); Incidence of hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and death within 30 days of a positive SARS-CoV-2 test. Results The cumulative 30-day incidence of death was 0.8% in cohort members < 65 years, 7.1% in those aged 65–79 years and 20.6% in those aged ≥80 years. The respective 30-day incidences of hospitalization were 8.2, 21.7 and 29.5%, of ICU admission were 2.7, 8.6, and 11% and of mechanical ventilation were 1, 3.9 and 3.2%. Median CCI (interquartile range) ranged from 0.0 (0.0, 2.0) in the youngest, to 4 (2.0, 7.0) in the oldest age group. The adjusted association of CCI with all outcomes was attenuated at older ages such that the threshold level of CCI above which the risk for each outcome exceeded the reference group (1st quartile) was lower in younger than in older cohort members (p < 0.001 for all age group interactions). Limitations The CCI is calculated based on diagnostic codes, which may not provide an accurate assessment of comorbid burden. Conclusions Age differences in the distribution and prognostic significance of overall comorbid burden could inform clinical management, vaccination prioritization and population health during the pandemic and argue for more work to understand the role of age and comorbidity in shaping the care of hospitalized patients with SARS-CoV-2. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-021-02340-5.
Collapse
Affiliation(s)
- A M O'Hare
- Division of Nephrology, Veterans Affairs Puget Sound Healthcare System and University of Washington, 1660 South Columbian Way, Seattle, WA, 98108, USA. .,Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
| | - K Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - V S Fan
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - K Crothers
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - M C Eastment
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - J A Dominitz
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - J A Shah
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - P Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - E Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - G N Ioannou
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| |
Collapse
|
9
|
Ioannou GN, Liang PS, Locke E, Green P, Berry K, O’Hare AM, Shah JA, Crothers K, Eastment MC, Fan VS, Dominitz JA. Cirrhosis and Severe Acute Respiratory Syndrome Coronavirus 2 Infection in US Veterans: Risk of Infection, Hospitalization, Ventilation, and Mortality. Hepatology 2021; 74:322-335. [PMID: 33219546 PMCID: PMC7753324 DOI: 10.1002/hep.31649] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Whether patients with cirrhosis have increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the extent to which infection and cirrhosis increase the risk of adverse patient outcomes remain unclear. APPROACH AND RESULTS We identified 88,747 patients tested for SARS-CoV-2 between March 1, 2020, and May 14, 2020, in the Veterans Affairs (VA) national health care system, including 75,315 with no cirrhosis-SARS-CoV-2-negative (C0-S0), 9,826 with no cirrhosis-SARS-CoV-2-positive (C0-S1), 3,301 with cirrhosis-SARS-CoV-2-negative (C1-S0), and 305 with cirrhosis-SARS-CoV-2-positive (C1-S1). Patients were followed through June 22, 2020. Hospitalization, mechanical ventilation, and death were modeled in time-to-event analyses using Cox proportional hazards regression. Patients with cirrhosis were less likely to test positive than patients without cirrhosis (8.5% vs. 11.5%; adjusted odds ratio, 0.83; 95% CI, 0.69-0.99). Thirty-day mortality and ventilation rates increased progressively from C0-S0 (2.3% and 1.6%) to C1-S0 (5.2% and 3.6%) to C0-S1 (10.6% and 6.5%) and to C1-S1 (17.1% and 13.0%). Among patients with cirrhosis, those who tested positive for SARS-CoV-2 were 4.1 times more likely to undergo mechanical ventilation (adjusted hazard ratio [aHR], 4.12; 95% CI, 2.79-6.10) and 3.5 times more likely to die (aHR, 3.54; 95% CI, 2.55-4.90) than those who tested negative. Among patients with SARS-CoV-2 infection, those with cirrhosis were more likely to be hospitalized (aHR, 1.37; 95% CI, 1.12-1.66), undergo ventilation (aHR, 1.61; 95% CI, 1.05-2.46) or die (aHR, 1.65; 95% CI, 1.18-2.30) than patients without cirrhosis. Among patients with cirrhosis and SARS-CoV-2 infection, the most important predictors of mortality were advanced age, cirrhosis decompensation, and high Model for End-Stage Liver Disease score. CONCLUSIONS SARS-CoV-2 infection was associated with a 3.5-fold increase in mortality in patients with cirrhosis. Cirrhosis was associated with a 1.7-fold increase in mortality in patients with SARS-CoV-2 infection.
Collapse
Affiliation(s)
- George N. Ioannou
- Division of GastroenterologyVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Peter S. Liang
- Division of GastroenterologyVeterans Affairs New York Harbor Health Care System and NYU Langone HealthNew YorkNY
| | - Emily Locke
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Pamela Green
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Kristin Berry
- Research and DevelopmentVeterans Affairs Puget Sound Health Care SystemSeattleWA
| | - Ann M. O’Hare
- Division of NephrologyVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Javeed A. Shah
- Division of Allergy and Infectious DiseaseVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Kristina Crothers
- Division of Pulmonary and Critical CareVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - McKenna C. Eastment
- Division of Allergy and Infectious DiseaseVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Vincent S. Fan
- Division of Pulmonary and Critical CareVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Jason A. Dominitz
- Division of GastroenterologyVeterans Affairs Puget Sound Healthcare System and University of WashingtonSeattleWA
| |
Collapse
|
10
|
Ioannou GN, O'Hare AM, Berry K, Fan VS, Crothers K, Eastment MC, Locke E, Green P, Shah JA, Dominitz JA. Trends over time in the risk of adverse outcomes among patients with SARS-CoV-2 infection. Clin Infect Dis 2021; 74:416-426. [PMID: 33973000 PMCID: PMC8136056 DOI: 10.1093/cid/ciab419] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 01/08/2023] Open
Abstract
Background We aimed to describe trends in adverse outcomes among patients who tested positive for SARS-CoV-2 between February and September 2020 within a national healthcare system. Methods We identified enrollees in the national U.S. Veterans Affairs healthcare system who tested positive for SARS-CoV-2 between 2/28/2020 and 9/30/2020 (n=55,952), with follow-up extending to 11/19/2020. We determined trends over time in incidence of the following outcomes that occurred within 30 days of testing positive: hospitalization, intensive care unit (ICU) admission, mechanical ventilation and death. Results Between February and July 2020, there were marked downward trends in the 30-day incidence of hospitalization (44.2% to 15.8%), ICU admission (20.3% to 5.3%), mechanical ventilation (12.7% to 2.2%), and death (12.5% to 4.4%), which subsequently plateaued between July and September 2020. These trends persisted after adjustment for sociodemographic characteristics, comorbid conditions, documented symptoms and laboratory tests, including among subgroups of patients hospitalized, admitted to the ICU or treated with mechanical ventilation. From February to September, there were decreases in the use of hydroxychloroquine (56.5% to 0%), azithromycin (48.3% to 16.6%) vasopressors (20.6% to 8.7%), and dialysis (11.6% to 3.8%) and increases in the use of dexamethasone (3.4% to 53.1%), other corticosteroids (4.9% to 29.0%) and remdesivir (1.7% to 45.4%) among hospitalized patients. Conclusions The risk of adverse outcomes in SARS-CoV-2-positive patients decreased markedly between February and July, with subsequent stabilization from July to September. These trends were not explained by changes in measured baseline patient characteristics and may reflect changing treatment practices or viral pathogenicity.
Collapse
Affiliation(s)
- George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Ann M O'Hare
- Division of Nephrology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Vincent S Fan
- Division of Pulmonary, Critical Care and Sleep, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Kristina Crothers
- Division of Pulmonary, Critical Care and Sleep, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - McKenna C Eastment
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Emily Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Javeed A Shah
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA
| |
Collapse
|
11
|
Dragnich AG, Yee N, Gylys-Colwell I, Locke ER, Nguyen HQ, Moy ML, Magzamen S, Fan VS. Sociodemographic Characteristics and Physical Activity in Patients with COPD: A 3-Month Cohort Study. COPD 2021; 18:265-271. [PMID: 33970723 DOI: 10.1080/15412555.2021.1920902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Decreased physical activity (PA) is associated with morbidity and mortality in COPD patients. In this secondary analysis of data from a 12-week longitudinal study, we describe factors associated with PA in COPD. Participants completed the Physical Activity Checklist (PAC) daily for a 7- to 8-day period. PA was measured monthly using the Physical Activity Scale for the Elderly (PASE). At three different time points, daily step count was measured for one week with an Omron HJ-720ITC pedometer. The 35 participants were primarily male (94%) and White (91%), with an average age of 66.5 years and FEV1 44.9% predicted. Common activities reported on the PAC were walking (93%), preparing a meal (89%), and traveling by vehicle (96%). PA measured by both PASE score (p = 0.01) and average daily step count (p = 0.04) decreased during follow-up. In repeated measures multivariable modeling, participants living with others had a higher daily step count (ß = 942 steps, p = 0.01) and better PASE scores (ß = 46.4, p < 0.001). Older age was associated with decreased step count (ß = -77 steps, p < 0.001) whereas White race was associated with lower PASE scores (ß = -55.4, p < 0.001) compared to non-White race. Other demographic factors, quality of life, and medications were not associated with PA. A better understanding of the role of social networks and social support may help develop interventions to improve PA in COPD.
Collapse
Affiliation(s)
- Alex G Dragnich
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Nathan Yee
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ina Gylys-Colwell
- Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Emily R Locke
- Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Marilyn L Moy
- Pulmonary and Critical Care Medicine Section, VA Boston Health Care System, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Sheryl Magzamen
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| | - Vincent S Fan
- Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| |
Collapse
|
12
|
Eastment MC, Berry K, Locke E, Green P, O'Hare A, Crothers K, Dominitz JA, Fan VS, Shah JA, Ioannou GN. BMI and Outcomes of SARS-CoV-2 Among US Veterans. Obesity (Silver Spring) 2021; 29:900-908. [PMID: 33336934 PMCID: PMC8084878 DOI: 10.1002/oby.23111] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/13/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study is to examine the associations of BMI with testing positive for severe acute respiratory coronavirus 2 (SARS-CoV-2) and risk of adverse outcomes in a cohort of Veterans Affairs enrollees. METHOD Adjusted relative risks/hazard ratios (HRs) were calculated for the associations between BMI category (underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity) and testing positive for SARS-CoV-2 or experiencing hospitalization, intensive care unit admission, mechanical ventilation, and death among those testing positive. RESULTS Higher BMI categories were associated with higher risk of a positive SARS-CoV-2 test compared with the normal weight category (class 3 obesity adjusted relative risk: 1.34, 95% CI: 1.28-1.42). Among 25,952 patients who tested positive for SARS-CoV-2, class 3 obesity was associated with higher risk of mechanical ventilation (adjusted HR [aHR]: 1.77, 95% CI: 1.35-2.32) and mortality (aHR: 1.42, 95% CI: 1.12-1.78) compared with normal weight individuals. These associations were present primarily in patients younger than 65 and were attenuated or absent in older age groups (interaction P < 0.05). CONCLUSION Veterans Affairs enrollees with higher BMI were more likely to test positive for SARS-CoV-2 and were more likely to be mechanically ventilated or die if infected with SARS-CoV-2. Higher BMI contributed relatively more to the risk of death in those younger than 65 years of age as compared with other age categories.
Collapse
Affiliation(s)
- McKenna C Eastment
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Kristin Berry
- VA Office of Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Emily Locke
- VA Office of Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Pamela Green
- VA Office of Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Ann O'Hare
- Division of Nephrology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Kristina Crothers
- Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Vincent S Fan
- Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - Javeed A Shah
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| | - George N Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA
| |
Collapse
|
13
|
Ioannou GN, Green P, Fan VS, Dominitz JA, O’Hare AM, Backus LI, Locke E, Eastment MC, Osborne TF, Ioannou NG, Berry K. Development of COVIDVax Model to Estimate the Risk of SARS-CoV-2-Related Death Among 7.6 Million US Veterans for Use in Vaccination Prioritization. JAMA Netw Open 2021; 4:e214347. [PMID: 33822066 PMCID: PMC8025111 DOI: 10.1001/jamanetworkopen.2021.4347] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/11/2021] [Indexed: 01/04/2023] Open
Abstract
Importance A strategy that prioritizes individuals for SARS-CoV-2 vaccination according to their risk of SARS-CoV-2-related mortality would help minimize deaths during vaccine rollout. Objective To develop a model that estimates the risk of SARS-CoV-2-related mortality among all enrollees of the US Department of Veterans Affairs (VA) health care system. Design, Setting, and Participants This prognostic study used data from 7 635 064 individuals enrolled in the VA health care system as of May 21, 2020, to develop and internally validate a logistic regression model (COVIDVax) that predicted SARS-CoV-2-related death (n = 2422) during the observation period (May 21 to November 2, 2020) using baseline characteristics known to be associated with SARS-CoV-2-related mortality, extracted from the VA electronic health records (EHRs). The cohort was split into a training period (May 21 to September 30) and testing period (October 1 to November 2). Main Outcomes and Measures SARS-CoV-2-related death, defined as death within 30 days of testing positive for SARS-CoV-2. VA EHR data streams were imported on a data integration platform to demonstrate that the model could be executed in real-time to produce dashboards with risk scores for all current VA enrollees. Results Of 7 635 064 individuals, the mean (SD) age was 66.2 (13.8) years, and most were men (7 051 912 [92.4%]) and White individuals (4 887 338 [64.0%]), with 1 116 435 (14.6%) Black individuals and 399 634 (5.2%) Hispanic individuals. From a starting pool of 16 potential predictors, 10 were included in the final COVIDVax model, as follows: sex, age, race, ethnicity, body mass index, Charlson Comorbidity Index, diabetes, chronic kidney disease, congestive heart failure, and Care Assessment Need score. The model exhibited excellent discrimination with area under the receiver operating characteristic curve (AUROC) of 85.3% (95% CI, 84.6%-86.1%), superior to the AUROC of using age alone to stratify risk (72.6%; 95% CI, 71.6%-73.6%). Assuming vaccination is 90% effective at preventing SARS-CoV-2-related death, using this model to prioritize vaccination was estimated to prevent 63.5% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than the estimate for prioritizing vaccination based on age (45.6%) or the US Centers for Disease Control and Prevention phases of vaccine allocation (41.1%). Conclusions and Relevance In this prognostic study of all VA enrollees, prioritizing vaccination based on the COVIDVax model was estimated to prevent a large proportion of deaths expected to occur during vaccine rollout before sufficient herd immunity is achieved.
Collapse
Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, University of Washington, Seattle
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Vincent S. Fan
- Division of Pulmonary, Critical Care, and Sleep, Veterans Affairs Puget Sound Healthcare System, University of Washington, Seattle
| | - Jason A. Dominitz
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System, University of Washington, Seattle
| | - Ann M. O’Hare
- Division of Nephrology, Veterans Affairs Puget Sound Healthcare System, University of Washington, Seattle
| | - Lisa I. Backus
- Department of Veterans Affairs, Population Health Services, Palo Alto Healthcare System, Palo Alto, California
| | - Emily Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - McKenna C. Eastment
- Division of Allergy and Infectious Diseases, Veterans Affairs Puget Sound Healthcare System, University of Washington, Seattle
| | - Thomas F. Osborne
- Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Nikolas G. Ioannou
- Paul G. Allen School of Computer Science and Engineering, University of Washington, Seattle
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| |
Collapse
|
14
|
Yohannes AM, Kohen R, Nguyen HQ, Pike KC, Borson S, Fan VS. Serotonin transporter gene polymorphisms and depressive symptoms in patients with chronic obstructive pulmonary disease. Expert Rev Respir Med 2020; 15:681-687. [PMID: 33325315 DOI: 10.1080/17476348.2021.1865159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.Methods: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.Results: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).Conclusions: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.
Collapse
Affiliation(s)
| | - Ruth Kohen
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Huong Q Nguyen
- Department of research and evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Kenneth C Pike
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Soo Borson
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Vincent S Fan
- VA Puget Sound, University of Washington, Seattle, WA, USA
| |
Collapse
|
15
|
Ioannou GN, Locke E, Green P, Berry K, O’Hare AM, Shah JA, Crothers K, Eastment MC, Dominitz JA, Fan VS. Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection. JAMA Netw Open 2020; 3:e2022310. [PMID: 32965502 PMCID: PMC7512055 DOI: 10.1001/jamanetworkopen.2020.22310] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/18/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Identifying independent risk factors for adverse outcomes in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can support prognostication, resource utilization, and treatment. Objective To identify excess risk and risk factors associated with hospitalization, mechanical ventilation, and mortality in patients with SARS-CoV-2 infection. Design, Setting, and Participants This longitudinal cohort study included 88 747 patients tested for SARS-CoV-2 nucleic acid by polymerase chain reaction between Feburary 28 and May 14, 2020, and followed up through June 22, 2020, in the Department of Veterans Affairs (VA) national health care system, including 10 131 patients (11.4%) who tested positive. Exposures Sociodemographic characteristics, comorbid conditions, symptoms, and laboratory test results. Main Outcomes and Measures Risk of hospitalization, mechanical ventilation, and death were estimated in time-to-event analyses using Cox proportional hazards models. Results The 10 131 veterans with SARS-CoV-2 were predominantly male (9221 [91.0%]), with diverse race/ethnicity (5022 [49.6%] White, 4215 [41.6%] Black, and 944 [9.3%] Hispanic) and a mean (SD) age of 63.6 (16.2) years. Compared with patients who tested negative for SARS-CoV-2, those who tested positive had higher rates of 30-day hospitalization (30.4% vs 29.3%; adjusted hazard ratio [aHR], 1.13; 95% CI, 1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI, 3.74-4.61), and death (10.8% vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83). Among patients who tested positive for SARS-CoV-2, characteristics significantly associated with mortality included older age (eg, ≥80 years vs <50 years: aHR, 60.80; 95% CI, 29.67-124.61), high regional COVID-19 disease burden (eg, ≥700 vs <130 deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45), higher Charlson comorbidity index score (eg, ≥5 vs 0: aHR, 1.93; 95% CI, 1.54-2.42), fever (aHR, 1.51; 95% CI, 1.32-1.72), dyspnea (aHR, 1.78; 95% CI, 1.53-2.07), and abnormalities in the certain blood tests, which exhibited dose-response associations with mortality, including aspartate aminotransferase (>89 U/L vs ≤25 U/L: aHR, 1.86; 95% CI, 1.35-2.57), creatinine (>3.80 mg/dL vs 0.98 mg/dL: aHR, 3.79; 95% CI, 2.62-5.48), and neutrophil to lymphocyte ratio (>12.70 vs ≤2.71: aHR, 2.88; 95% CI, 2.12-3.91). With the exception of geographic region, the same covariates were independently associated with mechanical ventilation along with Black race (aHR, 1.52; 95% CI, 1.25-1.85), male sex (aHR, 2.07; 95% CI, 1.30-3.32), diabetes (aHR, 1.40; 95% CI, 1.18-1.67), and hypertension (aHR, 1.30; 95% CI, 1.03-1.64). Notable characteristics that were not significantly associated with mortality in adjusted analyses included obesity (body mass index ≥35 vs 18.5-24.9: aHR, 0.97; 95% CI, 0.77-1.21), Black race (aHR, 1.04; 95% CI, 0.88-1.21), Hispanic ethnicity (aHR, 1.03; 95% CI, 0.79-1.35), chronic obstructive pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI, 0.81-1.12), and smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13). Most deaths in this cohort occurred in patients with age of 50 years or older (63.4%), male sex (12.3%), and Charlson Comorbidity Index score of at least 1 (11.1%). Conclusions and Relevance In this national cohort of VA patients, most SARS-CoV-2 deaths were associated with older age, male sex, and comorbidity burden. Many factors previously reported to be associated with mortality in smaller studies were not confirmed, such as obesity, Black race, Hispanic ethnicity, chronic obstructive pulmonary disease, hypertension, and smoking.
Collapse
Affiliation(s)
- George N. Ioannou
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Emily Locke
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Pamela Green
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Kristin Berry
- Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ann M. O’Hare
- Division of Nephrology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Javeed A. Shah
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Kristina Crothers
- Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - McKenna C. Eastment
- Division of Allergy and Infectious Disease, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Jason A. Dominitz
- Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| | - Vincent S. Fan
- Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle
| |
Collapse
|
16
|
Nici L, Mammen MJ, Charbek E, Alexander PE, Au DH, Boyd CM, Criner GJ, Donaldson GC, Dreher M, Fan VS, Gershon AS, Han MK, Krishnan JA, Martinez FJ, Meek PM, Morgan M, Polkey MI, Puhan MA, Sadatsafavi M, Sin DD, Washko GR, Wedzicha JA, Aaron SD. Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e56-e69. [PMID: 32283960 PMCID: PMC7193862 DOI: 10.1164/rccm.202003-0625st] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society. Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy. Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.
Collapse
|
17
|
Yee N, Locke ER, Pike KC, Chen Z, Lee J, Huang JC, Nguyen HQ, Fan VS. Frailty in Chronic Obstructive Pulmonary Disease and Risk of Exacerbations and Hospitalizations. Int J Chron Obstruct Pulmon Dis 2020; 15:1967-1976. [PMID: 32848382 PMCID: PMC7429100 DOI: 10.2147/copd.s245505] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/24/2020] [Indexed: 12/12/2022] Open
Abstract
Background Frailty is a complex clinical syndrome associated with vulnerability to adverse health outcomes. While frailty is thought to be common in chronic obstructive pulmonary disease (COPD), the relationship between frailty and COPD-related outcomes such as risk of acute exacerbations of COPD (AE-COPD) and hospitalizations is unclear. Purpose To examine the association between physical frailty and risk of acute exacerbations, hospitalizations, and mortality in patients with COPD. Methods A longitudinal analysis of data from a cohort of 280 participants was performed. Baseline frailty measures included exhaustion, weakness, low activity, slowness, and undernutrition. Outcome measures included AE-COPD, hospitalizations, and mortality over 2 years. Negative binomial regression and Cox proportional hazard modeling were used. Results Sixty-two percent of the study population met criteria for pre-frail and 23% were frail. In adjusted analyses, the frailty syndrome was not associated with COPD exacerbations. However, among the individual components of the frailty syndrome, weakness measured by handgrip strength was associated with increased risk of COPD exacerbations (IRR 1.46, 95% CI 1.09–1.97). The frailty phenotype was not associated with all-cause hospitalizations but was associated with increased risk of non-COPD-related hospitalizations. Conclusion This longitudinal cohort study shows that a high proportion of patients with COPD are pre-frail or frail. The frailty phenotype was associated with an increased risk of non-COPD hospitalizations but not with all-cause hospitalizations or COPD exacerbations. Among the individual frailty components, low handgrip strength was associated with increased risk of COPD exacerbations over a 2-year period. Measuring handgrip strength may identify COPD patients who could benefit from programs to reduce COPD exacerbations.
Collapse
Affiliation(s)
- Nathan Yee
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Emily R Locke
- Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Kenneth C Pike
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Zijing Chen
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, USA
| | - Jungeun Lee
- College of Nursing, University of Rhode Island, Kingston, RI, USA
| | - Joe C Huang
- Division of Gerontology & Geriatric Medicine, University of Washington, Seattle, WA, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Vincent S Fan
- Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.,Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
18
|
Leitao Filho FS, Mattman A, Schellenberg R, Criner GJ, Woodruff P, Lazarus SC, Albert RK, Connett J, Han MK, Gay SE, Martinez FJ, Fuhlbrigge AL, Stoller JK, MacIntyre NR, Casaburi R, Diaz P, Panos RJ, Cooper JA, Bailey WC, LaFon DC, Sciurba FC, Kanner RE, Yusen RD, Au DH, Pike KC, Fan VS, Leung JM, Man SFP, Aaron SD, Reed RM, Sin DD. Serum IgG Levels and Risk of COPD Hospitalization: A Pooled Meta-analysis. Chest 2020; 158:1420-1430. [PMID: 32439504 DOI: 10.1016/j.chest.2020.04.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 04/01/2020] [Accepted: 04/10/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hypogammaglobulinemia (serum IgG levels < 7.0 g/L) has been associated with increased risk of COPD exacerbations but has not yet been shown to predict hospitalizations. RESEARCH QUESTION To determine the relationship between hypogammaglobulinemia and the risk of hospitalization in patients with COPD. STUDY DESIGN AND METHODS Serum IgG levels were measured on baseline samples from four COPD cohorts (n = 2,259): Azithromycin for Prevention of AECOPD (MACRO, n = 976); Simvastatin in the Prevention of AECOPD (STATCOPE, n = 653), Long-Term Oxygen Treatment Trial (LOTT, n = 354), and COPD Activity: Serotonin Transporter, Cytokines and Depression (CASCADE, n = 276). IgG levels were determined by immunonephelometry (MACRO; STATCOPE) or mass spectrometry (LOTT; CASCADE). The effect of hypogammaglobulinemia on COPD hospitalization risk was evaluated using cumulative incidence functions for this outcome and deaths (competing risk). Fine-Gray models were performed to obtain adjusted subdistribution hazard ratios (SHR) related to IgG levels for each study and then combined using a meta-analysis. Rates of COPD hospitalizations per person-year were compared according to IgG status. RESULTS The overall frequency of hypogammaglobulinemia was 28.4%. Higher incidence estimates of COPD hospitalizations were observed among participants with low IgG levels compared with those with normal levels (Gray's test, P < .001); pooled SHR (meta-analysis) was 1.29 (95% CI, 1.06-1.56, P = .01). Among patients with prior COPD admissions (n = 757), the pooled SHR increased to 1.58 (95% CI, 1.20-2.07, P < .01). The risk of COPD admissions, however, was similar between IgG groups in patients with no prior hospitalizations: pooled SHR = 1.15 (95% CI, 0.86-1.52, P =.34). The hypogammaglobulinemia group also showed significantly higher rates of COPD hospitalizations per person-year: 0.48 ± 2.01 vs 0.29 ± 0.83, P < .001. INTERPRETATION Hypogammaglobulinemia is associated with a higher risk of COPD hospital admissions.
Collapse
Affiliation(s)
- Fernando Sergio Leitao Filho
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andre Mattman
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Robert Schellenberg
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Prescott Woodruff
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Stephen C Lazarus
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | | | - John Connett
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Meilan K Han
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Steven E Gay
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | - Fernando J Martinez
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Anne L Fuhlbrigge
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | - Neil R MacIntyre
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Richard Casaburi
- Division of Respiratory and Critical Care Physiology and Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA
| | - Philip Diaz
- Department of Internal Medicine, Ohio State University, Columbus, OH
| | - Ralph J Panos
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J Allen Cooper
- Birmingham VA Medical Center, Birmingham, AL; Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - William C Bailey
- Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - David C LaFon
- Department of Medicine, University of Alabama Medical School, Birmingham, AL
| | - Frank C Sciurba
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Richard E Kanner
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine in Saint Louis, Saint Louis, MO
| | - David H Au
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA
| | - Kenneth C Pike
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA
| | - Vincent S Fan
- Division of Pulmonary, Critical Care and Sleep Medicine and School of Nursing, University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle, WA
| | - Janice M Leung
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shu-Fan Paul Man
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shawn D Aaron
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Robert M Reed
- Department of Medicine, University of Maryland, Baltimore, MD
| | - Don D Sin
- Centre for Heart Lung Innovation, St. Paul's Hospital & Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
| |
Collapse
|
19
|
Nguyen HQ, Moy ML, Liu ILA, Fan VS, Gould MK, Desai SA, Towner WJ, Yuen G, Lee JS, Park SJ, Xiang AH. Effect of Physical Activity Coaching on Acute Care and Survival Among Patients With Chronic Obstructive Pulmonary Disease: A Pragmatic Randomized Clinical Trial. JAMA Netw Open 2019; 2:e199657. [PMID: 31418811 PMCID: PMC6704745 DOI: 10.1001/jamanetworkopen.2019.9657] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE While observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD), there are no population-based trials to date testing the effectiveness of physical activity (PA) interventions to reduce acute care use or improve survival. OBJECTIVE To evaluate the long-term effectiveness of a community-based PA coaching intervention in patients with COPD. DESIGN, SETTING, AND PARTICIPANTS Pragmatic randomized clinical trial with preconsent randomization to the 12-month Walk On! (WO) intervention or standard care (SC). Enrollment occurred from July 1, 2015, to July 31, 2017; follow-up ended in July 2018. The setting was Kaiser Permanente Southern California sites. Participants were patients 40 years or older who had any COPD-related acute care use in the previous 12 months; only patients assigned to WO were approached for consent to participate in intervention activities. INTERVENTIONS The WO intervention included collaborative monitoring of PA step counts, semiautomated step goal recommendations, individualized reinforcement, and peer/family support. Standard COPD care could include referrals to pulmonary rehabilitation. MAIN OUTCOMES AND MEASURES The primary outcome was a composite binary measure of all-cause hospitalizations, observation stays, emergency department visits, and death using adjusted logistic regression in the 12 months after randomization. Secondary outcomes included self-reported PA, COPD-related acute care use, symptoms, quality of life, and cardiometabolic markers. RESULTS All 2707 eligible patients (baseline mean [SD] age, 72 [10] years; 53.7% female; 74.3% of white race/ethnicity; and baseline mean [SD] percent forced expiratory volume in the first second of expiration predicted, 61.0 [22.5]) were randomly assigned to WO (n = 1358) or SC (n = 1349). The intent-to-treat analysis showed no differences between WO and SC on the primary all-cause composite outcome (odds ratio [OR], 1.09; 95% CI, 0.92-1.28; P = .33) or in the individual outcomes. Prespecified, as-treated analyses compared outcomes between all SC and 321 WO patients who participated in any intervention activities (23.6% [321 of 1358] uptake). The as-treated, propensity score-weighted model showed nonsignificant positive estimates in favor of WO participants compared with SC on all-cause hospitalizations (OR, 0.84; 95% CI, 0.65-1.10; P = .21) and death (OR, 0.62; 95% CI, 0.35-1.11; P = .11). More WO participants reported engaging in PA compared with SC (47.4% [152 of 321] vs 30.7% [414 of 1349]; P < .001) and had improvements in the Patient-Reported Outcomes Measurement Information System 10 physical health domain at 6 months. There were no group differences in other secondary outcomes. CONCLUSIONS AND RELEVANCE Participation in a PA coaching program by patients with a history of COPD exacerbations was insufficient to effect improvements in acute care use or survival in the primary analysis. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02478359.
Collapse
Affiliation(s)
- Huong Q. Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Marilyn L. Moy
- Harvard Medical School, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Vincent S. Fan
- University of Washington, Seattle
- VA Puget Sound Health Care System, Seattle, Washington
| | - Michael K. Gould
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - William J. Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - George Yuen
- Kaiser Permanente Southern California, Orange County, Anaheim
| | - Janet S. Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Stacy J. Park
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Anny H. Xiang
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| |
Collapse
|
20
|
Hooper LG, Dieye Y, Ndiaye A, Diallo A, Sack CS, Fan VS, Neuzil KM, Ortiz JR. Traditional cooking practices and preferences for stove features among women in rural Senegal: Informing improved cookstove design and interventions. PLoS One 2018; 13:e0206822. [PMID: 30458001 PMCID: PMC6245512 DOI: 10.1371/journal.pone.0206822] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 10/20/2018] [Indexed: 11/23/2022] Open
Abstract
Nearly half the world’s population burns solid fuel for cooking, heating, and lighting. The incomplete combustion of these fuels is associated with detrimental health and environmental effects. The design and distribution of improved cookstoves that increase combustion efficiency and reduce indoor air pollution are a global priority. However, promoting exclusive and sustainable use of the improved stoves has proved challenging. In 2012, we conducted a survey in a community in rural Senegal to describe stove ownership and preferences for different stove technologies. This report aims to describe local stove and fuel use, to identify household preferences related to stove features and function, and to elicit the community perceptions of cleaner-burning stove alternatives with a focus on liquid propane gas. Similar to many resource-limited settings, biomass fuel use was ubiquitous and multiple stoves were used, even when cleaner burning alternatives were available; less than 1% of households that owned a liquid propane stove used it as the primary cooking device. Despite nearly universal use of the traditional open fire (92% of households), women did not prefer this stove when presented with other options. Propane gas, solar, and improved cookstoves were all viewed as more desirable when compared to the traditional open fire, however first-hand experience and knowledge of these stoves was limited. The stove features of greatest value were, in order: large cooking capacity, minimal smoke production, and rapid heating. Despite the low desirability and smoke emisions from the traditional open fire, its pervasive use, even in the presence of alternative stove options, may be related to its ability to satisfy the practical needs of the surveyed cooks, namely large cooking capacity and rapid, intense heat generation. Our data suggest women in this community want alternative stove options that reduce smoke exposure, however currently available stoves, including liquid propane gas, do not address all of the cooks’ preferences.
Collapse
Affiliation(s)
- Laura G. Hooper
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | | | - Assane Ndiaye
- Vitrome Institute de Recherche pour le Developpement, Dakar, Senegal
| | - Aldiouma Diallo
- Vitrome Institute de Recherche pour le Developpement, Dakar, Senegal
| | - Coralynn S. Sack
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Vincent S. Fan
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
| | - Kathleen M. Neuzil
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Justin R. Ortiz
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| |
Collapse
|
21
|
Locke ER, Thomas RM, Woo DM, Nguyen EHK, Tamanaha BK, Press VG, Reiber GE, Kaboli PJ, Fan VS. Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease. Telemed J E Health 2018; 25:230-236. [PMID: 30016216 DOI: 10.1089/tmj.2017.0330] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions. INTRODUCTION Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction. MATERIALS AND METHODS Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods. RESULTS Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training. DISCUSSION This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique. CONCLUSIONS Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.
Collapse
Affiliation(s)
- Emily R Locke
- 1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Rachel M Thomas
- 1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Deborah M Woo
- 2 Pharmacy and Nutritional Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Ethan H K Nguyen
- 2 Pharmacy and Nutritional Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Bryson K Tamanaha
- 2 Pharmacy and Nutritional Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Valerie G Press
- 3 Department of Medicine, University of Chicago, Chicago, Illinois
| | - Gayle E Reiber
- 1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Peter J Kaboli
- 4 The Comprehensive Access and Delivery Research and Evaluation (CADRE) Center, Iowa City VA Health Care System, Iowa City, Iowa.,5 Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Vincent S Fan
- 1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.,6 Department of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
22
|
Nguyen HQ, Moy ML, Fan VS, Gould MK, Xiang A, Bailey A, Desai S, Coleman KJ. Applying the pragmatic-explanatory continuum indicator summary to the implementation of a physical activity coaching trial in chronic obstructive pulmonary disease. Nurs Outlook 2018; 66:455-463. [PMID: 30144938 DOI: 10.1016/j.outlook.2018.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 05/08/2018] [Accepted: 05/26/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD). Despite practice guidelines recommending regular physical activity (PA), there are no large-scale experimental studies to confirm that patients at high risk for COPD exacerbations can increase their PA and consequently, have improved outcomes. PURPOSE The purpose of this case study is to describe the use of a widely accepted pragmatic trials framework for the design and implementation of a pragmatic clinical trial (PCT) of PA coaching for COPD in a real-world setting. METHOD The aim of the trial was to determine the effectiveness of a 12-month PA coaching intervention (Walk On!) compared to standard care for 2,707 patients at high risk for COPD exacerbations from a large integrated health care system. The descriptions of our implementation experiences are anchored within the pragmatic-explanatory continuum indicator summary (PRECIS-2) framework. DISCUSSION Facilitators of PCT implementation include early and ongoing engagement and support of multiple stakeholders including patients, health system leaders, administrators, physician champions, and frontline clinicians, an organizational/setting that prioritizes positive lifestyle behaviors, and a flexible intervention that allows for individualization. Pragmatic challenges include reliance on electronic data that are not complete or available in real-time for patient identification, timing of outreach may not synchronize with patients' readiness for change, and high turnover of clinical staff drawn from the existing workforce. DISCUSSION PRECIS-2 is a useful guide for organizing decisions about study designs and implementation approaches to help diverse stakeholders recognize the compromises between internal and external validity with those decisions.
Collapse
Affiliation(s)
- Huong Q Nguyen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - Marilyn L Moy
- Harvard Medical School, VA Boston Healthcare System, Pulmonary and Critical Care Section, Boston, MA
| | - Vincent S Fan
- University of Washington, Seattle, Puget Sound VA Health System, Seattle, WA
| | - Michael K Gould
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Anny Xiang
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Smita Desai
- Kaiser Permanente Southern California, San Diego, CA
| | - Karen J Coleman
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| |
Collapse
|
23
|
Abstract
BACKGROUND Studies have linked ambient air pollution to chronic obstructive pulmonary disease (COPD) healthcare encounters. However, the association between air quality and rescue medication use is unknown. OBJECTIVES We assessed the role of air pollution exposure for increased short-acting beta-2-agonist (SABA) use in patients with COPD through use of remote monitoring technology. METHODS Participants received a portable electronic inhaler sensor to record the date, time and location for SABA use over a 3-month period. Ambient air pollution data and meteorological data were collected from a centrally located federal monitoring station. Mixed-effects Poisson regression was used to examine the association of daily inhaler use with pollutant levels. Four criteria pollutants (PM2.5, PM10, O3 and NO2), two particulate matter species (elemental carbon (EC) and organic carbon), estimated coarse fraction of PM10 (PM10-2.5) and four multipollutant air quality measures were each examined separately, adjusting for covariates that passed a false discovery rate (FDR) screening. RESULTS We enrolled 35 patients with COPD (94.3% male and mean age: 66.5±8.5) with a mean forced expiratory volume in 1 s (FEV1) % predicted of 44.9+17.2. Participants had a median of 92 observation days (range 52-109). Participants' average SABA inhaler use ranged from 0.4 to 13.1 puffs/day (median 2.8). Controlling for supplemental oxygen use, long-acting anticholinergic use, modified Medical Research Council Dyspnoea Scale and influenza season, an IQR increase in PM10 concentration (8.0 µg/m3) was associated with a 6.6% increase in daily puffs (95% CI 3.5% to 9.9%; FDR <0.001). NO2 and EC concentration were also significantly associated with inhaler use (3.9% and 2.9% per IQR increase, respectively). CONCLUSIONS Exposure to increased ambient air pollution were associated with a significant increase in SABA use for patients with COPD residing in a low-pollution area.
Collapse
Affiliation(s)
- Sheryl Magzamen
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA.,Veterans Administration Eastern Colorado Health Care System, Denver, Colorado, USA
| | - Assaf P Oron
- Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
| | - Emily R Locke
- Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA
| | - Vincent S Fan
- Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA.,School of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
24
|
Lee J, Nguyen HQ, Jarrett ME, Mitchell PH, Pike KC, Fan VS. Effect of symptoms on physical performance in COPD. Heart Lung 2018; 47:149-156. [PMID: 29395264 DOI: 10.1016/j.hrtlng.2017.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 12/26/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) patients experience multiple symptoms including dyspnea, anxiety, depression, and fatigue, which are highly correlated with each other. Together, those symptoms may contribute to impaired physical performance. OBJECTIVES The purpose of this study was to examine interrelationships among dyspnea, anxiety, depressive symptoms, and fatigue as contributing factors to physical performance in COPD. METHODS This study used baseline data of 282 COPD patients from a longitudinal observational study to explore the relationship between depression, inflammation, and functional status. Data analyses included confirmatory factor analyses and structural equation modeling. RESULTS Dyspnea, anxiety and depression had direct effects on fatigue, and both dyspnea and anxiety had direct effects on physical performance. Higher levels of dyspnea were significantly associated with impaired physical performance whereas higher levels of anxiety were significantly associated with enhanced physical performance. CONCLUSION Dyspnea was the strongest predictor of impaired physical performance in patients with COPD.
Collapse
Affiliation(s)
- Jungeun Lee
- School of Nursing, University of Washington, Seattle, WA, USA.
| | - Huong Q Nguyen
- Reseach & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | | | - Kenneth C Pike
- School of Nursing, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
25
|
Sumino K, Locke ER, Magzamen S, Gylys-Colwell I, Humblet O, Nguyen HQ, Thomas RM, Fan VS. Use of a Remote Inhaler Monitoring Device to Measure Change in Inhaler Use with Chronic Obstructive Pulmonary Disease Exacerbations. J Aerosol Med Pulm Drug Deliv 2017; 31:191-198. [PMID: 29035120 DOI: 10.1089/jamp.2017.1383] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Remote inhaler monitoring is an emerging technology that enables the healthcare team to monitor the time and location of a patient's inhaler use. We assessed the feasibility of remote inhaler monitoring for chronic obstructive pulmonary disease (COPD) patients and the pattern of albuterol inhaler use associated with COPD exacerbations. METHODS Thirty-five participants with COPD used an electronic inhaler sensor for 12 weeks which recorded the date and time of each albuterol actuation. Self-reported COPD exacerbations and healthcare utilization were assessed monthly. We used generalized estimating equations with a logit link to compare the odds of an exacerbation day to a nonexacerbation day by the frequency of daily albuterol use. RESULTS Average daily albuterol use on nonexacerbation days varied greatly between patients, ranging from 1.5 to 17.5 puffs. There were 48 exacerbation events observed in 29 participants during the study period, of which 16 were moderate-to-severe exacerbations. During the moderate-to-severe exacerbation days, the median value in average daily albuterol use increased by 14.1% (interquartile range: 2.7%-56.9%) compared to average nonexacerbation days. A 100% increase in inhaler use was associated with increased odds of a moderate-to severe exacerbation (odds ratio 1.54; 95% CI: 1.21-1.97). Approximately 74% of participants reported satisfaction with the sensor. CONCLUSIONS The electronic inhaler sensor was well received in older patients with COPD over a 12-week period. Increased albuterol use captured by the device was associated with self-reported episodes of moderate-to-severe exacerbations.
Collapse
Affiliation(s)
- Kaharu Sumino
- 1 Department of Medicine, Washington University School of Medicine , St. Louis, Missouri.,2 VA Saint Louis Health System, Saint Louis VA Medical Center , St. Louis, Missouri
| | - Emily R Locke
- 3 Department of Health Services Research and Development, VA Puget Sound Health Care System , Seattle, Washington
| | - Sheryl Magzamen
- 4 Environmental and Radiological Health Sciences, Colorado State University , Fort Collins, Colorado
| | - Ina Gylys-Colwell
- 3 Department of Health Services Research and Development, VA Puget Sound Health Care System , Seattle, Washington
| | | | - Huong Q Nguyen
- 6 Department of Research and Evaluation, Kaiser Permanente Southern California , Pasadena, California
| | - Rachel M Thomas
- 3 Department of Health Services Research and Development, VA Puget Sound Health Care System , Seattle, Washington
| | - Vincent S Fan
- 3 Department of Health Services Research and Development, VA Puget Sound Health Care System , Seattle, Washington.,7 Department of Medicine, University of Washington , Seattle, Washington
| |
Collapse
|
26
|
Thomas RM, Locke ER, Woo DM, Nguyen EHK, Press VG, Layouni TA, Trittschuh EH, Reiber GE, Fan VS. Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life. Respir Care 2017; 62:1412-1422. [PMID: 28720676 DOI: 10.4187/respcare.05445] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence. METHODS In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention. RESULTS A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, P = .01), fatigue (+0.6 points, P < .001), emotional function (+0.5 points, P = .001), and mastery (+0.7 points, P < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, P = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points (P < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 (P = .045). The pharmacist reported technical issues in 64% of visits. CONCLUSIONS Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.
Collapse
Affiliation(s)
- Rachel M Thomas
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Emily R Locke
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Deborah M Woo
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Ethan H K Nguyen
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Valerie G Press
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Troy A Layouni
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Emily H Trittschuh
- Geriatric Research Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.,Department of Psychiatry and Behavioral Sciences
| | - Gayle E Reiber
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
| | - Vincent S Fan
- Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care.,Department of Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
27
|
Hansel NN, Paulin LM, Gassett AJ, Peng RD, Alexis N, Fan VS, Bleecker E, Bowler R, Comellas AP, Dransfield M, Han MK, Kim V, Krishnan JA, Pirozzi C, Cooper CB, Martinez F, Woodruff PG, Breysse PJ, Barr RG, Kaufman JD. Design of the Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) AIR Study. BMJ Open Respir Res 2017; 4:e000186. [PMID: 28948026 PMCID: PMC5595208 DOI: 10.1136/bmjresp-2017-000186] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/29/2017] [Indexed: 01/03/2023] Open
Abstract
Introduction Population-based epidemiological evidence suggests that exposure to ambient air pollutants increases hospitalisations and mortality from chronic obstructive pulmonary disease (COPD), but less is known about the impact of exposure to air pollutants on patient-reported outcomes, morbidity and progression of COPD. Methods and analysis The Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) Air Pollution Study (SPIROMICS AIR) was initiated in 2013 to investigate the relation between individual-level estimates of short-term and long-term air pollution exposures, day-to-day symptom variability and disease progression in individuals with COPD. SPIROMICS AIR builds on a multicentre study of smokers with COPD, supplementing it with state-of-the-art air pollution exposure assessments of fine particulate matter, oxides of nitrogen, ozone, sulfur dioxide and black carbon. In the parent study, approximately 3000 smokers with and without airflow obstruction are being followed for up to 3 years for the identification of intermediate biomarkers which predict disease progression. Subcohorts undergo daily symptom monitoring using comprehensive daily diaries. The air monitoring and modelling methods employed in SPIROMICS AIR will provide estimates of individual exposure that incorporate residence-specific infiltration characteristics and participant-specific time-activity patterns. The overarching study aim is to understand the health effects of short-term and long-term exposures to air pollution on COPD morbidity, including exacerbation risk, patient-reported outcomes and disease progression. Ethics and dissemination The institutional review boards of all the participating institutions approved the study protocols. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals.
Collapse
Affiliation(s)
- Nadia N Hansel
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura M Paulin
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Roger D Peng
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neil Alexis
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Vincent S Fan
- University of Washington, Seattle, Washington, USA.,VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Eugene Bleecker
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | | | - Mark Dransfield
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - MeiLan K Han
- University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Victor Kim
- Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Cheryl Pirozzi
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | | | | | - Prescott G Woodruff
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Patrick J Breysse
- National Center for Environmental Health/Agency for Toxic Substances & Disease Registry, Atlanta, Georgia, USA
| | | | | |
Collapse
|
28
|
Hooper LG, Dieye Y, Ndiaye A, Diallo A, Fan VS, Neuzil KM, Ortiz JR. Estimating pediatric asthma prevalence in rural senegal: A cross-sectional survey. Pediatr Pulmonol 2017; 52:303-309. [PMID: 27551858 DOI: 10.1002/ppul.23545] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 07/12/2016] [Accepted: 07/22/2016] [Indexed: 12/13/2022]
Abstract
RATIONALE In Senegal, the prevalence of childhood asthma and utilization of appropriate asthma therapies is unknown. METHODOLOGY We used the International Study of Asthma and Allergies in Childhood (ISAAC) survey instrument to assess childhood respiratory health in rural Senegal. We interviewed the caregivers of children aged 5 through 8 years of age in the four largest Niakhar villages in August 2012. RESULTS We interviewed 1,103 primary caregivers for 1,513 children, representing 91% of all age-eligible children in the study area. Overall, 206 (14%) children had wheeze at any time in the past, 130 (9%) had wheeze within the past year, and only 41 (3%) reported a clinical diagnosis of asthma. Among children with wheeze within the past year, 81 (62%) had symptoms of severe asthma. Nocturnal cough was reported in 186 (14%) children who denied any history of wheezing illness. Only four (3%) children with wheeze in the past year had ever received bronchodilator therapy. Children with wheeze in the past year were significantly more likely to seek medical care for respiratory symptoms and to be perceived as less healthy than their peers. Children of lower socioeconomic status were significantly more likely to have wheeze. CONCLUSIONS Nearly one in ten children in Niakhar, Senegal had symptoms suggestive of asthma; however, few children have a diagnosis of asthma or use appropriate therapies. This study highlights an opportunity to raise community awareness of asthma in rural Senegal and to increase access to appropriate medical therapies. Pediatr Pulmonol. 2017;52:303-309. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Laura G Hooper
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Assane Ndiaye
- Institute de Recherche pour le Developpement, Dakar, Senegal
| | - Aldiouma Diallo
- Institute de Recherche pour le Developpement, Dakar, Senegal
| | - Vincent S Fan
- Department of Medicine, University of Washington, Seattle, Washington.,VA Puget Sound Health Care System, Seattle, Washington
| | - Kathleen M Neuzil
- Department of Medicine, University of Washington, Seattle, Washington.,Department of Global Health, University of Washington, Seattle, Washington.,PATH, Seattle, Washington
| | - Justin R Ortiz
- Department of Medicine, University of Washington, Seattle, Washington.,Department of Global Health, University of Washington, Seattle, Washington.,PATH, Seattle, Washington
| |
Collapse
|
29
|
Lo Cascio CM, Quante M, Hoffman EA, Bertoni AG, Aaron CP, Schwartz JE, Avdalovic MV, Fan VS, Lovasi GS, Kawut SM, Austin JHM, Redline S, Barr RG. Percent Emphysema and Daily Motor Activity Levels in the General Population: Multi-Ethnic Study of Atherosclerosis. Chest 2016; 151:1039-1050. [PMID: 27940190 DOI: 10.1016/j.chest.2016.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 10/14/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND COPD is associated with reduced physical capacity. However, it is unclear whether pulmonary emphysema, which can occur without COPD, is associated with reduced physical activity in daily life, particularly among people without COPD and never smokers. We hypothesized that greater percentage of emphysema-like lung on CT scan is associated with reduced physical activity assessed by actigraphy and self-report. METHODS The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled participants free of clinical cardiovascular disease from the general population. Percent emphysema was defined as percentage of voxels < -950 Hounsfield units on full-lung CT scans. Physical activity was measured by wrist actigraphy over 7 days and a questionnaire. Multivariable linear regression was used to adjust for age, sex, race/ethnicity, height, weight, education, smoking, pack-years, and lung function. RESULTS Among 1,435 participants with actigraphy and lung measures, 47% had never smoked, and 8% had COPD. Percent emphysema was associated with lower activity levels on actigraphy (P = .001), corresponding to 1.5 hour less per week of moderately paced walking for the average participant in quintile 2 vs 4 of percent emphysema. This association was significant among participants without COPD (P = .004) and among ever (P = .01) and never smokers (P = .03). It was also independent of coronary artery calcium and left ventricular ejection fraction. There was no evidence that percent emphysema was associated with self-reported activity levels. CONCLUSIONS Percent emphysema was associated with decreased physical activity in daily life objectively assessed by actigraphy in the general population, among participants without COPD, and nonsmokers.
Collapse
Affiliation(s)
| | - Mirja Quante
- Department of Medicine, Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eric A Hoffman
- Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest University, Winston-Salem, NC
| | - Carrie P Aaron
- Department of Medicine, Columbia University, New York, NY
| | - Joseph E Schwartz
- Department of Medicine, Columbia University, New York, NY; Department of Psychiatry and Behavioral Science, Stony Brook University, Stony Brook, NY
| | - Mark V Avdalovic
- Department of Internal Medicine, UC Davis School of Medicine, Sacramento, CA
| | - Vincent S Fan
- VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Gina S Lovasi
- Department of Medicine, Columbia University, New York, NY
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Susan Redline
- Department of Medicine, Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - R Graham Barr
- Department of Medicine, Columbia University, New York, NY.
| |
Collapse
|
30
|
Nguyen HQ, Herting JR, Pike KC, Gharib SA, Matute-Bello G, Borson S, Kohen R, Adams SG, Fan VS. Symptom profiles and inflammatory markers in moderate to severe COPD. BMC Pulm Med 2016; 16:173. [PMID: 27914470 PMCID: PMC5135800 DOI: 10.1186/s12890-016-0330-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 11/22/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Physical and psychological symptoms are the hallmark of patients' subjective perception of their illness. The purpose of this analysis was to determine if patients with COPD have distinctive symptom profiles and to examine the association of symptom profiles with systemic biomarkers of inflammation. METHODS We conducted latent class analyses of three physical (dyspnea, fatigue, and pain) and two psychological symptoms (depression and anxiety) in 302 patients with moderate to severe COPD using baseline data from a longitudinal observational study of depression in COPD. Systemic inflammatory markers included IL1, IL8, IL10, IL12, IL13, INF, GM-CSF, TNF-α (levels >75thcentile was considered high); and CRP (levels >3 mg/L was considered high). Multinominal logistic regression models were used to examine the association between symptom classes and inflammation while adjusting for key socio-demographic and disease characteristics. RESULTS We found that a 4-class model best fit the data: 1) low physical and psychological symptoms (26%, Low-Phys/Low-Psych), 2) low physical but moderate psychological symptoms (18%, Low-Phys/Mod Psych), 3) high physical but moderate psychological symptoms (25%, High-Phys/Mod Psych), and 4) high physical and psychological symptoms (30%, High-Phys/High Psych). Unadjusted analyses showed associations between symptom class with high levels of IL7, IL-8 (p ≤ .10) and CRP (p < .01). In the adjusted model, those with a high CRP level were less likely to be in the High-Phys/Mod-Psych class compared to the Low-Phys/Low-Psych (OR: 0.41, 95%CI 0.19, 0.90) and Low-Phys/Mod-Psych classes (OR: 0.35, 95%CI 0.16, 0.78); elevated CRP was associated with in increased odds of being in the High-Phys/High-Psych compared to the High-Phys/Mod-Psych class (OR: 2.22, 95%CI 1.08, 4.58). Younger age, having at least a college education, oxygen use and depression history were more prominent predictors of membership in the higher symptom classes. CONCLUSIONS Patients with COPD can be classified into four distinct symptom classes based on five commonly co-occurring physical and psychological symptoms. Systemic biomarkers of inflammation were not associated with symptom class. Additional work to test the reliability of these symptom classes, their biological drivers and their validity for prognostication and tailoring therapy in larger and more diverse samples is needed. TRIAL REGISTRATION Clinicaltrials.gov, NCT01074515 .
Collapse
Affiliation(s)
- Huong Q Nguyen
- Kaiser Permanente Southern California, 100 S. Los Robles, Pasadena, CA, 91101, USA.
| | | | | | | | | | | | | | - Sandra G Adams
- University of Texas Health Science Center at San Antonio and The South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Vincent S Fan
- University of Washington & Puget Sound Veterans Administration, Seattle, USA
| |
Collapse
|
31
|
Trivedi R, Slightam C, Fan VS, Rosland AM, Nelson K, Timko C, Asch SM, Zeliadt SB, Heidenreich P, Hebert PL, Piette JD. A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study. Front Public Health 2016; 4:171. [PMID: 27626029 PMCID: PMC5004799 DOI: 10.3389/fpubh.2016.00171] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 08/03/2016] [Indexed: 11/15/2022] Open
Abstract
Background Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers. Objective To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others. Methods We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants’ feedback was used to develop a family-centered self-management program called “SUCCEED: Self-management Using Couples’ Coping EnhancEment in Diseases.” The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants’ program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life. Results Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED’s sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time. Conclusion In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.
Collapse
Affiliation(s)
- Ranak Trivedi
- Stanford University, Stanford, CA, USA; VA Palo Alto Health Care System, Menlo Park, CA, USA
| | | | - Vincent S Fan
- VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Ann-Marie Rosland
- University of Michigan, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Karin Nelson
- VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | | | - Steven M Asch
- Stanford University, Stanford, CA, USA; VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Steven B Zeliadt
- VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - Paul Heidenreich
- Stanford University, Stanford, CA, USA; VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Paul L Hebert
- VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA
| | - John D Piette
- University of Michigan, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| |
Collapse
|
32
|
Fan VS, Gylys-Colwell I, Locke E, Sumino K, Nguyen HQ, Thomas RM, Magzamen S. Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability. Respir Med 2016; 116:100-6. [PMID: 27296828 DOI: 10.1016/j.rmed.2016.05.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/08/2016] [Accepted: 05/11/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Overuse of short-acting beta-agonists (SABA) is described in asthma, but little is known about overuse of SABA in chronic obstructive pulmonary disease (COPD). METHODS Prospective 3-month cohort study of patients with moderate-to-severe COPD who were provided a portable electronic inhaler sensor to monitor daily SABA use. Subjects wore a pedometer for 3 seven-day periods and were asked to complete a daily diary of symptoms and inhaler use. Overuse was defined as >8 actuations of their SABA per day while clinically stable. RESULTS Among 32 participants, 15 overused their SABA inhaler at least once (mean 8.6 ± 5.0 puffs/day), and 6 overused their inhaler more than 50% of monitored days. Compared to those with no overuse, overusers had greater dyspnea (modified Medical Research Council Dyspnea Scale: 2.7 vs. 1.9, p = 0.02), were more likely to use home oxygen (67% vs. 29%, p = 0.04), and were more likely to be on maximal inhaled therapy (long-acting beta-agonist, long-acting antimuscarinic agent, and an inhaled steroid: 40% vs. 6%, p = 0.03), and most had completed pulmonary rehabilitation (67% vs. 0%, p < 0.001). However, 27% of overusers of SABA were not on guideline-concordant COPD therapy. CONCLUSIONS Overuse of SABA was common and associated with increased disease severity and symptoms, even though overusers were on more COPD-related inhalers and more had completed pulmonary rehabilitation. More research is needed to understand factors associated with inhaler overuse and how to improve correct inhaler use.
Collapse
Affiliation(s)
- Vincent S Fan
- VA Puget Sound Health Care System, Seattle, WA, USA; University of Washington, Seattle, WA, USA.
| | | | - Emily Locke
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Kaharu Sumino
- Saint Louis VA Medical Center, St. Louis, MO, USA; Washington University School of Medicine, St. Louis, MO, USA
| | - Huong Q Nguyen
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | | | - Sheryl Magzamen
- Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA
| |
Collapse
|
33
|
Schure MB, Borson S, Nguyen HQ, Trittschuh EH, Thielke SM, Pike KC, Adams SG, Fan VS. Associations of cognition with physical functioning and health-related quality of life among COPD patients. Respir Med 2016; 114:46-52. [DOI: 10.1016/j.rmed.2016.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/08/2016] [Accepted: 03/09/2016] [Indexed: 02/02/2023]
|
34
|
Fan VS, Gharib SA, Martin TR, Wurfel MM. COPD disease severity and innate immune response to pathogen-associated molecular patterns. Int J Chron Obstruct Pulmon Dis 2016; 11:467-77. [PMID: 27019597 PMCID: PMC4786062 DOI: 10.2147/copd.s94410] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The airways of COPD patients are often colonized with bacteria leading to increased airway inflammation. This study sought to determine whether systemic cytokine responses to microbial pathogen-associated molecular patterns (PAMPs) are increased among subjects with severe COPD. In an observational cross-sectional study of COPD subjects, PAMP-induced cytokine responses were measured in whole blood ex vivo. We used PAMPs derived from microbial products recognized by toll-like receptors 1, 2, 4, 5, 6, 7, and 8. Patterns of cytokine response to PAMPs were assessed using hierarchical clustering. One-sided Student’s t-tests were used to compare PAMP-induced cytokine levels in blood from patients with and without severe COPD, and for subjects with and without chronic bronchitis. Of 28 male patients, 12 had moderate COPD (FEV1 50%–80%) and 16 severe COPD (FEV1 <50%); 27 participants provided data on self-reported chronic bronchitis, of which 15 endorsed chronic bronchitis symptoms and 12 did not. Cytokine responses to PAMPs in severe COPD were generally lower than in subjects with milder COPD. This finding was particularly strong for PAMP-induced interleukin (IL)-10, granulocyte colony stimulating factor, and IL-1β. Subjects with chronic bronchitis showed higher PAMP-induced IL-1RA responses to most of the PAMPs evaluated. COPD patients with more severe disease demonstrated a diminished cytokine response to PAMPs, suggesting that chronic colonization with bacteria may dampen the systemic innate immune response.
Collapse
Affiliation(s)
- Vincent S Fan
- VA Puget Sound Health Care System, Seattle, WA, USA; Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Seattle WA, USA
| | - Sina A Gharib
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Seattle WA, USA; Computational Medicine Core, Center for Lung Biology, University of Washington, Seattle, WA, USA
| | - Thomas R Martin
- VA Puget Sound Health Care System, Seattle, WA, USA; Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Seattle WA, USA
| | - Mark M Wurfel
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Washington, Seattle WA, USA
| |
Collapse
|
35
|
Nguyen HQ, Bailey A, Coleman KJ, Desai S, Fan VS, Gould MK, Maddock L, Miller K, Towner W, Xiang AH, Moy ML. Patient-centered physical activity coaching in COPD (Walk On!): A study protocol for a pragmatic randomized controlled trial. Contemp Clin Trials 2015; 46:18-29. [PMID: 26597414 DOI: 10.1016/j.cct.2015.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 10/19/2015] [Accepted: 10/23/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Physical inactivity is significantly associated with more frequent hospitalizations and increased mortality in COPD even after adjusting for disease severity. While practice guidelines recommend regular physical activity for all patients with COPD, health systems are challenged in operationalizing an effective and sustainable approach to assist patients in being physically active. METHODS A pragmatic randomized controlled trial design was used to determine the effectiveness of a 12-month home and community-based physical activity coaching intervention (Walk On!) compared to standard care for 1650 patients at high risk for COPD exacerbations from a large integrated health care system. Eligible patients with a COPD-related hospitalization, emergency department visit, or observational stay in the previous 12months were automatically identified from the electronic medical records (EMR) system and randomized to treatment arms. The Walk On! intervention included collaborative monitoring of step counts, semi-automated step goal recommendations, individualized reinforcement from a physical activity coach, and peer/family support. RESULTS The primary composite outcome included all-cause hospitalizations, emergency department visits, observational stays, and death in the 12months following randomization. Secondary outcomes included COPD-related utilization, cardio-metabolic markers, physical activity, symptoms, and health-related quality of life. With the exception of patient reported outcomes, all utilization and clinical variables were automatically captured from the EMR. CONCLUSIONS If successful, findings from this multi-stakeholder driven trial of a generalizable and scalable physical activity intervention, carefully designed with sufficient flexibility, intensity, and support for a large ethnically diverse sample could re-define the standard of care to effectively address physical inactivity in COPD.
Collapse
Affiliation(s)
- Huong Q Nguyen
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States.
| | | | - Karen J Coleman
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States
| | - Smita Desai
- Kaiser Permanente Southern California, San Diego, United States
| | | | - Michael K Gould
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States
| | - Leah Maddock
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States
| | - Kimberly Miller
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States
| | - William Towner
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States
| | - Anny H Xiang
- Department of Research & Evaluation, Kaiser Permanente Southern California, United States
| | - Marilyn L Moy
- Harvard Medical School, VA Boston Healthcare System, Pulmonary and Critical Care Section, United States
| |
Collapse
|
36
|
Corson AH, Fan VS, White T, Sullivan SD, Asakura K, Myint M, Dale CR. A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs. J Hosp Med 2015; 10:390-5. [PMID: 25809958 DOI: 10.1002/jhm.2354] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 02/25/2015] [Accepted: 03/03/2015] [Indexed: 11/07/2022]
Abstract
PURPOSE Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs. METHODS The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and laboratory cost per patient. RESULTS The baseline (n = 7824) and intervention (n = 5759) cohorts were similar in their demographics, though the distribution of primary discharge diagnosis-related groups differed. At baseline, a mean of 2.06 (standard deviation 1.40) common labs were ordered per patient-day. Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared to baseline (95% confidence interval [CI], 0.34 to 0.11; P < 0.01). There were nonsignificant reductions in hospital mortality in the intervention period compared to baseline (2.2% vs 1.8%, P = 0.1) as well as volume of blood transfused in patients who received a transfusion (127.2 mL decrease; 95% CI, -257.9 to 3.6; P = 0.06). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618). CONCLUSION Implementation of a multifaceted QI intervention within a community-based hospitalist group was associated with a significant, but modest, decrease in the number of ordered lab tests and hospital costs. No effect was seen on hospital length of stay, mortality, or readmission rate. This intervention suggests that a community-based hospitalist QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care.
Collapse
Affiliation(s)
- Adam H Corson
- Department of Hospital Medicine, Swedish Medical Center, Seattle, Washington
| | - Vincent S Fan
- Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Travis White
- Department of Hospital Medicine, Swedish Medical Center, Seattle, Washington
| | - Sean D Sullivan
- Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, University of Washington, Seattle, Washington
| | - Kenji Asakura
- Department of Hospital Medicine, Swedish Medical Center, Seattle, Washington
| | - Michael Myint
- Department of Quality & Value, Swedish Medical Group, Seattle, Washington
| | - Christopher R Dale
- Department of Quality & Value, Swedish Medical Group, Seattle, Washington
| |
Collapse
|
37
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Eugenio EC, Beaver KA, Fan VS. Response to Thomas E. Finucane, MD. J Am Geriatr Soc 2015; 63:203-4. [PMID: 25597586 DOI: 10.1111/jgs.13209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Denise C Cooper
- Veteran Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | | | | | | | | | | | | |
Collapse
|
38
|
Fleehart S, Fan VS, Nguyen HQ, Lee J, Kohen R, Herting JR, Matute-Bello G, Adams SG, Pagalilauan G, Borson S. Prevalence and correlates of suicide ideation in patients with COPD: a mixed methods study. Int J Chron Obstruct Pulmon Dis 2014; 10:1321-9. [PMID: 25587219 PMCID: PMC4262376 DOI: 10.2147/copd.s65507] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The purpose of this study was to examine the prevalence and correlates of suicidal ideation (SI) in patients with stable moderate to very severe chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS We conducted an exploratory mixed methods analysis of data from participants in a longitudinal observational study of depression in COPD. We measured depression with the Patient Health Questionnaire-9 (PHQ-9), which includes an item on SI. We compared participants with and without SI in relation to sociodemographics, symptoms, anxiety, and healthcare resource use with independent t-tests and chi-square tests. Content analysis was performed on qualitative data gathered during a structured SI safety assessment. RESULTS Of 202 participants, 121 (60%) had depressive symptoms (PHQ ≥6); 51 (25%) had a PHQ-9 ≥10, indicating a high likelihood of current major depression; and 22 (11%) reported SI. Compared to the 99 depressed participants without SI, those with SI were more likely to be female (59% vs 27%, P=0.004); had worse dyspnea (P=0.009), depression (P<0.001), and anxiety (P=0.003); and were also more likely to have received treatment for depression and/or anxiety (82% vs 40%, P<0.001) and more hospitalizations for COPD exacerbations (P=0.03) but had similar levels of airflow obstruction and functioning than participants without SI. Themes from the qualitative analysis among those with SI included current or prior adverse life situations, untreated or partially treated complex depression, loss of a key relationship, experience of illness and disability, and poor communication with providers. CONCLUSION Our findings suggest that current SI is common in COPD, may occur disproportionately in women, can persist despite mental health treatment, and has complex relationships with both health and life events. Adequate management of SI in COPD may therefore require tailored, comprehensive treatment approaches that integrate medical and mental health objectives.
Collapse
Affiliation(s)
- Sara Fleehart
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Vincent S Fan
- VAPuget Sound Health Care Center, Seattle, WA, USA ; School of Medicine, University of Washington, Seattle, WA, USA
| | - Huong Q Nguyen
- Reseach and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Jungeun Lee
- School of Nursing, University of Washington, Seattle, WA, USA
| | - Ruth Kohen
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Jerald R Herting
- Department of Sociology, University of Washington, Seattle, WA, USA
| | - Gustavo Matute-Bello
- VAPuget Sound Health Care Center, Seattle, WA, USA ; School of Medicine, University of Washington, Seattle, WA, USA
| | - Sandra G Adams
- School of Medicine, University of Texas Health Science Center ; South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | - Soo Borson
- School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
39
|
Fan VS, Locke ER, Diehr P, Wilsdon A, Enright P, Yende S, Avdalovic M, Barr G, Kapur VK, Thomas R, Krishnan JA, Lovasi G, Thielke S. Disability and recovery of independent function in obstructive lung disease: the cardiovascular health study. Respiration 2014; 88:329-38. [PMID: 25228204 DOI: 10.1159/000363772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 05/19/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Chronic obstructive lung disease frequently leads to disability. Older patients may experience transitions between states of disability and independence over time. OBJECTIVE To identify factors associated with transition between states of disability and independent function in obstructive lung disease. METHODS We analyzed data on 4,394 participants in the Cardiovascular Health Study who completed prebronchodilator spirometry. We calculated the 1-year probability of developing and resolving impairment in ≥1 instrumental activity of daily living (IADL) or ≥1 activity of daily living (ADL) using transition probability analysis. We identified factors associated with resolving disability using relative risk (RR) regression. RESULTS The prevalence of IADL impairment was higher with moderate (23.9%) and severe (36.9%) airflow obstruction compared to normal spirometry (22.5%; p < 0.001). Among participants with severe airflow obstruction, 23.5% recovered independence in IADLs and 40.5% recovered independence in ADLs. In the adjusted analyses, airflow obstruction predicted the development of IADL, but not ADL impairment. Participants with severe airflow obstruction were less likely to resolve IADL impairment [RR 0.67 and 95% confidence interval (CI) 0.49-0.94]. Compared to the most active individuals (i.e. who walked ≥28 blocks per week), walking less was associated with a decreased likelihood of resolving IADL impairment (7-27 blocks: RR 0.81 and 95% CI 0.69-0.86 and <7 blocks: RR 0.73 and 95% CI 0.61-0.86). Increased strength (RR 1.16 and 95% CI 1.05-1.29) was associated with resolving IADL impairment. CONCLUSIONS Disability is common in older people, especially in those with severe airflow obstruction. Increased physical activity and muscle strength are associated with recovery. Research is needed on interventions to improve these factors among patients with obstructive lung disease and disability.
Collapse
Affiliation(s)
- Vincent S Fan
- Health Services Research and Development, Department of Veterans Affairs, Seattle, Wash., USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Beaver KA, Eugenio EC, Fan VS. Post-traumatic Stress Disorder, Race/Ethnicity, and Coronary Artery Disease Among Older Patients with Depression. J Racial Ethn Health Disparities 2014. [DOI: 10.1007/s40615-014-0020-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
41
|
Cooper DC, Trivedi RB, Nelson KM, Reiber GE, Eugenio EC, Beaver KA, Fan VS. Antidepressant adherence and risk of coronary artery disease hospitalizations in older and younger adults with depression. J Am Geriatr Soc 2014; 62:1238-45. [PMID: 24890000 DOI: 10.1111/jgs.12849] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To assess whether the relationship between antidepressant adherence and coronary artery disease (CAD) hospitalizations varied between older and younger adults with depression. DESIGN Retrospective cohort study. SETTING Department of Veterans Affairs outpatient clinics nationwide. PARTICIPANTS Chronically depressed individuals (n = 50,261; aged 20-97) who had been prescribed an antidepressant were identified from records indicating an outpatient clinic visit for depression (index depression visit) during fiscal years 2009 and 2010. Individuals were considered chronically depressed if they had had prior depression visits and treatment for depression within the previous 4 months. The sample was age-stratified into younger (<65) and older (≥ 65) groups. MEASUREMENTS After the index depression visit, medication possession ratios were calculated from pharmacy refill data to determine whether participants had 80% or greater adherence to antidepressant refills during a 6-month treatment observation period. International Classification of Diseases, Ninth Revision, codes were used to derive CAD-related hospitalizations during the follow-up period. Mean follow-up was 24 months. Data were analyzed using Cox proportional hazard models. RESULTS Older participants with 80% or greater antidepressant adherence had 26% lower risk of CAD hospitalizations (hazard ratio = 0.74, 95% confidence interval = 0.60-0.93). Antidepressant adherence was not significantly related to CAD hospitalizations in younger adults. CONCLUSION Older adults with chronic depression with 80% or greater antidepressant adherence had significantly lower risk of CAD hospitalizations at follow-up than those with less than 80% adherence. These preliminary results suggest that older adults with depression may derive cardiovascular benefits from clinical efforts to increase antidepressant adherence.
Collapse
Affiliation(s)
- Denise C Cooper
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veteran Affairs Puget Sound Health Care System, Seattle, Washington; Department of Health Services, University of Washington, Seattle, Washington
| | | | | | | | | | | | | |
Collapse
|
42
|
|
43
|
Wiener RS, Ouellette DR, Diamond E, Fan VS, Maurer JR, Mularski RA, Peters JI, Halpern SD. An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine. Chest 2014; 145:1383-1391. [PMID: 24889436 PMCID: PMC4694177 DOI: 10.1378/chest.14-0670] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 03/19/2014] [Indexed: 12/11/2022] Open
Abstract
The American Board of Internal Medicine Foundation's Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated--and when they are not.
Collapse
Affiliation(s)
- Renda Soylemez Wiener
- Pulmonary Center, Boston University School of Medicine, Boston, MA; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, NH.
| | - Daniel R Ouellette
- Pulmonary and Critical Care Medicine, Henry Ford Health System, Detroit, MI
| | | | - Vincent S Fan
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA; Department of Medicine, University of Washington, Seattle, WA
| | - Janet R Maurer
- Department of Medicine, College of Medicine, The University of Arizona, Phoenix, AZ; Quality Improvement and Compliance, National Imaging Associates/Magellan Health Services, Inc, Phoenix, AZ
| | - Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR; Department of Pulmonary/Critical Care Medicine, Northwest Permanente PC, Portland, OR; Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Jay I Peters
- UT Health Science Center, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX
| | - Scott D Halpern
- Departments of Medicine, Biostatistics and Epidemiology, and Medical Ethics and Health Policy, and the Leonard Davis Institute Center for Health Incentives and Behavioral Economics, The University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
44
|
Kapur VK, Wilsdon AG, Au D, Avdalovic M, Enright P, Fan VS, Hansel NN, Heckbert SR, Jiang R, Krishnan JA, Mukamal K, Yende S, Barr RG. Obesity is associated with a lower resting oxygen saturation in the ambulatory elderly: results from the cardiovascular health study. Respir Care 2014; 58:831-7. [PMID: 23107018 DOI: 10.4187/respcare.02008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The contribution of obesity to hypoxemia has not been reported in a community-based study. Our hypothesis was that increasing obesity would be independently associated with lower SpO2 in an ambulatory elderly population. METHODS The Cardiovascular Health Study ascertained resting SpO2 in 2,252 subjects over age 64. We used multiple linear regression to estimate the association of body mass index (BMI) with SpO2 and to adjust for potentially confounding factors. Covariates including age, sex, race, smoking, airway obstruction (based on spirometry), self reported diagnosis of emphysema, asthma, heart failure, and left ventricular function (by echocardiography) were evaluated. RESULTS Among 2,252 subjects the mean and median SpO2 were 97.6% and 98.0% respectively; 5% of subjects had SpO2 values below 95%. BMI was negatively correlated with SpO2 (Spearman R = -0.27, P < .001). The mean difference in SpO2 between the lowest and highest BMI categories (< 25 kg/m(2) and ≥ 35 kg/m(2)) was 1.33% (95% CI 0.89-1.78%). In multivariable linear regression analysis, SpO2 was significantly inversely associated with BMI (1.4% per 10 units of BMI, 95% CI 1.2-1.6, for whites/others, and 0.87% per 10 units of BMI, 95% CI 0.47-1.27, for African Americans). CONCLUSIONS We found a narrow distribution of SpO2 values in a community-based sample of ambulatory elderly. Obesity was a strong independent contributor to a low SpO2, with effects comparable to or greater than other factors clinically associated with lower SpO2.
Collapse
Affiliation(s)
- Vishesh K Kapur
- Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington 98104, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Quiñones AR, Thielke SM, Beaver KA, Trivedi RB, Williams EC, Fan VS. Racial and ethnic differences in receipt of antidepressants and psychotherapy by veterans with chronic depression. Psychiatr Serv 2014; 65:193-200. [PMID: 24178411 PMCID: PMC7108428 DOI: 10.1176/appi.ps.201300057] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study characterized racial-ethnic differences in treatment of veterans with chronic depression by examining antidepressant and psychotherapy use among non-Hispanic black, non-Hispanic white, Hispanic, Asian, and American Indian-Alaska Native (AI/AN) veterans. METHODS Logistic regression models were estimated with data from the U.S. Department of Veterans Affairs (VA) medical records for a sample of 62,095 chronically depressed patients. Data (2009-2010) were from the VA External Peer Review Program. Three primary outcome measures were used: receipt of adequate antidepressant therapy (≥80% medications on hand), receipt of adequate psychotherapy (at least six sessions in six months), and receipt of guideline-concordant treatment (either of these treatments). RESULTS Compared with whites, nearly all minority groups had lower odds of adequate antidepressant use and guideline-concordant care in unadjusted and adjusted models (antidepressant adjusted odds ratio [AOR] range=.53-.82, p<.05; guideline-concordant AOR range=.59-.83, p<.05). Although receipt of adequate psychotherapy was more common among veterans from minority groups in unadjusted analyses, differences between Hispanic, AI/AN, and white veterans were no longer significant after covariate adjustment. After adjustment for distance to the VA facility, the difference between black and white veterans was no longer significant. CONCLUSIONS A better understanding of how patient preferences and provider and system factors interact to generate differences in depression care is needed to improve care for patients from racial-ethnic minority groups. It will become increasingly important to differentiate between health service use patterns that stem from genuine differences in patient preferences and those that signify inequitable quality of depression care.
Collapse
|
46
|
Shah FA, Pike F, Alvarez K, Angus D, Newman AB, Lopez O, Tate J, Kapur V, Wilsdon A, Krishnan JA, Hansel N, Au D, Avdalovic M, Fan VS, Barr RG, Yende S. Bidirectional relationship between cognitive function and pneumonia. Am J Respir Crit Care Med 2013; 188:586-92. [PMID: 23848267 PMCID: PMC3827700 DOI: 10.1164/rccm.201212-2154oc] [Citation(s) in RCA: 131] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Relationships between chronic health conditions and acute infections remain poorly understood. Preclinical studies suggest crosstalk between nervous and immune systems. OBJECTIVES To determine bidirectional relationships between cognition and pneumonia. METHODS We conducted longitudinal analyses of a population-based cohort over 10 years. We determined whether changes in cognition increase risk of pneumonia hospitalization by trajectory analyses and joint modeling. We then determined whether pneumonia hospitalization increased risk of subsequent dementia using a Cox model with pneumonia as a time-varying covariate. MEASUREMENTS AND MAIN RESULTS Of the 5,888 participants, 639 (10.9%) were hospitalized with pneumonia at least once. Most participants had normal cognition before pneumonia. Three cognition trajectories were identified: no, minimal, and severe rapid decline. A greater proportion of participants hospitalized with pneumonia were on trajectories of minimal or severe decline before occurrence of pneumonia compared with those never hospitalized with pneumonia (proportion with no, minimal, and severe decline were 67.1%, 22.8%, and 10.0% vs. 76.0%, 19.3%, and 4.6% for participants with and without pneumonia, respectively; P < 0.001). Small subclinical changes in cognition increased risk of pneumonia, even in those with normal cognition and physical function before pneumonia (β = -0.02; P < 0.001). Participants with pneumonia were subsequently at an increased risk of dementia (hazard ratio, 2.24 [95% confidence interval, 1.62-3.11]; P = 0.01). Associations were independent of demographics, health behaviors, other chronic conditions, and physical function. Bidirectional relationship did not vary based on severity of disease, and similar associations were noted for those with severe sepsis and other infections. CONCLUSIONS A bidirectional relationship exists between pneumonia and cognition and may explain how a single episode of infection in well-appearing older individuals accelerates decline in chronic health conditions and loss of functional independence.
Collapse
Affiliation(s)
- Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, PA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Nguyen HQ, Fan VS, Herting J, Lee J, Fu M, Chen Z, Borson S, Kohen R, Matute-Bello G, Pagalilauan G, Adams SG. Patients with COPD with higher levels of anxiety are more physically active. Chest 2013; 144:145-151. [PMID: 23370503 DOI: 10.1378/chest.12-1873] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Physical activity (PA) has been found to be an excellent predictor of mortality beyond traditional measures in COPD. We aimed to determine the association between depression and anxiety with accelerometry-based PA in patients with COPD. METHODS We performed a cross-sectional analysis of baseline data from 148 stable patients with COPD enrolled in an ongoing, longitudinal, observational study. We measured PA (total daily step count) with a Stepwatch Activity Monitor over 7 days, depression and anxiety with the Hospital Anxiety and Depression Scales (HADSs), dyspnea with the Shortness of Breath Questionnaire, and functional capacity with the 6-min walk test. RESULTS Increased anxiety was associated with higher levels of PA such that for every one-point increase in the HADS-Anxiety score there was a corresponding increase of 288 step counts per day (β=288 steps, P<.001), after adjusting for all other variables. Higher levels of depressive symptoms were associated with lower PA (β=-176 steps, P=.02) only when anxiety was in the model. The interaction term for anxiety and depression approached significance (β=26, P=.10), suggesting that higher levels of anxiety mitigate the negative effects of depression on PA. CONCLUSIONS The increased PA associated with anxiety in COPD is, to our knowledge, a novel finding. However, it is unclear whether anxious patients with COPD are more restless, and use increased psychomotor activity as a coping mechanism, or whether those with COPD who push themselves to be more physically active experience more anxiety symptoms. Future studies should evaluate for anxiety and PA to better inform how to improve clinical outcomes. TRIAL REGISTRY Clinicaltrials.gov; No.: NCT01074515; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA.
| | - Vincent S Fan
- University of Washington & Puget Sound Veterans Administration, Seattle, WA
| | | | | | | | | | | | | | | | | | - Sandra G Adams
- University of Texas Health Science Center at San Antonio and The South Texas Veterans Health Care System, San Antonio, TX
| |
Collapse
|
48
|
Locke E, Thielke S, Diehr P, Wilsdon AG, Barr RG, Hansel N, Kapur VK, Krishnan J, Enright P, Heckbert SR, Kronmal RA, Fan VS. Effects of respiratory and non-respiratory factors on disability among older adults with airway obstruction: the Cardiovascular Health Study. COPD 2013; 10:588-96. [PMID: 23819728 DOI: 10.3109/15412555.2013.781148] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND High rates of disability associated with chronic airway obstruction may be caused by impaired pulmonary function, pulmonary symptoms, other chronic diseases, or systemic inflammation. METHODS We analyzed data from the Cardiovascular Health Study, a longitudinal cohort of 5888 older adults. Categories of lung function (normal; restricted; borderline, mild-moderate, and severe obstruction) were delineated by baseline spirometry (without bronchodilator). Disability-free years were calculated as total years alive and without self-report of difficulty performing &γτ;1 Instrumental Activities of Daily Living over 6 years of follow-up. Using linear regression, we compared disability-free years by lung disease category, adjusting for demographic factors, body mass index, smoking, cognition, and other chronic co-morbidities. Among participants with airflow obstruction, we examined the association of respiratory factors (FEV1 and dyspnea) and non-respiratory factors (ischemic heart disease, congestive heart failure, diabetes, muscle weakness, osteoporosis, depression and cognitive impairment) on disability-free years. RESULTS The average disability free years were 4.0 out of a possible 6 years. Severe obstruction was associated with 1 fewer disability-free year compared to normal spirometry in the adjusted model. For the 1,048 participants with airway obstruction, both respiratory factors (FEV1 and dyspnea) and non-respiratory factors (heart disease, coronary artery disease, diabetes, depression, osteoporosis, cognitive function, and weakness) were associated with decreased disability-free years. CONCLUSIONS Severe obstruction is associated with greater disability compared to patients with normal spirometery. Both respiratory and non-respiratory factors contribute to disability in older adults with abnormal spirometry.
Collapse
Affiliation(s)
- Emily Locke
- 1Health Services Research and Development, Department of Veterans Affairs, Seattle, WA, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Dale CR, Madtes DK, Fan VS, Gorden JA, Veenstra DL. Navigational bronchoscopy with biopsy versus computed tomography-guided biopsy for the diagnosis of a solitary pulmonary nodule: a cost-consequences analysis. J Bronchology Interv Pulmonol 2012; 19:294-303. [PMID: 23207529 PMCID: PMC3611239 DOI: 10.1097/lbr.0b013e318272157d] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Solitary pulmonary nodules (SPNs) are frequent and can be malignant. Both computed tomography-guided biopsy and electromagnetic navigational bronchoscopy (ENB) with biopsy can be used to diagnose a SPN. A nondiagnostic computed tomography (CT)-guided or ENB biopsy is often followed by video-assisted thoracoscopic surgery (VATS) biopsy. The relative costs and consequences of these strategies are not known. METHODS A decision tree was created with values from the literature to evaluate the clinical consequences and societal costs of a CT-guided biopsy strategy versus an ENB biopsy strategy for the diagnosis of a SPN. The serial use of ENB after nondiagnostic CT-guided biopsy and CT-guided biopsy after nondiagnostic ENB biopsy were tested as alternate strategies. RESULTS In a hypothetical cohort of 100 patients, use of the ENB biopsy strategy on average results in 13.4 fewer pneumothoraces, 5.9 fewer chest tubes, 0.9 fewer significant hemorrhage episodes, and 0.6 fewer respiratory failure episodes compared with a CT-guided biopsy strategy. ENB biopsy increases average costs by $3719 per case and increases VATS rates by an absolute 20%. The sequential diagnostic strategy that combines CT-guided biopsy after nondiagnostic ENB biopsy and vice versa decreases the rate of VATS procedures to 3%. A sequential approach starting with ENB decreases average per case cost relative to CT-guided biopsy followed by VATS, if needed, by $507; and a sequential approach starting with CT-guided biopsy decreases the cost relative to CT-guided biopsy followed by VATS, if needed, by $979. CONCLUSIONS An ENB with biopsy strategy is associated with decreased pneumothorax rate but increased costs and increased use of VATS. Combining CT-guided biopsy and ENB with biopsy serially can decrease costs and complications.
Collapse
Affiliation(s)
| | - David K. Madtes
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, WA,
| | | | | | | |
Collapse
|
50
|
Dale CR, Hayden SJ, Treggiari MM, Curtis JR, Seymour CW, Yanez ND, Fan VS. Association between hospital volume and network membership and an analgesia, sedation and delirium order set quality score: a cohort study. Crit Care 2012; 16:R106. [PMID: 22709540 PMCID: PMC3580663 DOI: 10.1186/cc11390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 06/18/2012] [Indexed: 12/24/2022]
Abstract
Introduction Protocols for the delivery of analgesia, sedation and delirium care of the critically ill, mechanically ventilated patient have been shown to improve outcomes but are not uniformly used. The extent to which elements of analgesia, sedation and delirium guidelines are incorporated into order sets at hospitals across a geographic area is not known. We hypothesized that both greater hospital volume and membership in a hospital network are associated with greater adherence of order sets to sedation guidelines. Methods Sedation order sets from all nonfederal hospitals without pediatric designation in Washington State that provided ongoing care to mechanically ventilated patients were collected and their content systematically abstracted. Hospital data were collected from Washington State sources and interviews with ICU leadership in each hospital. An expert-validated score of order set quality was created based on the 2002 four-society guidelines. Clustered multivariable linear regression was used to assess the relationship between hospital characteristics and the order set quality score. Results Fifty-one Washington State hospitals met the inclusion criteria and all provided order sets. Based on expert consensus, 21 elements were included in the analgesia, sedation and delirium order set quality score. Each element was equally weighted and contributed one point to the score. Hospital order set quality scores ranged from 0 to 19 (median = 8, interquartile range 6 to 14). In multivariable analysis, a greater number of acute care days (P = 0.01) and membership in a larger hospital network (P = 0.01) were independently associated with a greater quality score. Conclusions Hospital volume and membership in a larger hospital network were independently associated with a higher quality score for ICU analgesia, sedation and delirium order sets. Further research is needed to determine whether greater order-set quality is associated with improved outcomes in the critically ill. The development of critical care networks might be one strategy to improve order set quality scores.
Collapse
|