Comorbid posttraumatic stress disorder and major depressive disorder are associated with asthma morbidity among World Trade Center workers.

BACKGROUND: World Trade Center (WTC) rescue and recovery workers have a high burden of asthma, comorbid posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). PTSD is associated with worse asthma outcomes. OBJECTIVE: In this study, we evaluated whether the relationship between PTSD and asthma morbidity is modified by the presence of MDD. METHODS: We used data from a cohort of WTC workers with asthma. Asthma control (asthma control questionnaire), resource utilization, and quality of life (asthma quality of life questionnaire) were evaluated. We used regression analyses to evaluate the adjusted association of PTSD and MDD with asthma control, resource utilization, and quality of life. RESULTS: Of the study cohort of 293 WTC workers with asthma, 19% had PTSD alone, 2% had MDD alone, and 12% had PTSD and MDD. Adjusted mean differences (95% confidence interval) in asthma control questionnaire scores were 1.32 (0.85-1.80) for WTC workers with PTSD and MDD, 0.44 (0.03-0.84) for those with PTSD alone, and 0.50 (-0.38 to 1.38) for workers with MDD alone compared with those without MDD or PTSD. WTC workers with PTSD and MDD, PTSD alone, and MDD alone had mean (95% confidence interval) adjusted differences in asthma quality of life questionnaire scores of -1.67 (-2.22 to -1.12), -0.56 (-2.23 to -1.12), and -1.21 (-2.23 to -0.18), respectively, compared with workers without MDD or PTSD. Similar patterns were observed for acute resource utilization. CONCLUSION: PTSD and MDD seem to have a synergistic effect that worsens asthma control and quality of life. Efforts to improve asthma outcomes in this population should address the negative impacts of these common mental health conditions.

Facilitators and Barriers of a Health Department-based Mailed Fecal Testing Program.

BACKGROUND Mailed at-home stool testing offers a promising strategy for overcoming barriers to colorectal cancer (CRC) screening in vulnerable populations. This paper evaluates the facilitators and barriers of successful implementation of a mailed fecal testing program among Medicaid populations within a health department setting.METHOD Interviews were conducted with key informants involved in intervention start-up and implementation tasks. The Consolidated Framework for Implementation Research (CFIR) was used to design the interview guide and structure the analysis. Axial coding was used to connect the themes to each other under the major categories of facilitators and barriers.RESULTS Overall, the process evaluation suggests that with strong partnerships, effective champions, and existing infrastructure, a large county health department can successfully implement a mailed fecal testing program targeted at Medicaid beneficiaries. The identified facilitators and challenges to implementation provide important information for similar emerging programs.LIMITATIONS The sample size of this evaluation is small. Additionally, we are unable to discern whether participating stakeholders' responses represent the feelings of non-interviewed staff, program implementers, or participants. We were not able to collect data on patient perspectives of the intervention. The nursing staff and interns were not able to be included in the process evaluation. Lastly, the information taken from this process evaluation may not be applicable to organizations and systems with different attributes.CONCLUSION The process evaluation suggests strong partnerships, effective champions, and elegant program designs were key contributors to successful implementation of a CRC screening program targeted at Medicaid beneficiaries in a large county health department.

Evaluating Shared Decision Making for Lung Cancer Screening.

Importance: The US Preventive Services Task Force recommends that shared decision making (SDM) involving a thorough discussion of benefits and harms should occur between clinicians and patients before initiating lung cancer screening (LCS) with low-dose computed tomography. The Centers for Medicare & Medicaid Services require an SDM visit using a decision aid as a prerequisite for LCS coverage. However, little is known about how SDM about LCS occurs in practice. Objective: To assess the quality of SDM about the initiation of LCS in clinical practice. Design, Setting, and Participants: A qualitative content analysis was performed of transcribed conversations between primary care or pulmonary care physicians and 14 patients presumed to be eligible for LCS, recorded between April 1, 2014, and March 1, 2018, that were identified within a large database. Main Outcomes and Measures: Independent observer ratings of communication behaviors of physicians using the OPTION (Observing Patient Involvement in Decision Making) scale, a validated 12-item measure of SDM (total score, 0-100 points, where 0 indicates no evidence of SDM and 100 indicates evidence of SDM at the highest skill level); time spent discussing LCS during visits; and evidence of decision aid use. Results: A total of 14 conversations about initiating LCS were identified; 9 patients were women, and 5 patients were men; the mean (SD) patient age was 63.9 (5.1) years; 7 patients had Medicare, and 8 patients were current smokers. Half the conversations were conducted by primary care physicians. The mean total OPTION score for the 14 LCS conversations was 6 on a scale of 0 to 100 (range, 0-17). None of the conversations met the minimum skill criteria for 8 of the 12 SDM behaviors. Physicians universally recommended LCS. Discussion of harms (such as false positives and their sequelae or overdiagnosis) was virtually absent. The mean total visit length of a discussion was 13:07 minutes (range, 3:48-27:09 minutes). The mean time spent discussing LCS was 0:59 minute (range, 0:16-2:19 minutes), or 8% of the total visit time (range, 1%-18%). There was no evidence that decision aids or other patient education materials for LCS were used. Conclusions and Relevance: In this small sample of recorded encounters about initiating LCS, the observed quality of SDM was poor and explanation of potential harms of screening was virtually nonexistent. Time spent discussing LCS was minimal, and there was no evidence that decision aids were used. Although these findings are preliminary, they raise concerns that SDM for LCS in practice may be far from what is intended by guidelines.