Environmental management of asthma in clinical practice: Results from the 2012 National Ambulatory Medical Care Survey.

Background: The National Asthma Education and Prevention Program guidelines emphasize environmental control as an integral part of asthma management; however, limited national-level data exist on how clinicians implement environmental control recommendations. Objective: We analyzed data on clinicians' self-reported use of recommended environmental control practices in a nationally representative sample (n = 1645) of primary care physicians, asthma specialists, and advanced practice providers from the National Asthma Survey of Physicians, a supplemental questionnaire to the 2012 National Ambulatory Medical Care Survey. Methods: We examined clinician and practice characteristics as well as clinicians' decisions and strategies regarding environmental trigger assessment and environmental control across provider groups. Regression modeling was used to identify clinician and practice characteristics associated with implementation of guideline recommendations. Results: A higher percentage of specialists assessed asthma triggers at home, school, and/or work than primary care or advanced practice providers (almost always: 53.6% vs 29.4% and 23.7%, respectively, P < .001). Almost all clinicians (>93%) recommended avoidance of secondhand tobacco smoke, whereas recommendations regarding cooking appliances (eg, proper ventilation) were infrequent. Although assessment and recommendation practices differed between clinician groups, modeling results showed that clinicians who reported almost always assessing asthma control were 5- to 6-fold more likely to assess environmental asthma triggers. Use of asthma action plans was also strongly associated with implementation of environmental control recommendations. Conclusions: Environmental assessment and recommendations to patients varied among asthma care providers. High adherence to other key guideline components, such as assessing asthma control, was associated with environmental assessment and recommendation practices on environmental control.

Sampling Procedures for the Collection of Electronic Health Record Data From Federally Qualified Health Centers, 2021-2022 National Ambulatory Medical Care Survey.

As part of modernization efforts, in 2021 the National Ambulatory Medical Care Survey (NAMCS) began collecting electronic health records (EHRs) for ambulatory care visits in its Health Center (HC) Component. As a result, the National Center for Health Statistics (NCHS)needed to adjust the approaches used in the sampling design for the HC Component. This report provides details on these changes to the 2021-2022 NAMCS.

National Hospital Care Survey Demonstration Projects: Severe Maternal Morbidity in Inpatient and Emergency Departments.

Objective-This report demonstrates the ability of the National Hospital Care Survey (NHCS) to examine delivery hospitalizations involving severe maternal morbidity (SMM). These data are unweighted and not nationally representative, so the results are intended to illustrate the unique capability of NHCS to track patients across hospitalizations and emergency department (ED) visits rather than provide nationally representative estimates of these outcomes.

CD4+ T cells from children with active juvenile idiopathic arthritis show altered chromatin features associated with transcriptional abnormalities.

Juvenile idiopathic arthritis (JIA) is one of the most common chronic diseases in children. While clinical outcomes for patients with juvenile JIA have improved, the underlying biology of the disease and mechanisms underlying therapeutic response/non-response are poorly understood. We have shown that active JIA is associated with distinct transcriptional abnormalities, and that the attainment of remission is associated with reorganization of transcriptional networks. In this study, we used a multi-omics approach to identify mechanisms driving the transcriptional abnormalities in peripheral blood CD4+ T cells of children with active JIA. We demonstrate that active JIA is associated with alterations in CD4+ T cell chromatin, as assessed by ATACseq studies. However, 3D chromatin architecture, assessed by HiChIP and simultaneous mapping of CTCF anchors of chromatin loops, reveals that normal 3D chromatin architecture is largely preserved. Overlapping CTCF binding, ATACseq, and RNAseq data with known JIA genetic risk loci demonstrated the presence of genetic influences on the observed transcriptional abnormalities and identified candidate target genes. These studies demonstrate the utility of multi-omics approaches for unraveling important questions regarding the pathobiology of autoimmune diseases.

Use of National Asthma Guidelines by Allergists and Pulmonologists: A National Survey.

BACKGROUND: Little is known about specialist-specific variations in guideline agreement and adoption. OBJECTIVE: To assess similarities and differences between allergists and pulmonologists in adherence to cornerstone components of the National Asthma Education and Prevention Program's Third Expert Panel Report. METHODS: Self-reported guideline agreement, self-efficacy, and adherence were assessed in allergists (n = 134) and pulmonologists (n = 99) in the 2012 National Asthma Survey of Physicians. Multivariate models were used to assess if physician and practice characteristics explained bivariate associations between specialty and "almost always" adhering to recommendations (ie, ≥75% of the time). RESULTS: Allergists and pulmonologists reported high guideline self-efficacy and moderate guideline agreement. Both groups "almost always" assessed asthma control (66.2%, standard error [SE] 4.3), assessed school/work asthma triggers (71.3%, SE, 3.9), and endorsed inhaled corticosteroids use (95.5%, SE 2.0). Repeated assessment of the inhaler technique, use of asthma action/treatment plans, and spirometry were lower (39.7%, SE 4.0; 30.6%, SE 3.6; 44.7%, SE 4.1, respectively). Compared with pulmonologists, more allergists almost always performed spirometry (56.6% vs 38.6%, P = .06), asked about nighttime awakening (91.9% vs 76.5%, P = .03) and emergency department visits (92.2% vs 76.5%, P = .03), assessed home triggers (70.5% vs 52.6%, P = .06), and performed allergy testing (61.8% vs 21.3%, P < .001). In multivariate analyses, practice-specific characteristics explained differences except for allergy testing. CONCLUSIONS: Overall, allergists and pulmonologists adhere to the asthma guidelines with notable exceptions, including asthma action plan use and inhaler technique assessment. Recommendations with low implementation offer opportunities for further exploration and could serve as targets for increasing guideline uptake.

Primary care clinician adherence with asthma guidelines: the National Asthma Survey of Physicians.

Background and objectives: Although primary care clinicians provide >60% of U.S. asthma care, no nationally representative study has examined variation in adherence among primary care groups to four cornerstone domains of the Expert Panel Report-3 asthma guidelines: assessment/monitoring, patient education, environmental assessment, and medications. We used the 2012 National Asthma Survey of Physicians: National Ambulatory Medical Care Survey to compare adherence by family/general medicine practitioners (FM/GM), internists, pediatricians and Community Health Center mid-level clinicians (CHC). Methods: Adherence was self-reported (n = 1355 clinicians). Adjusted odds of almost always adhering to each recommendation (≥75% of the time) were estimated controlling for clinician/practice characteristics, and agreement and self-efficacy with guideline recommendations. Results: A higher percentage of pediatricians adhered to most assessment/monitoring recommendations compared to FM/GM and other groups (e.g. 71.6% [SE 4.0] almost always assessed daytime symptoms versus 50.6% [SE 5.1]-51.1% [SE 5.8], t-test p < 0.05) but low percentages from all groups almost always performed spirometry (6.8% [SE 2.0]-16.8% [SE 4.7]). Pediatricians were more likely to provide asthma action/treatment plans than FM/GM and internists. Internists were more likely to assess school/work triggers than pediatricians and CHC (environmental assessment). All groups prescribed inhaled corticosteroids for daily control (84.0% [SE 3.7]-90.7% [SE 2.5]) (medications). In adjusted analyses, pediatric specialty, high self-efficacy and frequent specialist referral were associated with high adherence. Conclusions: Pediatricians were more likely to report high adherence than other clinicians. Self- efficacy and frequent referral were also associated with adherence. Adherence was higher for history-taking recommendations and lower for recommendations involving patient education, equipment and expertise.

Characteristics of Asthma Visits to Physician Offices in the United States: 2012-2015 National Ambulatory Medical Care Survey.

Objective-This report describes asthma visits to offices of nonfederally employed U.S. physicians. Methods-Asthma visits are defined by the first-listed diagnosis from National Ambulatory Medical Care Survey data. Asthma visit rates among the general population and among persons with asthma (at-risk rates) were estimated. Trends from 2001 through 2016 were assessed. Asthma visit characteristics were assessed for the period 2012-2015 (the diagnostic coding system was changed to the International Classification of Diseases, 10th Revision, Clinical Modification in 2016). The consistency of visit characteristics with national asthma guidelines was also assessed. Results-From 2001 through 2016, population-based asthma visit rates declined from 40.2 to 30.7 visits per 1,000 persons, and at-risk visit rates from 55.5 to 36.7 visits per 100 persons with asthma. During 2012-2015, there was an annual average of 10.2 million asthma visits: 63.5% were by non-Hispanic white persons, 53.8% by female patients, and 32.5% by children under age 15 years. Population and at-risk visit rates were similar across sex and racial and ethnic groups. Children aged 0-4 years had the highest at-risk asthma visit rate. Primary care physicians saw 60.0% of asthma visits. Asthma severity was documented in 34.5% of visits, asthma control in 40.9%, spirometry in 14.9%, and peak flow in 3.3%. Asthma education was provided in 21.4% of asthma visits and asthma action plans in 9.9%. Bronchodilators were the most commonly mentioned medication class (24.9%). A quick-acting relief medication was the most frequently mentioned (albuterol, 16.9%), followed by asthma-control medications (montelukast, 4.7%; fluticasone-salmeterol, 3.7%; and prednisone, 2.7%). Conclusions-Asthma physician office visit rates declined from 2001 through 2016. During 2012-2015, primary care providers saw nearly two-thirds of asthma visits. Physician adherence to documenting asthma severity or control and providing patient education appeared low. Quick-acting relief medication was the most frequently prescribed medication.

National Hospital Care Survey Demonstration Projects: Pneumonia Inpatient Hospitalizations and Emergency Department Visits.

This report demonstrates the use of the National Hospital Care Survey (NHCS) for the study of pneumonia inpatient hospitalizations and emergency department (ED) visits. The analysis is based on unweighted data of inpatient and ED encounters from the 2014 NHCS and is intended to illustrate the capabilities of the survey, including the ability to link inpatient hospitalizations or ED visits across settings and with other data sources, once hospital participation allows for nationally representative estimates.

Clinician Agreement, Self-Efficacy, and Adherence with the Guidelines for the Diagnosis and Management of Asthma.

BACKGROUND: The 2007 Guidelines for the Diagnosis and Management of Asthma provide evidence-based recommendations to improve asthma care. Limited national-level data are available about clinician agreement and adherence to these guidelines. OBJECTIVE: To assess clinician-reported adherence with specific guideline recommendations, as well as agreement with and self-efficacy to implement guidelines. METHODS: We analyzed 2012 National Asthma Survey of Physicians data for 1412 primary care clinicians and 233 asthma specialists about 4 cornerstone guideline domains: asthma control, patient education, environmental control, and pharmacologic treatment. Agreement and self-efficacy were measured using Likert scales; 2 overall indices of agreement and self-efficacy were compiled. Adherence was compared between primary care clinicians and asthma specialists. Logistic regression models assessed the association of agreement and self-efficacy indices with adherence. RESULTS: Asthma specialists expressed stronger agreement, higher self-efficacy, and greater adherence with guideline recommendations than did primary care clinicians. Adherence was low among both groups for specific core recommendations, including written asthma action plan (30.6% and 16.4%, respectively; P < .001); home peak flow monitoring, (12.8% and 11.2%; P = .34); spirometry testing (44.7% and 10.8%; P < .001); and repeated assessment of inhaler technique (39.7% and 16.8%; P < .001). Among primary care clinicians, greater self-efficacy was associated with greater adherence. For specialists, self-efficacy was associated only with increased odds of spirometry testing. Guideline agreement was generally not associated with adherence. CONCLUSIONS: Agreement with and adherence to asthma guidelines was higher for specialists than for primary care clinicians, but was low in both groups for several key recommendations. Self-efficacy was a good predictor of guideline adherence among primary care clinicians but not among specialists.

Hospitalization for Total Knee Replacement Among Inpatients Aged 45 and Over: United States, 2000-2010.

In 2010, total knee replacement was the most frequently performed inpatient procedure on adults aged 45 and over. In the 11-year period from 2000 through 2010, an estimated 5.2 million total knee replacements were performed. Adults aged 45 and over comprised 98.1% of those surgeries. This report uses data from the National Hospital Discharge Survey (NHDS) to present trends in the rate of hospitalizations for total knee replacement, mean age at hospitalization, and discharge status for inpatients aged 45 and over from 2000 through 2010.

Perceptions of the food marketing environment among African American teen girls and adults.

Obesity disproportionately affects African American adolescents, particularly girls. While ethnically targeted marketing of unhealthful food products contributes to this disparity, it is not known how African Americans perceive the food marketing environment in their communities. Qualitative methods, specifically photovoice and group discussions, were used to understand perceptions of African American adults and teen girls regarding targeted food marketing to adolescent girls. An advisory committee of four students, two faculty, and two parents was formed, who recruited peers to photograph their environments and participate in group discussions to answer "what influences teen girls to eat what they do." Seven adults and nine teens (all female) participated in the study. Discussions were transcribed, coded, and analyzed with ATLAS.ti to identify common and disparate themes among participants. Results indicated that adults and teens perceived the type of food products, availability of foods, and price to influence the girls' choices. The girls spoke about products that were highly convenient and tasty as being particularly attractive. The adults reported that advertisements and insufficient nutrition education were also influencers. The teens discussed that the places in which food products were available influenced their choices. Results suggest that the marketing of highly available, convenient food at low prices sell products to teen girls. Future work is needed to better understand the consumer's perspective on the food and beverage marketing strategies used.

Inpatient care for septicemia or sepsis: a challenge for patients and hospitals.

Septicemia and sepsis are serious bloodstream infections that can rapidly become life-threatening. They arise from various infections, including those of the skin, lungs, abdomen, and urinary tract. Patients with these conditions are often treated in a hospital's intensive care unit. Early aggressive treatment increases the chance of survival. In 2008, an estimated $14.6 billion was spent on hospitalizations for septicemia, and from 1997 through 2008, the inflation-adjusted aggregate costs for treating patients hospitalized for this condition increased on average annually by 11.9%. Despite high treatment expenditures, septicemia and sepsis are often fatal. Those who survive severe sepsis are more likely to have permanent organ damage, cognitive impairment, and physical disability. Septicemia is a leading cause of death. The purpose of this report is to describe the most recent trends in care for hospital inpatients with these diagnoses.

National Hospital Discharge Survey: 2007 summary.

OBJECTIVES: This report presents national estimates of hospital inpatient care in the United States during 2007 and selected trend data. Numbers and rates of discharges, diagnoses, and procedures are shown by age and sex. Average lengths of stay are presented for all discharges and for selected diagnostic categories by age and by sex. METHODS: The estimates are based on data collected through the 2007 National Hospital Discharge Survey, an annual national probability sample survey of discharges from nonfederal, general, and short-stay hospitals. Sample data are weighted to produce annual estimates of inpatient care, excluding newborns. Diagnoses and procedures are coded using the International Classification of Diseases, Ninth Revision, Clinical Modification. RESULTS: In 2007, there were an estimated 34.4 million hospital discharges, excluding newborns. The total hospitalization rate leveled off from 1995 to 2007 after declining during the period from 1980 to 1995. Throughout the period from 1970 to 2007 the rates for those aged 65 years and over were significantly higher than the rates for the younger groups. Although those aged 65 years and over accounted for only 13 percent of the total population, they comprised 37 percent of hospital discharges and 43 percent of hospital days. One-quarter of inpatients under age 15 years were hospitalized for respiratory diseases. There were 45 million inpatient procedures during 2007 and 15 percent of these were cardiovascular. Males aged 45-64 and 65 years and over had higher cardiac catheterization rates than females in these age groups each year from 1997 to 2007. From 2002 to 2007 the rate of inpatient cardiac catheterization procedures declined.

Probability and delay discounting of hypothetical sexual outcomes.

The present study used the discounting procedure to characterize choice behaviors regarding hypothetical sexual outcomes. Eighty-six adult undergraduate students completed computerized delay and probability discounting tasks concerning hypothetical money and hypothetical sexual activity. Consistent with other discounting findings, hyperbolic and hyperbola-like decay models described individual and group median indifference point data well. These findings contribute to a growing literature on the relevance of the discounting procedure to decision-making processes and suggest that the discounting procedure may be useful for understanding the processes that underlie social problem behaviors associated with impulsive sexual decisions.

A more efficient enzyme-linked immunosorbent assay for measurement of alpha-synuclein in cerebrospinal fluid.

We describe a modification of a previously described assay for the quantification of alpha-synuclein in naive cerebrospinal fluid, which allows for a more efficient quantification of alpha-synuclein. Detection limit of the assay is 3.8 ng/ml and the assay is linear until 300 ng/ml. Inter-assay and intra-assay coefficients of variation are below 15% in a wide range of concentrations. Mean recovery of the assay is 94%. The 95% upper limit of the reference range (p95) in a group of neurological controls above the age of 45 years is 62 ng/ml. This assay can be routinely applied for quantification of alpha-synuclein in cerebrospinal fluid, but not in serum, and this may serve as a possible biomarker for alpha-synucleinopathies such as Parkinson's disease and multiple system atrophy.