Pre-Operative Predictors for Discharge to Post-Acute Care Facilities After Total Knee Arthroplasty.

BACKGROUND: Joint replacement surgery is in increasing demand and is the most common inpatient surgery for Medicare beneficiaries. The venue for post-operative rehabilitation, including early outpatient therapy after surgery, influences recovery and quality of life. As part of a comprehensive total joint program at Kaiser Permanente Colorado, we developed and validated a predictive model to anticipate and plan the disposition for rehabilitation of our patients after total knee arthroplasty (TKA). METHODS: We analyzed data for TKA patients who completed a pre-operative Total Knee Risk Assessment in 2017 (the model development cohort) or during the first 6 months of 2018 (the model validation cohort). The Total Knee Risk Assessment, which is used to guide disposition for rehabilitation, included questions in mobility, social, and environment domains. Multivariable logistic regression was used to predict discharge to post-acute care facilities (PACFs) (ie, skilled nursing facilities or acute rehabilitation centers). RESULTS: Data for a total of 1481 and 631 patients who underwent TKA were analyzed in the development and validation cohorts, respectively. Ninety-three patients (6.3%) in the development cohort and 22 patients (3.5%) in the validation cohort were discharged to PACFs. Eight risk factors for discharge to PACFs were included in the final multivariable model. Patients with a diagnosis of neurological disorder and with a mobility/balance issue had the greatest chance of discharge to PACFs. CONCLUSION: This validated predictive model for discharge disposition following TKA may be used as a tool in shared decision-making and discharge planning for patients undergoing TKA.

Development and Validation of a Model for Predicting Rehabilitation Care Location Among Patients Discharged Home After Total Knee Arthroplasty.

BACKGROUND: Demand for joint replacement is increasing, with many patients receiving postsurgical physical therapy (PT) in non-inpatient settings. Clinicians need a reliable tool to guide decisions about the appropriate PT setting for patients discharged home after surgery. We developed and validated a model to predict PT location for patients in our health system discharged home after total knee arthroplasty. METHODS: We analyzed data for patients who completed a preoperative total knee risk assessment in 2017 (model development cohort) or during the first 6 months of 2018 (model validation cohort). The initial total knee risk assessment, to guide rehabilitation disposition, included 28 variables in mobility, social, and environment domains, and on patient demographics and comorbidities. Multivariable logistic regression was used to identify factors that best predict discharge to home health service (HHS) vs home with outpatient PT. Model performance was assessed by standard criteria. RESULTS: The development cohort included 259 patients (19%) discharged to HHS and 1129 patients (81%) discharged to home with outpatient PT. The validation cohort included 609 patients, with 91 (15%) discharged to HHS. The final model included age, gender, motivation for outpatient PT, and reliable transportation. Patients without motivation for outpatient PT had the highest probability of discharge to HHS, followed by those without reliable transportation. Model performance was excellent in the development and validation cohort, with c-statistics of 0.91 and 0.86, respectively. CONCLUSION: We developed and validated a predictive model for total knee arthroplasty PT discharge location. This model includes 4 variables with accurate prediction to guide patient-clinician preoperative decision making.

Evaluation of care management intensity and bariatric surgical weight loss.

OBJECTIVES: To examine the effect of pre- and postoperative care management on weight loss following bariatric surgery. STUDY DESIGN: We conducted a retrospective cohort study supplemented by cross-sectional surveys across 9 bariatric surgery centers. METHODS: Based on the intensity of patient contact, care management intensity (CMI) was defined as high, moderate, or low for preoperative programs, and high or low for postoperative programs. Multivariable linear regression assessed 1- and 2-year post operative weight loss as a function of CMI. RESULTS: In the 9 centers, 4433 individuals underwent Roux-en-Y gastric bypass or adjustable gastric band placement between 2005 and 2009. Two sites had low, 5 had moderate, and 2 had high preoperative CMI; 5 sites had low and 4 had high postoperative CMI. In analyses stratified by procedure and adjusted for multiple covariates including site, we found no statistically significant associations between either preoperative or postoperative CMI and post operative change in body mass index at year 1 or year 2. Results were limited by heterogeneity of care management across sites and an inability to assess adherence to care management programs. CONCLUSIONS: Prospective investigations that incorporate quantifiable measures of CMI and measure individual adherence to components of care management programs are needed to more accurately determine the effect of care management on weight loss. Additional investigations should examine the effect of CMI on other relevant outcomes, such as nutritional status and quality of life, that may be more directly affected by care management.

A pharmacist-led, American Heart Association Heart360 Web-enabled home blood pressure monitoring program.

BACKGROUND: To determine whether a pharmacist-led, Heart360-enabled, home blood pressure monitoring (HBPM) intervention improves blood pressure (BP) control compared with usual care (UC). METHODS AND RESULTS: This randomized, controlled trial was conducted in 10 Kaiser Permanente Colorado clinics. Overall, 348 patients with BP above recommended levels were randomized to the HBPM (n=175) or UC (n=173) groups. There were no statistically significant differences in baseline characteristics between the groups; however, there was a trend toward a higher baseline BP for the HBPM group compared with the UC group (148.8 versus 145.5 mm Hg for systolic BP; 89.6 versus 88.0 mm Hg for diastolic BP). At 6 months, the proportion of patients achieving BP goal was significantly higher in the HBPM group (54.1%) than in the UC group (35.4%; P<0.001). Compared with the UC group, the HBPM group experienced a -12.4-mm Hg larger (95% confidence interval, -16.3 to -8.6) reduction in systolic BP and a -5.7-mm Hg larger (95% confidence interval, -7.8 to -3.6) reduction in diastolic BP. The impact of the intervention on BP reduction was even larger for the subgroup of patients with diabetes mellitus or chronic kidney disease. The HBPM group had more e-mail and telephone contacts and greater medication regimen intensification. The proportion of patients reporting high satisfaction with hypertension care was significantly greater in the HBPM group (58%) than in the UC group (42%), P<0.001. CONCLUSIONS: A pharmacist-led, Heart360-supported, home BP monitoring intervention led to greater BP reductions, superior BP control, and higher patient satisfaction than UC.

Blood pressure trajectories and associations with treatment intensification, medication adherence, and outcomes among newly diagnosed coronary artery disease patients.

BACKGROUND: Blood pressure (BP) control among coronary artery disease patients remains suboptimal in clinical practice, potentially due to gaps in treatment intensification and medication adherence. However, longitudinal studies evaluating these relationships and outcomes are limited. METHODS AND RESULTS: We assessed BP trajectories among health maintenance organization patients with hypertension and incident coronary artery disease. BP trajectories were modeled over the year after coronary artery disease diagnosis, stratified by target BP goal. Treatment intensification (increase in BP therapies in the setting of an elevated BP), medication adherence (percentage of days covered with BP therapies), and outcomes (all-cause mortality, myocardial infarction, and revascularization) were evaluated in multivariable models: 9569 patients had a <140/90 mm Hg BP target and 12,861 had a <130/80 mm Hg BP target. Within each group, 4 trajectories were identified: good, borderline, improved, and poor control. After adjustment, increasing BP treatment intensity was significantly associated with better BP trajectories in both groups. Medication adherence had inconsistent effects. There were no significant differences in combined outcomes by BP trajectory, but among the diabetes and renal disease cohort, borderline control patients were less likely to have myocardial infarction (odds ratio, 0.61; 95% confidence interval, 0.40-0.93), and good control patients were less likely to have myocardial infarction (odds ratio, 0.53; 95% confidence interval, 0.34-0.84) or a revascularization procedure (odds ratio, 0.66; 95% confidence interval, 0.47-0.93) compared with poor control patients. CONCLUSIONS: In this health maintenance organization population, treatment intensification but not medication adherence significantly affects BP trajectories in the year after coronary artery disease diagnosis. Better BP trajectories are associated with lower rates of myocardial infarction and revascularization.

Association of longitudinal measures of hemoglobin and outcomes after hospitalization for heart failure.

BACKGROUND: Cross-sectional assessments of hemoglobin (Hb) are associated with mortality in patients with heart failure (HF). Our objectives were to characterize patterns of change in Hb over time in patients with HF and to evaluate the relationship between longitudinal measures of Hb and adverse outcomes. METHODS: The study included 2,478 patients with a primary discharge diagnosis of HF from January 2001 to December 2006. Outcomes included time to death and time to death or HF hospitalization. The association between baseline Hb and outcomes was evaluated using multivariable Cox regression. The longitudinal association was evaluated using a time-dependent Hb predictor variable and using anemia trajectory groups. RESULTS: For a median of 475 days, baseline Hb was associated with a trend toward increased mortality (hazard ratio [HR] 1.02, 95% CI 0.99-1.06 per g/dL decline). With a time-dependent approach, the magnitude of the association was greater (HR 1.35, 95% CI 1.30-1.39 per g/dL decline). In trajectory analysis, 35% of the cohort had variable patterns of anemia. Persistently low Hb (HR 1.65, 95% CI 1.27-2.14) and a progressive decline in Hb (HR 1.54, 95% CI 1.16-2.05) were associated with increased mortality risk. Patients with recovery of anemia had similar outcomes as those patients who are persistently nonanemic. Results were similar for the composite of death or HF hospitalization. CONCLUSIONS: Variability in Hb over time is common in patients with HF, and declining Hb is associated with a poor prognosis. Longitudinal characterization of Hb levels has greater prognostic significance than a single measurement. Systematic surveillance of Hb levels may help identify high-risk patients with heart failure.

Missed opportunities for reperfusion therapy for ST-segment elevation myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study.

BACKGROUND: Although it is known that reperfusion therapy for ST-elevation myocardial infarction (STEMI) is underused, the reasons for the failure to provide this potentially life-saving treatment are not well described. METHODS: In a cohort of 2215 consecutive patients presenting with acute myocardial infarction to 5 emergency departments in Colorado and California between 2000 and 2002, patients with ischemic symptoms and ST-segment elevation on electrocardiogram without documented guideline-based contraindications to therapy were identified as eligible reperfusion candidates. Multivariable logistic models were constructed to identify factors associated with the failure to receive reperfusion. The emergency department records of patients not receiving reperfusion were reviewed to categorize the reasons therapy was not provided. RESULTS: Of 460 eligible patients, 102 (22%) did not receive reperfusion therapy. Patient factors associated with failure to receive reperfusion therapy included older age, peripheral vascular disease, and absence of chest pain; patients seen by both resident and attending physicians were more likely to receive treatment than those seen by an attending alone. In cases where reperfusion was not provided, ST-segment elevation was not identified in 34% (n = 35), left bundle-branch block was not considered as an indication in 13% (n = 13), there was documentation of a reason for withholding therapy not supported by guidelines in 34% (n = 35), and there was no documentation of reasons for withholding reperfusion in 19% (n = 19). CONCLUSIONS: Initiatives to improve electrocardiogram interpretation and evidence-based patient selection may reduce gaps in the delivery of reperfusion therapy to eligible candidates and thereby potentially improve STEMI outcomes.

Association of exercise capacity on treadmill with future cardiac events in patients referred for exercise testing.

BACKGROUND: Little is known about the association between exercise capacity and nonfatal cardiac events in patients referred for exercise treadmill testing (ETT). Our objective was to determine the prognostic importance of exercise capacity for nonfatal cardiac events in a clinical population. METHODS: A cohort study was performed of 9191 patients referred for ETT. Median follow-up was 2.7 years. Exercise capacity was quantified as the proportion of age- and sex-predicted metabolic equivalents achieved and categorized as less than 85%, 85% to 100%, and greater than 100%. Individual primary outcomes were myocardial infarction, unstable angina, and coronary revascularization. All-cause mortality was a secondary outcome. RESULTS: Patients with lower exercise capacity were more likely to be female (55.38% vs 42.62%); to have comorbidities such as diabetes (23.16% vs 9.61%) and hypertension (59.43% vs 44.05%); and to have abnormal ETT findings such as chest pain on the treadmill (12.09% vs 7.63%), abnormal heart rate recovery (82.74% vs 64.13%), and abnormal chronotropic index (32.89% vs 12.20%). In multivariable analysis, including other ETT variables, lower exercise capacity (<85% of predicted) was associated with increased risk of myocardial infarction (hazard ratio [HR], 2.36; 95% confidence interval [CI], 1.55-3.60), unstable angina (HR, 2.39; 95% CI, 1.78-3.21), coronary revascularization (HR, 1.75; 95% CI, 1.46- 2.08), and all-cause mortality (HR, 2.90; 95% CI, 1.88-4.47) compared with exercise capacity greater than 100% of predicted. CONCLUSION: Adjusting for patient characteristics and other ETT variables, reduced exercise capacity was associated with both nonfatal cardiovascular events and mortality in patients referred for ETT.

Patient sex and quality of ED care for patients with myocardial infarction.

OBJECTIVE: The aim of the study was to assess the quality of care between male and female emergency department (ED) patients with acute myocardial infarction (AMI). METHODS: A 2-year retrospective cohort study of 2215 patients with AMI presenting immediately to 5 EDs from July 1, 2000, through June 30, 2002 was conducted. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from chart and electrocardiogram reviews. Multivariable regression models were used to assess the independent association between sex and the ED administration of aspirin, beta-blockers, and reperfusion therapy to eligible patients with AMI. RESULTS: There were 849 women and 1366 men in the study. Female patients were older than male patients (74.3 years for women vs 66.8 years for men, P < .001). Among ideal patients, women were less likely than men to receive aspirin (76.3% of women vs 81.3% of men, P < .01), beta-blockers (51.7% of women vs 61.4% of men, P < .01), and reperfusion therapy (64.0% of women vs 72.8% of men, P < .05). However, after adjustment for age, there was no longer a significant relationship between sex and the use of aspirin (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.95-1.03), beta-blockers (OR, 0.94; 95% CI, 0.82-1.04), or reperfusion therapy (OR, 1.01; 95% CI, 0.89-1.09). In models adjusting for additional demographic, clinical, and hospital characteristics, there remained no association between sex and the processes of care. CONCLUSION: Women with AMI treated in the ED have a lower likelihood of receiving aspirin, beta-blocker, and reperfusion therapy. However, this association appears to be explained by the age difference between men and women with AMI. Although there are no apparent sex disparities in care, ED AMI management remains suboptimal for both sexes.

Chest pain on exercise treadmill test predicts future cardiac hospitalizations.

BACKGROUND: Patients often have chest pain during exercise treadmill testing (ETT). However, the evidence supporting chest pain as an independent adverse prognostic factor during ETT has been inconsistent. The objective of this study was to determine the importance of chest pain during ETT in predicting future nonfatal cardiac hospitalizations. METHODS: This was a prospective cohort study of all patients undergoing ETT between July 2001 and June 2004 in a large managed care organization. The primary outcome of interest was nonfatal cardiac hospitalizations including myocardial infarction and unstable angina. Multivariable Cox proportional hazards regression assessed the independent association between chest pain during ETT and subsequent nonfatal cardiac hospitalizations, adjusting patient, clinical and other treadmill variables. RESULTS: Of the 8,459 patients undergoing ETT, 697 (8.2%) patients had chest pain during the test. Patients with chest pain during ETT had more nonfatal cardiac hospitalizations compared to patients without chest pain (11.9% vs. 2.6%; p < 0.0001). In multivariable Cox regression analysis, patients with chest pain during ETT remained at significantly increased risk of nonfatal cardiac hospitalizations (HR 3.44; 95% CI 2.60-4.56). The association between chest pain and adverse outcomes was consistent among prespecified subgroups including patients without ST-segment changes and with good functional capacity on ETT. CONCLUSIONS: Chest pain during ETT, even without ECG changes, predicts subsequent cardiac hospitalizations. Future studies should evaluate whether aggressive management of such patients can prevent subsequent hospitalizations.

Implications of the failure to identify high-risk electrocardiogram findings for the quality of care of patients with acute myocardial infarction: results of the Emergency Department Quality in Myocardial Infarction (EDQMI) study.

BACKGROUND: The impact of misinterpretation of the ECG in patients with acute myocardial infarction (AMI) in the emergency department (ED) setting is not well known. Our goal was to assess the prevalence of the failure to identify high-risk ECG findings in ED patients with AMI and to determine whether this failure is associated with lower-quality care. METHODS AND RESULTS: In a retrospective cohort study of consecutive patients presenting to 5 EDs in California and Colorado from July 1, 2000, through June 30, 2002, with confirmed AMI (n=1684), we determined the frequency of the failure by the treating provider to identify significant ST-segment depressions, ST-segment elevations, or T-wave inversions on the presenting ECG. In multivariable models, we assessed the relationship between missed high-risk ECG findings and evidence-based therapy in the ED after adjustment for patient characteristics and site of care. High-risk ECG findings were not documented in 201 patients (12%). The failure to identify high-risk findings was independently associated with a higher odds of not receiving treatment among ideal candidates for aspirin (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.51 to 2.94), beta-blockers (OR, 1.85; 95% CI, 1.14 to 3.03), and reperfusion therapy (OR, 7.69; 95% CI, 3.57 to 16.67). Among patients with missed high-risk ECG findings, in-hospital mortality was 7.9% compared with 4.9% among those without missed findings (P=0.1). CONCLUSIONS: The failure to identify high-risk ECG findings in patients with AMI results in lower-quality care in the ED. Systematic processes to improve ECG interpretation may have important implications for patient treatment and outcomes.

Randomized trial to improve laboratory safety monitoring of ongoing drug therapy in ambulatory patients.

STUDY OBJECTIVE: To determine whether an electronic tool effectively increases the percentage of patients receiving laboratory monitoring during ongoing drug therapy. DESIGN: Randomized trial. SETTING: Outpatient medical offices of a group model health maintenance organization. PATIENTS: A total of 9,139 patients prescribed ongoing therapy with any of 14 drugs, resulting in 4,871 patient-drug combinations in the intervention group and 4,780 in the usual-care (control) group. INTERVENTION: Physicians and pharmacists jointly developed monitoring guidelines based on published recommendations. Pharmacists were electronically alerted to missing laboratory results and then ordered tests, reminded patients to undergo tests, and reviewed and managed abnormal results. MEASUREMENTS AND MAIN RESULTS: In the intervention group, 64% of patientdrug combinations were monitored, whereas in the usual-care group 58% were monitored (p < 0.001). Differences in monitoring were observed in the intervention versus usual-care groups for amiodarone (71% vs 55%, p<0.01), theophylline (54% vs 28%, p<0.001), carbamazepine (49% vs 32%, p<0.001), lithium (42% vs 28%, p<0.01), phenytoin (44% vs 33%, p<0.001), and metformin (72% vs 67%, p<0.001). Of 1981 laboratory tests ordered, 1,472 (74%) were completed. The tests revealed 181 serum drug concentrations outside the therapeutic range and 126 abnormal serum creatinine, alanine aminotransferase, aspartate aminotransferase, and thyroid-stimulating hormone levels, and complete blood counts. CONCLUSION: A computerized tool plus collaboration of health care professionals effectively increased the number of patients who received laboratory safety monitoring of drug therapy.

Improving laboratory monitoring at initiation of drug therapy in ambulatory care: a randomized trial.

BACKGROUND: The importance of laboratory monitoring for drugs is reflected in product labeling and published guidelines, but monitoring recommendations are followed inconsistently. Opportunity exists to improve monitoring, with the potential to decrease therapy complications. METHODS: The objective of this randomized trial was to determine whether computerized alerts were effective at increasing the percentage of ambulatory patients with laboratory monitoring at initiation of drug therapy. Physicians and pharmacists teamed up to develop organization-specific guidelines for monitoring selected drugs. In collaboration with physicians, pharmacists were alerted to missing laboratory test results, ordered missing tests, reminded patients to obtain tests, assessed test completion, reviewed test results, and managed abnormal results. Eligible individuals included patients with therapy initiated for any of 15 drugs among 400,000 health plan members. RESULTS: In the intervention group, 79.1% (n = 4076; 95% confidence interval [CI], 78.0%-80.2%) of dispensings were monitored compared with 70.2% (n = 3522; 95% CI, 68.9%-71.5%) in the usual-care group (P < .001). For example, 78.6% of amiodarone (95% CI, 73.1%-83.5%) dispensing was monitored in the intervention group vs 51.4% (95% CI, 44.4%-58.4%) in the group receiving usual care (P < .001). CONCLUSIONS: This study demonstrates the effectiveness of a computerized tool plus collaboration among health care professionals at increasing the percentage of patients receiving laboratory monitoring at initiation of therapy. Coupling data available from information systems with the knowledge and skills of physicians and pharmacists can result in improved patient monitoring.

Older emergency department patients with acute myocardial infarction receive lower quality of care than younger patients.

STUDY OBJECTIVE: We assessed the independent relationship between age and the quality of medical care provided to patients presenting to the emergency department (ED) with acute myocardial infarction. METHODS: We conducted a 2-year retrospective cohort study of 2,216 acute myocardial infarction patients presenting urgently to 5 EDs in Colorado and California from July 1, 2000, through June 30, 2002. Data on patient characteristics, clinical presentation, and ED processes of care were obtained from the ED record and ECG review. Patients were divided into 6 groups based on their age at the time of their ED visit: younger than 50 years, 50 to 59 years, 60 to 69 years, 70 to 79 years, 80 to 89 years, and 90 years or older. Hierarchic multivariable regression was used to assess the independent association between age and the provision of aspirin, beta-blockers, and reperfusion therapy (fibrinolytic agent or percutaneous coronary intervention) in the ED to eligible acute myocardial infarction patients. RESULTS: Of ideal candidates for treatment in the ED, 1,639 (80.5%) of 2,036 received aspirin, 552 (60.3%) of 916 received beta-blockers, and 358 (77.8%) of 460 received acute reperfusion therapy. After adjustment for demographic, medical history, and clinical factors, older patients were less likely to receive aspirin (odds ratio [OR] 0.85, 95% confidence interval [CI] 0.77 to 0.93), beta-blockers (OR 0.79, 95% CI 0.71 to 0.88), and reperfusion therapy (OR 0.30, 95% CI 0.18 to 0.52). CONCLUSION: Older patients presenting to the ED with acute myocardial infarction receive lower-quality medical care than younger patients. Further investigation to identify the reasons for this disparity and to intervene to reduce gaps in care quality will likely lead to improved outcomes for older acute myocardial infarction patients.

Laboratory monitoring of drugs at initiation of therapy in ambulatory care.

BACKGROUND AND OBJECTIVES: Product labeling and published guidelines reflect the importance of monitoring laboratory parameters for drugs with a risk of organ system toxicity or electrolyte imbalance. Limited information exists about adherence to laboratory monitoring recommendations. The objective of this study was to describe laboratory monitoring among ambulatory patients dispensed medications for which laboratory testing is recommended at therapy initiation. DESIGN AND SUBJECTS: We conducted a retrospective cross-sectional analysis of patients in 10 geographically distributed health maintenance organizations who were newly prescribed medications with recommended laboratory test monitoring. The main outcome measure was the proportion of initial drug dispensing without recommended baseline laboratory monitoring for 35 newly initiated drugs or drug classes. RESULTS: One hundred seven thousand, seven hundred sixty-three of 279,354 (39%) initial drug dispensings occurred without recommended laboratory monitoring. Patients without monitoring were younger than patients who had monitoring (median 57 vs 61 years, P<.001). Thirty-two percent of dispensings where a serum creatinine was indicated did not have it evaluated (range across drugs, 12% to 61%); 39% did not have liver function testing (range 10% to 75%); 32% did not have hematologic monitoring (range 9% to 51%); and 34% did not have electrolyte monitoring (range 20% to 62%) (P<.001). CONCLUSIONS: Substantial opportunity exists to improve laboratory monitoring of drugs for which such monitoring is recommended. This study emphasizes the need for research to identify the clinical implications of not conducting recommended laboratory monitoring, existing barriers to monitoring, and methods to improve practice.

Adherence to CDC STD guideline recommendations for the treatment of Chlamydia trachomatis infection in two managed care organizations.

BACKGROUND: The extent of adherence to the Centers for Disease Control and Prevention (CDC) STD guidelines by clinicians practicing in managed care settings is unknown. GOAL The goal was to assess adherence to the CDC guideline recommendations for the treatment of genital chlamydial infection, by clinicians at two group model managed care organizations. DESIGN: Retrospective cohort study of men and women with laboratory-confirmed chlamydial infection. Patients were members of either the Kaiser Permanente Foundation Health Plan of Colorado or HealthPartners of Minneapolis/St. Paul who had tested positive for cervical or urethral chlamydial infection during the period from January 1, 1998, through June 30, 1999. RESULTS: During the study period, 1,078 patients with positive tests for genital Chlamydia trachomatis were identified. More than 97% of men and nonpregnant women and more than 98% of pregnant women were prescribed treatment, consistent with current CDC guidelines. CONCLUSION: Adherence to CDC-recommended therapy was high for patients with genital chlamydial infections at these two managed care organizations.

Work-related exacerbation of asthma.

Adults with asthma who had been enrolled in an HMO for at least a year were requested to complete a questionnaire about their health status. Approximately 25% of the 1,461 participants responded positively to "Does your current work environment make your asthma worse?" and were classified as having workplace exacerbation of asthma. Those with workplace exacerbation were more likely to have never attended college, be current or former smokers, have a history of other respiratory diseases, have missed work or usual activities at least one day in the past for weeks, and report their asthma was moderate, severe, or very severe. Percentages with workplace exacerbation of asthma were highest for mining and construction (36%), wholesale and retail trade (33%), and public administration (33%), and lowest for educational services (22%), finance, insurance, and real estate (22%), and non-medical and non-educational services (18%). Future studies are needed for objective validation of self-reported workplace exacerbation, and to follow subjects prospectively to clarify the temporal sequence of workplace exacerbation and asthma severity, and how other respiratory conditions and smoking might contribute to work-related worsening of asthma.