The relationships between Physical activity and asthma control and Body Mass Index (BMI) in patients with asthma.

OBJECTIVE: Asthma is one of the most common chronic conditions in developed countries. We examined whether physical activity (PA) is related to asthma control and body mass index (BMI) in asthma patients. METHODS: Cross-sectional data collected on PA (ActiGraph GT3X-BT), asthma control (the Asthma Control Questionnaire; ACQ), and BMI were examined in 206 adults (mean[sd] age 47.2[13.8] years; 49.5% had an obese BMI) with clinically diagnosed asthma. Relationships between PA and continuous BMI and asthma control were assessed using linear regression. Differences in PA across obesity (non-obese: <30 Kg/m2/obese: ≥30 Kg/m2) and asthma control categories (controlled: ≤0.75/uncontrolled: >0.75 ACQ score) were also examined. RESULTS: Median (p25, p75) steps counts and peak cadence were 6035 (4248, 8461) steps/day and 123 (115, 133) steps in a minute, respectively. There were nearly 2000 fewer steps/day among those with uncontrolled asthma versus controlled and among those with obese BMI versus nonobese, respectively (both p < 0.05). In regression models adjusted for relevant covariates each 1-unit increase in ACQ score was associated with -686 [95%CI -997, -13] (p ≤ 0.05) average steps/day. The statistical significance of these findings was attenuated (p ≥ 0.05) when BMI was added to the model. However, the point estimate was not reduced (-766 [95%CI -1060, 34]. CONCLUSIONS: Overall step counts were low in this population despite peak cadence values suggesting that most participants could perform moderate intensity activity. Increasing step counts should be considered an important lifestyle intervention goal in obese and non-obese asthma patients with low PA levels.

Rates of Undiagnosed Cognitive Impairment and Performance on the Montreal Cognitive Assessment Among Older Adults in Primary Care.

BACKGROUND: The number of adults in the USA with cognitive impairment is increasing; however, few studies report prevalence rates of undiagnosed cognitive impairment among older adults in primary care. OBJECTIVE: To determine the prevalence of undiagnosed cognitive impairment among adults ages 55 years and older in primary care settings and provide normative data for the Montreal Cognitive Assessment in this context. DESIGN: Single interview, observational study. PARTICIPANTS: English-speaking adults ages 55 years and older without diagnoses of cognitive impairment recruited from primary care practices in New York City, NY, and Chicago, IL (n = 872). MAIN MEASURES: Montreal Cognitive Assessment (MoCA). Undiagnosed cognitive impairment was defined by age and education adjusted z-scores more than 1.0 and 1.5 standard deviations below published norms, corresponding to mild or moderate to severe cognitive impairment, respectively. KEY RESULTS: The mean age was 66.8 (8.0) years, 44.7% were male, 32.9% were Black or African-American, and 29.1% were Latinx. Undiagnosed cognitive impairment was identified in 20.8% of subjects (mild impairment, 10.5%; moderate-severe impairment, 10.3%). Impairment at any level of severity was associated in bivariate analyses with several patient characteristics, most notably for race and ethnicity (White, non-Latinx, 6.9% vs. Black, non-Latinx, 26.8%, Latinx, 28.2%, other race, 21.9%; p < 0.0001), place of birth (US 17.5% vs. non-US 30.7%, p < 0.0001), depression (33.1% vs. no depression, 18.1%; p < 0.0001), and impairment in activities of daily living (≥ 1 ADL impairment, 34.0% vs. no ADL impairment, 18.2%; p < 0.0001). CONCLUSIONS: Undiagnosed cognitive impairment is common among urban dwelling older adults attending primary care practices, and was associated with several patient characteristics, including non-White race and ethnicity and depression. Normative data for the MoCA from this study may serve as a useful resource for studies of similar patient populations.

The indirect influence of 'invisible' support on pulmonary function among adults with chronic obstructive pulmonary disease.

Individuals living with chronic obstructive pulmonary disease (COPD) often require support from family or friends. We examined whether invisible support - support that is provided but goes unnoticed - is related to pulmonary function, and whether this association is mediated by depressive symptoms and illness perceptions. Sixty-six dyads of individuals with COPD and their informal caregivers reported on receipt and provision of support, respectively. Those with COPD completed measures of depressive symptoms, illness perceptions and pulmonary function. Although invisible support was not directly related to pulmonary function, mediation analyses revealed a combined indirect effect through lower depressive symptoms and less negative illness perceptions. Interventions teaching skillful delivery of support to caregivers may reduce depressive symptoms and threatening illness cognitions, which may contribute to improvements in symptom burden among patients with COPD.

Differences in L-arginine metabolism and asthma morbidity among asthma patients with and without obstructive sleep apnea.

BACKGROUND: Imbalance in L-arginine and nitric oxide (NO) metabolism has been implicated in the pathophysiology of asthma and obstructive sleep apnea (OSA), and both diseases impact the other's morbidity. We sought to determine whether L-arginine/NO metabolism differs between adults with asthma with or without comorbid OSA, and its association with asthma morbidity. METHODS: This is a cross-sectional study of 322 adults with asthma recruited in Denver, CO and New York City, NY. Data were collected on OSA status, spirometry, and metrics of asthma control and morbidity. L-Arginine metabolites were quantified in patient serum. Bivariate analyses and multiple regression were performed to determine differences between L-arginine metabolism, OSA and association with asthma morbidity. RESULTS: Among the 322 participants, 92 (28.5%) had OSA. The cohort was 81.6% female, 23.4% identified as Black and 30.6% as Latino. Patients with asthma and OSA had significantly higher serum concentrations of NO synthase inhibitor asymmetric dimethylarginine (ADMA) (p-value = 0.019), lower L-arginine to ornithine ratios (p-value = 0.003), and increased ornithine (p-value = 0.001) and proline levels (p-value < 0.001) compared to those without OSA. In adjusted models, OSA was associated with worse asthma control, adjusted mean difference in asthma control questionnaire of 0.36 (95% confidence interval [CI]: 0.06 to 0.65), and asthma quality of life questionnaire, adjusted mean difference: - 0.53 (95% CI: - 0.85 to - 0.21), after adjusting for relevant covariates including body mass index and L-arginine metabolites. CONCLUSIONS: Adults with asthma and OSA had increased ADMA, an inhibitor of nitric oxide synthase, and greater metabolism of L-arginine via the arginase pathway compared to those with asthma alone, indicating a possible shared pathophysiological mechanism of these diseases.

Cognition, symptom perception, and medication non-adherence in older adults with asthma.

BACKGROUND: Cognitive impairment (CI) is highly prevalent in elderly asthmatics and is associated with worse asthma self-management (SM) and outcomes. CI may also explain why older adults may under-perceive asthma symptoms. We hypothesized that CI would be associated with low medication adherence and asthma symptom under-perception (ASP). We also hypothesized that ASP would mediate the relationship between CI and medication adherence. METHODS: Participants of this longitudinal cohort study were asthmatics (N = 334) ≥60 years (51% Hispanic, 25% Black). Cognitive measures assessed general cognition, attention, processing speed, executive functioning, memory, and language. Measures of SM were self-reported and electronically measured adherence to controller medications. ASP was assessed for 6 weeks by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter, followed by PEF blows. Participants were blinded to actual PEF values. Percentage of time that participants were in the over-perception zone was calculated as an average. RESULTS: In regression analyses, those with impairments in memory and general cognition had lower odds ratios (OR) for self-reported non-adherence (OR: 0.96, 95% CI 0.93 - 0.98 & OR: 0.90, 95% CI 0.83 - 0.96, respectively). CI was not associated with electronically measured non-adherence or ASP. In structural equation modeling, while CI was associated with adherence (ß = 0.04, SE = 0.021, p = 0.04), ASP did not mediate this relationship. CONCLUSIONS: While results confirmed the importance of cognition in asthma SM, these findings were not linked to ASP. Future analyses are needed to understand the role of confounding factors.

Comorbidities and depressive symptoms among older adults with asthma.

OBJECTIVE: Depression is associated with poor outcomes among older adults with asthma, and the presence of multiple comorbidities may magnify this relationship. We sought to determine the association of comorbidities with depressive symptoms among older adults with asthma. METHODS: Secondary analysis of data from a randomized controlled trial of older adults with poorly controlled asthma and comorbidities. Comorbidities were measured in two ways: (1) as a count of all the patient's chronic diseases, and (2) as a count of chronic illnesses with self-management intensive needs (diabetes, hypertension, congestive heart failure). Depressive symptoms were measured using the PROMIS SF8a scale. Multiple regression analyses tested the relationship between comorbidities and depressive symptoms, adjusting for sociodemographic factors. RESULTS: Overall, 25% of participants had moderate-severe levels of depressive symptoms, 87% had ≥ two comorbidities, and 41% had ≥ one comorbidity with self-management intensive needs. The count of all comorbidities was significantly associated with depressive symptoms (F (8, 330) = 7.7, p < 0.0001, R2 = 0.158) in adjusted models, whereas the count of self-management intensive conditions was not significantly associated with depressive symptoms in adjusted analyses. CONCLUSIONS: In older adults with asthma and multiple comorbidities, depressive symptoms increased with the overall count of comorbidities but not with the count of comorbidities with self-management intensive needs. Given the impact of depression on asthma outcomes for older adults, the mechanisms by which comorbid illness contributes to depressive symptoms in older asthmatics warrants further evaluation.

Patient characteristics associated with retention in an asthma self-management trial for older adults.

OBJECTIVE: New self-management interventions are being developed for older adults who suffer from worse asthma morbidity than their younger counterparts, but high rates of study drop out have hampered these efforts and there is limited literature on what factors may influence retention in behavioral intervention studies with older adults. This study analyzed illness beliefs and patient characteristics that may contribute to retention in an asthma self-management trial for older adults. METHODS: This is a secondary analysis of data from a randomized controlled trial of a self-management support intervention for adults 60 years and older with persistent, uncontrolled asthma. Multivariable logistic regression was used to evaluate the association of medication and illness beliefs, and other subject characteristics with study retention, which was defined as completion of the research study interview at 6 and 12 months. RESULTS: The randomized trial enrolled 388 individuals; 261 (67.3%) completed the 12-month interview. Higher perceived threat of chronic diseases relative to asthma was associated with higher study retention (OR = 1.11, 95% CI = 1.00-1.24) at 12 months. Other variables including asthma beliefs, age, cognitive function, health literacy, and asthma symptoms were not significantly associated with retention. CONCLUSIONS: Concern about non-asthma chronic conditions, but no other illness beliefs, or patient characteristics, were associated with retention in an asthma self-management support intervention. Further research, including qualitative studies, is needed to better understand why patients drop out of asthma behavioral intervention studies.

Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma.

OBJECTIVE: Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function. METHODS: We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average. RESULTS: Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (ß = 0.14, p = .029), worse self-reported asthma control (ß = 0.17, p = .003), and lower asthma-related quality of life (ß = -0.33, p < .001), but not with lung function (ß = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (ß = 0.14, p = .021), but not lung function (ß = -0.05, p = .41). CONCLUSIONS: Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.

Change in Health Literacy over a Decade in a Prospective Cohort of Community-Dwelling Older Adults.

BACKGROUND: Health literacy is often viewed as a static trait in longitudinal studies, which may over or underestimate an individual's ability to manage one's health. OBJECTIVES: We sought to examine health literacy over time among older adults using three widely used measures. DESIGN: A prospective cohort study. PARTICIPANTS: Community-dwelling adults ages 55 to 74 at baseline with at least one follow-up visit (N = 656) recruited from one academic internal medicine clinic and six community health centers in Chicago, IL. MEASURES: Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA), Newest Vital Sign (NVS), and Rapid Estimate of Adult Literacy in Medicine (REALM) at baseline and up to three follow-up time points. RESULTS: In unadjusted analyses, significant changes since baseline were found beginning at the second follow-up (mean (M) = 6.0 years, SD = 0.6) for the TOFHLA (M = - 0.9, SD = 0.95, p = 0.049) and the REALM (M = 0.3, SD = 2.5, p = 0.004) and at the last follow-up (M = 8.6 years, SD = 0.5) for the NVS (M = - 0.2, SD = 1.4, p = 0.02). There were non-linear effects of baseline age on TOFHLA and NVS scores over time (piecewise cubic spline p = 0.01 and p < 0.001, respectively) and no effect on REALM scores (B = 0.02, 95% CI - 0.01 to 0.04, p = 0.17) using multivariable mixed-effects linear regression models, controlling for race, education, income, and comorbidity. CONCLUSION: We found a negative relationship between age and health literacy over time as measured by the TOFHLA and NVS. Health literacy barriers appear to be more prevalent among individuals in later life, when self-care demands are similarly increasing. Clinicians might consider strategies to assess and respond to limited health literacy, particularly among patients 70 and older. REALM performance remained stable over 10 years of follow-up. This questions whether health literacy tools measure the same attribute. Prospective health literacy studies should carefully consider what measures to use, depending on their objective.

Patient characteristics associated with improvements in asthma control and reduction in emergency department visits for older adults with asthma.

OBJECTIVE: To identify patient characteristics associated with improvements in asthma control among older adults with asthma. METHODS: Secondary analysis of data from a randomized controlled trial of an asthma self-management support intervention for adults ages 60 and older with moderate-severe persistent asthma (n = 391). We tested the association of baseline patient characteristics with reduced emergency department (ED) visits and improvement in asthma control equal to or exceeding the minimal clinically important difference (MCID) in asthma control test (ACT) scores (3.0) 12 months. RESULTS: At baseline, the mean age was 68 years, 15.0% were male, 30.3% were black, and 56.5% were Hispanic. Patients with a history of ED visits in the 12 months preceding study enrollment were significantly more likely to experience an ED visit during the study period (adjusted odds ratio [AOR] 6.92, 95% confidence interval [CI] 2.18-21.9, p < .0001). Similarly, those with poorer asthma control (baseline ACT scores <13) had greater odds of achieving improved asthma control (AOR 13.7, 95% CI 5.32-35.1, p < .0001). No other variables had statistically significant associations with the outcomes. CONCLUSIONS: Low scores on the asthma control test and prior ED visits for asthma are strong correlates of later clinically meaningful changes in asthma control among older adults. Health systems preparing for population management of patients with asthma ought to consider incorporating serial collection of data on the ACT into the monitoring and management of older asthmatics, a high-risk patient population.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York.

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

Validity of the Medication Adherence Rating Scale for Adherence to Inhaled Corticosteroids among Older Adults with Asthma or Chronic Obstructive Pulmonary Disease.

Regular use of inhaled corticosteroids (ICS) is the standard of care for patients with persistent asthma and chronic obstructive pulmonary disease (COPD). Adherence to ICS is measured using the 10-item Medication Adherence Report Scale (MARS), a self-reported medication adherence assessment. However, data on the validity of this measure are limited. Data were obtained from two cohort studies that examined the association of health literacy with self-management behaviors among adults ages 65 and older with asthma and adults ages 40 and older with COPD. ICS adherence was objectively measured over a 4-week period using electronic monitoring devices. Adequate adherence by MARS assessment was defined as a score ≥4.5, and by electronic monitoring as ≥80% of doses prescribed. We assessed the criterion validity using correlations between self-reported adherence and electronic adherence. Receiver Operating Characteristic (ROC) curve analysis was performed between the two measures. Among patients with asthma, the continuous values for adherence measured by self-report and electronically were weakly correlated (r = 0.33, p < 0.001); similarly, the agreement between the dichotomized measures was weak (kappa 0.30, p=.49). Findings were similar for COPD patients: r = 0.26, p = 0.003; kappa 0.19, p = .60. Area under curve (AUC) values generated from ROC analysis was 0.69 and 0.61, for asthma and COPD patients, respectively. Commonly used measure for adherence performed weakly compared to electronic monitoring in separate populations of patients with asthma and COPD. Investigators measuring self-reported medication adherence among patients with these pulmonary diseases should consider using alternative instruments or using objective measures exclusively.

Homebound Status and the Critical Role of Caregiving Support.

The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.

Hepatitis C virus testing for case identification in persons born during 1945-1965: Results from three randomized controlled trials.

The Centers for Disease Control and Prevention and US Preventive Services Task Force recommend one-time hepatitis C virus (HCV) testing for persons born during 1945-1965 (birth cohort). However, few studies estimate the effect of birth cohort (BC) testing implementation on HCV diagnoses in primary care settings. We aimed to determine the probability of identifying HCV infections in primary care using targeted BC testing compared with usual care at three academic medical centers. From December 2012 to March 2014, each center compared one of three distinct interventions with usual care using an independently designed randomized controlled trial. Across centers, BC patients with no clinical documentation of previous HCV testing or diagnosis were randomly assigned to receive a one-time offering of HCV antibody (anti-HCV) testing via one of three independent implementation strategies (repeated-mailing outreach, electronic medical record-integrated provider best practice alert [BPA], and direct patient solicitation) or assigned to receive usual care. We estimated model-adjusted risk ratios (aRR) of anti-HCV-positive (anti-HCV+) identification using BC testing versus usual care. In the repeated mailing trial, 8992 patients (intervention, n = 2993; control, n = 5999) were included in the analysis. The intervention was eight times as likely to identify anti-HCV+ patients compared with controls (aRR, 8.0; 95% confidence interval [CI], 2.8-23.0; adjusted probabilities: intervention, 0.27%; control, 0.03%). In the BPA trial, data from 14,475 patients (BC, n = 8928; control, n = 5,547) were analyzed. The intervention was 2.6 times as likely to identify anti-HCV+ patients versus controls (aRR, 2.6; 95% CI, 1.1-6.4; adjusted probabilities: intervention, 0.29%; control, 0.11%). In the patient-solicitation trial, 8873 patients (BC, n = 4307; control, n = 4566) were analyzed. The intervention was five times as likely to identify anti-HCV+ patients compared with controls (aRR, 5.3; 95% CI, 2.3-12.3; adjusted probabilities: intervention, 0.68%; control, 0.11%). Conclusion: BC testing was effective in identifying previously undiagnosed HCV infections in primary care settings. (Hepatology 2018;67:524-533).

Perceived Adequacy of Tangible Social Support and Associations with Health Outcomes Among Older Primary Care Patients.

BACKGROUND: The availability and adequacy of tangible social support may be critical to older adults managing multiple chronic conditions, yet few studies have evaluated the perceived adequacy of needed tangible support and its relation to health outcomes. OBJECTIVE: We investigated the association between unmet, tangible social support needs, health status, and urgent healthcare use among community-dwelling older adults. DESIGN: Cross-sectional analysis. PARTICIPANTS: English-speaking older adults (n = 469) who participated in the Health Literacy and Cognitive Function cohort study. MAIN MEASURES: Perceived adequacy of tangible social support was measured using a brief, validated scale that determined (1) if an individual needed assistance managing his or her health, and (2) if yes, whether this need was met. Health status was measured using physical function, depression, and anxiety PROMIS short-form instruments. Urgent healthcare utilization (emergency department and hospitalization) was self-reported for the past 12 months. KEY RESULTS: Participants' mean age was 69 years; 73% were women and 31% were African American, and 16% identified unmet support needs. Unmet support needs were associated with worse physical (ß - 6.32; 95% CI - 8.31, - 4.34) and mental health (anxiety: ß 3.84; 95% CI 1.51, 6.17; depression: ß 2.45; 95% CI 0.32, 4.59) and greater urgent healthcare utilization (ED: OR 2.86; 95% CI 1.51, 5.41; hospitalization: OR 3.75; 95% CI 1.88, 7.50). CONCLUSIONS: Perceived unmet support needs were associated with worse health status and greater urgent healthcare use. Primary care practices might consider screening older patients for unmet tangible support needs, although appropriate responses should first be established if unmet needs are identified.

The effect of adapting Hospital at Home to facilitate implementation and sustainment on program drift or voltage drop.

BACKGROUND: Translating evidence-based interventions from study conditions to actual practice necessarily requires adaptation. We implemented an evidence-based Hospital at Home (HaH) intervention and evaluated whether adaptations could avoid diminished benefit from "voltage drop" (decreased benefit when interventions are applied under more heterogeneous conditions than existing in studies) or "program drift." (decreased benefit arising from deviations from study protocols). METHODS: Patients were enrolled in HaH over a 6-month pilot period followed by nine quarters of implementation activity. The program retained core components of the original evidence-based HaH model, but adaptations were made at inception and throughout the implementation. These adaptations were coded as to who made them, what was modified, for whom the adaptations were made, and the nature of the adaptations. We collected information on length of stay (LOS), 30-day readmissions and emergency department (ED) visits, escalations to the hospital, and patient ratings of care. Outcomes were assessed by quarter of admission. Selected outcomes were tracked and fed back to the program leadership. We used logistic or linear regression with an independent variable included for the numerical quarter of enrollment after the initial 6-month pilot phase. Models controlled for season and for patient characteristics. RESULTS: Adaptations were made throughout the implementation period. The nature of adaptations was most commonly to add or to substitute new program elements. HaH services substituting for a hospital stay were received by 295 patients (a mean of 33, range 11-44, per quarter). A small effect of quarter from program inception was seen for escalations (OR 1.09, 95% CI 1.01 to 1.18, p = 0.03), but no effect was observed for LOS (- 0.007 days/quarter; SE 0.02, p = 0.75), 30 day ED visit (OR 0.93, 95% CI 0.86 to 1.01, p = 0.09), 30-day readmission (OR 1.00, 95% CI 0.93 to 1.08, p = 0.99), or patient rating of overall hospital care (OR for highest overall rating 0.99, 95% CI 0.93 to 1.05, p = 0.66). CONCLUSIONS: We made adaptations to HaH at inception and over the course of implementation. Our findings indicate that adaptations to evidence-based programs may avoid diminished benefits due to potential 'program drift' or 'voltage drop.' TRIAL REGISTRATION: Not applicable. This study is not a clinical trial by the International Committee of Medical Journal Editors (ICMJE) definition because it is an observational study "in which the assignment of the medical intervention is not at the discretion of the investigator."

Health Literacy and Medication Adherence in COPD Patients: When Caregiver Presence Is Not Sufficient.

Limited health literacy (HL) is associated with a lower medication adherence in patients with chronic obstructive pulmonary disease (COPD). In this study, we examined the potential mitigating role of caregiver support on the relationship between HL and adherence to COPD medications. We conducted a prospective observational study of adults with COPD and their caregivers. HL was assessed using the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and COPD medication adherence was evaluated with the Medication Adherence Rating Scale (MARS). We also collected caregiver HL data for a subset of participants. We tested whether having a caregiver impacted the relationship between HL and medication adherence using cross-sectional data collected between 2011 and 2015. Our sample included 388 COPD patients and 97 caregivers. COPD patients with low HL had a lower medication adherence (odds ratio [OR]: 0.44, 95% confidence interval [CI]: 0.24-0.81) after adjusting for sociodemographic factors. Caregiver presence was not associated with increased patient medication adherence (OR: 1.28, 95% CI: 0.79-2.08). Among the subset of patients with caregivers, low patient HL remained associated with a lower medication adherence (OR: 0.28, 95% CI: 0.09-0.82) when adjusted for caregiver HL and sociodemographic factors. Low HL is associated with lower COPD medication adherence, and this effect is not mitigated by the presence of a caregiver. These findings suggest a need for effective strategies to manage high-risk COPD patients with low HL, even among those with adequate support from caregivers, and to design interventions for both patients and caregivers with low HL.

Uptake of hepatitis C screening, characteristics of patients tested, and intervention costs in the BEST-C study.

From December 2012 to March 2014, three randomized trials, each implementing a unique intervention in primary care settings (repeated mailing, an electronic health record best practice alert [BPA], and patient solicitation), evaluated hepatitis C virus (HCV) antibody testing, diagnosis, and costs for each of the interventions compared with standard-of-care testing. Multilevel multivariable models were used to estimate the adjusted risk ratio (aRR) for receiving an HCV antibody test, and costs were estimated using activity-based costing. The goal of this study was to estimate the effects of interventions conducted as part of the Birth-Cohort Evaluation to Advance Screening and Testing for Hepatitis C study on HCV testing and costs among persons of the 1945-1965 birth cohort (BC). Intervention resulted in substantially higher HCV testing rates compared with standard-of-care testing (26.9% versus 1.4% for repeated mailing, 30.9% versus 3.6% for BPA, and 63.5% versus 2.0% for patient solicitation) and significantly higher aRR for testing after controlling for sex, birth year, race, insurance type, and median household income (19.2 [95% confidence interval (CI), 9.7-38.2] for repeated mailing, 13.2 [95% CI, 3.6-48.6] for BPA, and 32.9 [95% CI, 19.3-56.1] for patient solicitation). The BPA intervention had the lowest incremental cost per completed test ($24 with fixed startup costs, $3 without) and also the lowest incremental cost per new case identified after omitting fixed startup costs ($1691). CONCLUSION: HCV testing interventions resulted in an increase in BC testing compared with standard-of-care testing but also increased costs. The effect size and incremental costs of BPA intervention (excluding startup costs) support more widespread adoption compared with the other interventions. (Hepatology 2017;65:44-53).

Pathways linking health literacy, health beliefs, and cognition to medication adherence in older adults with asthma.

BACKGROUND: Limited health literacy is associated with low adherence to asthma controller medications among older adults. OBJECTIVE: We sought to describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators. METHODS: We recruited adults aged 60 years and older with asthma from hospital and community practices in New York, New York, and Chicago, Illinois. We measured health literacy and medication adherence using the Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale, respectively. We used validated instruments to assess asthma illness and medication beliefs. We assessed cognition using a cognitive battery. Using structural equation modeling, we modeled illness and medication beliefs as mediators of the relationship between health literacy and adherence while controlling for cognition. RESULTS: Our study included 433 patients with a mean age of 67 ± 6.8 years. The sample had 84% women, 31% non-Hispanic blacks, and 39% Hispanics. The 36% of patients with limited health literacy were more likely to have misconceptions about asthma (P < .001) and asthma medications (P < .001). Health literacy had a direct effect (ß = 0.089; P < .001) as well as an indirect effect on adherence mediated by medications concerns (ß = 0.033; P = .002). Neither medication necessity (ß = 0.044; P = .138) nor illness beliefs (ß = 0.007; P = .143) demonstrated a mediational role between health literacy and adherence. CONCLUSIONS: Interventions designed to improve asthma controller medication adherence in older adults may be enhanced by addressing concerns about medications in addition to using communication strategies appropriate for populations with limited health literacy and cognitive impairments.