Effect of Lung Transplantation on Health-Related Quality of Life in the Era of the Lung Allocation Score: A U.S. Prospective Cohort Study.

Under the U.S. Lung Allocation Score (LAS) system, older and sicker patients are prioritized for lung transplantation (LT). The impact of these changes on health-related quality of life (HRQL) after transplant has not been determined. In a single-center prospective cohort study from 2010 to 2016, we assessed HRQL before and repeatedly after LT for up to 3 years using the SF12-Physical and Mental Health, the respiratory-specific Airway Questionnaire 20-Revised, and the Euroqol 5D/Visual Analog Scale utility measures by multivariate linear mixed models jointly modeled with death. We also tested changes in LT-Valued Life Activities disability, BMI, allograft function, and 6-min walk test exercise capacity as predictors of HRQL change. Among 211 initial participants (92% of those eligible), LT improved HRQL by all 5 measures (p < 0.05) and all but SF12-Mental Health improved by threefold or greater than the minimally clinically important difference. Compared to younger participants, those aged ≥65 improved less in SF12-Physical and Mental Health (p < 0.01). Improvements in disability accounted for much of the HRQL improvement. In the LAS era, LT affords meaningful and durable HRQL improvements, mediated by amelioration of disability. Identifying factors limiting HRQL improvement in selected subgroups, especially those aged ≥65, are needed to maximize the net benefits of LT.

Comparison of cardiac and pulmonary-specific quality-of-life measures in pulmonary arterial hypertension.

Studies systematically comparing the performance of health-related quality-of-life (HRQoL) instruments in pulmonary arterial hypertension (PAH) are lacking. We sought to address this by comparing cardiac and respiratory-specific measures of HRQoL in PAH. We prospectively assessed HRQoL in 128 patients with catheterisation-confirmed PAH at baseline and at 6, 12 and post-24 month follow-up visits. Cardiac-specific HRQoL was assessed using the Minnesota Living with Heart Failure Questionnaire (LHFQ); respiratory-specific HRQoL was assessed using the Airways Questionnaire 20 (AQ20); and general health status was assessed using the 36-item Short Form physical component summary (SF-36 PCS). The LHFQ and AQ20 were highly intercorrelated. Both demonstrated strong internal consistency and converged with the SF-36 PCS. Both discriminated patients based on World Health Organization (WHO) functional class, 6-min walking distance (6MWD) and Borg dyspnoea index (BDI), with the exception of a potential floor effect associated with low 6MWD. The LHFQ was more responsive than the AQ20 to changes over time in WHO functional class, 6MWD and BDI. In multivariate analyses, the LHFQ and AQ20 were each longitudinal predictors of general health status, independent of functional class, 6MWD and BDI. In conclusion, both cardiac-specific and respiratory-specific measures appropriately assess HRQoL in most patients with PAH. Overall, the LHFQ demonstrates stronger performance characteristics than the AQ20.

Occupational exposures and the risk of COPD: dusty trades revisited.

BACKGROUND: The contribution of occupational exposures to chronic obstructive pulmonary disease (COPD) and, in particular, their potential interaction with cigarette smoking remains underappreciated. METHODS: Data from the FLOW study of 1202 subjects with COPD (of which 742 had disease classified as stage II or above by Global Obstructive Lung Disease (GOLD) criteria) and 302 referent subjects matched by age, sex and race recruited from a large managed care organisation were analysed. Occupational exposures were assessed using two methods: self-reported exposure to vapours, gas, dust or fumes on the longest held job (VGDF) and a job exposure matrix (JEM) for probability of exposure based on occupation. Multivariate analysis was used to control for age, sex, race and smoking history. The odds ratio (OR) and adjusted population attributable fraction (PAF) associated with occupational exposure were calculated. RESULTS: VGDF exposure was associated with an increased risk of COPD (OR 2.11; 95% CI 1.59 to 2.82) and a PAF of 31% (95% CI 22% to 39%). The risk associated with high probability of workplace exposure by JEM was similar (OR 2.27; 95% CI 1.46 to 3.52), although the PAF was lower (13%; 95% CI 8% to 18%). These estimates were not substantively different when the analysis was limited to COPD GOLD stage II or above. Joint exposure to both smoking and occupational factors markedly increased the risk of COPD (OR 14.1; 95% CI 9.33 to 21.2). CONCLUSIONS: Workplace exposures are strongly associated with an increased risk of COPD. On a population level, prevention of both smoking and occupational exposure, and especially both together, is needed to prevent the global burden of disease.

Performance of self-reported occupational exposure compared to a job-exposure matrix approach in asthma and chronic rhinitis.

OBJECTIVES: Self-reported exposure to vapours, gas, dust or fumes (VGDF) has been widely used as an occupational exposure metric in epidemiological studies of chronic lung diseases. Our objective was to characterise the performance of VGDF for repeatability, systematic misclassification, and sensitivity and specificity against exposure likelihood by a job-exposure matrix (JEM). METHODS: We analysed data from two interviews, 24 months apart, of adults with asthma and chronic rhinitis. Using distinct job as the unit of analysis, we tested a single response item (exposure to VGDF) against assignment using a JEM. We further analysed VGDF and the JEM among a subset of 199 subjects who reported the same job at both interviews, using logistic regression analysis to test factors associated with VGDF inconsistency and discordance with the JEM. RESULTS: VGDF was reported for 193 (44%) of 436 distinct jobs held by the 348 subjects studied; moderate to high exposure likelihood by JEM was assigned to 120 jobs (28%). The sensitivity and specificity of VGDF against JEM were 71% and 66%, respectively. Among 199 subjects with the same job at both interviews, 32% had a discordant VGDF status (kappa = 0.35). Those with chronic rhinitis without concomitant asthma compared to asthma alone were more likely to have a VGDF report discordant with the JEM (OR 3.6, 95% CI 1.4 to 9.0; p = 0.01). Rhinitis was also associated with reported VGDF in a job classified by the JEM as low exposure (OR 3.9, 95% CI 1.6 to 9.4; p = 0.003). CONCLUSION: The VGDF item is moderately sensitive measured against JEM as a benchmark. The measure is a useful assessment method for epidemiological studies of occupational exposure risk.

Epidemiology and prevention of periodontal disease in individuals with diabetes.

OBJECTIVE: This article reviews the epidemiological evidence of the relationship between diabetes and periodontal disease, possible physiological mechanisms for the association, and effects of interventions on the occurrence and severity of periodontal disease among individuals with diabetes. RESEARCH DESIGN AND METHODS: A comprehensive qualitative review of published literature in the area was performed. RESULTS: Much of the research in this area was found to contain methodological problems, such as failing to specify the type of diabetes, small sample sizes, and inadequate control of covariates such as age or duration of diabetes. CONCLUSIONS: Trends indicate that periodontal disease is more prevalent and more severe among individuals with diabetes. This trend may be modified by factors such as oral hygiene, duration of diabetes, age, and degree of metabolic control of diabetes. Generally, poor oral hygiene, a long history of diabetes, greater age, and poor metabolic control are associated with more severe periodontal disease. The association of diabetes and periodontal disease may be due to numerous physiological phenomena found in diabetes, such as impaired resistance, vascular changes, altered oral microflora, and abnormal collagen metabolism. With some modifications, the same prevention and treatment procedures for periodontal disease recommended for the general population are appropriate for those with diabetes. People with diabetes who appear to be particularly susceptible to periodontal disease include those who do not maintain good oral hygiene or good metabolic control of their diabetes, those with diabetes of long duration or with other complications of diabetes, and teenagers and pregnant women.

Primary care physician attitudes regarding communication with hospitalists.

Hospitalist systems create discontinuity of care. Enhanced communication between the hospitalist and primary care physician (PCP) could mitigate the harms of discontinuity. We conducted a mailed survey of 4,155 physician members of the California Academy of Family Physicians to determine their preferences for and satisfaction with communication with hospitalists. We received 1,030 completed surveys (26%). PCPs overwhelmingly stated that they "very much prefer" to communicate with hospitalists by telephone (77%), at admission (73%), and discharge (78%). Only discharge medications (94%) and discharge diagnosis (90%) were deemed "very important" by >90% of PCPs. Of the 556 respondents (54%) who had ever used a hospitalist, 56% were very or somewhat satisfied with communication with hospitalists, and 68% agreed that hospitalists are a good idea. Regarding communication at discharge, only 33% of PCPs reported that discharge summaries always or usually arrive before the patient is seen for follow-up. Only 56% of PCPs in our survey were satisfied with communication with hospitalists. Hospitalists should communicate with PCPs in a timely manner by telephone, at least at admission and discharge, and provide the specific pieces of information deemed important by the vast majority of PCPs. Hospitalists should also ensure that discharge information arrives in time to assist the PCP in reassuming care of their patients. It may be possible to tailor communication to individual PCPs. Further research could assess the impact of such communication on patient satisfaction and outcomes.

Physician attitudes toward and prevalence of the hospitalist model of care: results of a national survey.

PURPOSE: We sought to determine the availability and utilization of, as well as physician attitudes toward, the hospitalist model in the United States. SUBJECTS AND METHODS: Using a telephone survey, we asked physicians who were board certified in internal medicine about their inpatient practice arrangements, the availability of hospitalist services, and their attitudes toward the hospitalist model. All physicians were generalists in active clinical practice. Using multivariable methods, we determined factors associated with attitudes toward the hospitalist model. RESULTS: We were able to contact 787 of 2,829 physicians who were randomly selected from a national list of board-certified internists, of whom 400 agreed to participate. Most respondents were familiar with the term "hospitalist" and had hospitalist services available in their community, and 28% used hospitalists for their inpatients. Few (2%) reported the presence of the "mandatory" hospitalist model. Physicians reported that the model was more commonly available in Western states (84% vs. 55% to 63% in other regions, P<0.0001). Seventy-three percent thought hospitalist systems would reduce continuity of care. Only 28% thought that patients would prefer care from an inpatient specialist, but 51% thought patients might get better care, and 47% thought patients might get more cost-effective care in a hospitalist system. In multivariable models, physicians who were in solo practice, those in specialties with more inpatient practice, and those who had more patients hospitalized each month responded more negatively about the model, whereas those with hospitalists in their community were more positive. CONCLUSIONS: Although agreeing that quality of care and efficiency might be improved, physicians were concerned about patient-doctor relationships and patient satisfaction in a hospitalist model. Future studies should determine the effect of the hospitalist model on these outcomes.

Measurement of environmental tobacco smoke exposure among adults with asthma.

Because the morbidity and mortality from adult asthma have been increasing, the identification of modifiable environmental exposures that exacerbate asthma has become a priority. Limited evidence suggests that exposure to environmental tobacco smoke (ETS) may adversely affect adults with asthma. To study the effects of ETS better, we developed a survey instrument to measure ETS exposure in a cohort of adults with asthma living in northern California, where public indoor smoking is limited. To validate this survey instrument, we used a passive badge monitor that measures actual exposure to ambient nicotine, a direct and specific measure of ETS. In this validation study, we recruited 50 subjects from an ongoing longitudinal asthma cohort study who had a positive screening question for ETS exposure or potential exposure. Each subject wore a passive nicotine badge monitor for 7 days. After the personal monitoring period, we readministered the ETS exposure survey instrument. Based on the survey, self-reported total ETS exposure duration ranged from 0 to 70 hr during the previous 7 days. Based on the upper-range boundary, bars or nightclubs (55 hr) and the home (50 hr) were the sites associated with greatest maximal self-reported exposure. As measured by the personal nicotine badge monitors, the overall median 7-day nicotine concentration was 0.03 microg/m(3) (25th-75th interquartile range 0-3.69 microg/m(3)). Measured nicotine concentrations were highest among persons who reported home exposure (median 0.61 microg/m(3)), followed by work exposure (0.03 microg/m(3)), other (outdoor) exposure (0.025 microg/m(3)), and no exposure (0 microg/m(3); p = 0.03). The Spearman rank correlation coefficient between self-reported ETS exposure duration and directly measured personal nicotine concentration during the same 7-day period was 0.47, supporting the survey's validity (p = 0.0006). Compared to persons with no measured exposure, lower-level [odds ratio (OR) 1.9; 95% confidence interval (CI), 0.4-8.8] and higher-level ETS exposures (OR 6.8; 95% CI, 1.4-32.3) were associated with increased risk of respiratory symptoms. A brief, validated survey instrument can be used to assess ETS exposure among adults with asthma, even with low levels of exposure. This instrument could be a valuable tool for studying the effect of ETS exposure on adult asthma health outcomes.

The Marks Asthma Quality of Life Questionnaire: further validation and examination of responsiveness to change.

We performed analyses to examine the structure, validity, and responsiveness to change of the Marks Asthma Quality of Life Questionnaire (AQLQ), originally validated in Australia in a self-administered format, among 539 U.S. subjects with asthma. Subjects were interviewed twice by telephone over an 18-month period. Based on factor analyses, the subscale structure of the AQLQ was modified slightly to eliminate item overlap among subscale scores. Cross-sectionally, total AQLQ scores were significantly correlated in expected directions with baseline asthma severity scores (r = 0.58), SF-36 physical (r = -0.66) and mental (r = -0.40) health status scores, and pulmonary function (FEV1% predicted, r = -0.14). Longitudinally, changes in AQLQ total and subscale scores were significantly (P<0.01) associated with changes in asthma severity and both physical and mental status. The AQLQ, administered by telephone, appears to be useful for assessing changes in the impact of adult asthma.

The work impact of asthma and rhinitis: findings from a population-based survey.

Asthma and rhinitis are common chronic conditions that affect adults of working age. Little is known about their relative impacts on work loss and decreased productivity. Using random digit telephone dialing, we carried out a population-survey of adults in Northern California aged 18-50 years. We interviewed 125 persons with asthma (with or without concomitant rhinitis) and 175 persons with rhinitis alone. Study eligibility was based on subject report of a physician's diagnosis of asthma and/or a rhinitis-related condition. Any adult labor force participation since condition onset was lower among those with asthma (88%) than among those with rhinitis alone (97%) (P = 0.002). In contrast, among those still employed, decreased job effectiveness was more frequently reported in the rhinitis group (43 of 121; 36%) compared to those with asthma (14 of 72; 19%) (P = 0.02). Condition-attributed lost work was common in both groups, with more than 20% reporting one or more complete or partial work days lost in the 4 weeks previous to interview. Taking into account age, gender, race, and smoking status, those with asthma were more likely to have no labor force participation after diagnosis (OR = 3.0; 95% CI 1.1-7.7) and less likely to report decreased job effectiveness among those remaining employed (OR = 0.4; 95% CI 0.2-0.9). Excluding subjects from the rhinitis group most likely to have unreported asthma based on past medication use had little impact on these associations. Both asthma and rhinitis negatively affect work productivity. Those with asthma are less likely to be employed at all, while among those remaining on the job, rhinitis is a more potent cause of decreased work effectiveness. The economic impact of asthma and rhinitis and related conditions may be under-appreciated.

Alternative therapies among adults with a reported diagnosis of asthma or rhinosinusitis : data from a population-based survey.

BACKGROUND: Asthma and rhinosinusitis are common medical conditions among adults. Alternative treatments could have important impacts on health status among those individuals with these conditions, but specific prevalence data for these treatments are limited. OBJECTIVE: To estimate the prevalence of specific alternative treatment modalities, including herbal agents, ingestion of caffeinated beverages, homeopathy, acupuncture, and massage therapies. DESIGN: Random population telephone sample. SETTING: Northern California. PARTICIPANTS: Three hundred adults aged 18 to 50 years with self-report of a physician diagnosis of asthma (n = 125) or rhinosinusitis without concomitant asthma (n = 175). MEASUREMENTS: Structured telephone interviews covering demographics and clinical variables, including the following alternative treatments used in the previous 12 months: herbal agents; caffeine-containing products; homeopathy; acupuncture; aromatherapy; reflexology; and massage. RESULTS: Any alternative practice was reported by 127 subjects (42%; 95% confidence interval [CI], 36 to 48%). Of these, 33 subjects (26%; 95% CI, 21 to 31%) were not current prescription medication users. Herbal use was reported by 72 subjects (24%), caffeine treatment by 54 subjects (18%), and other alternative treatments by 66 subjects (22%). Taking into account demographic variables, subjects with asthma were more likely than those with rhinitis alone to report caffeine self-treatment for their condition (odds ratio, 2.5; 95% CI, 1.4 to 4.8%), but herbal use and other alternative treatments did not differ significantly by condition group. CONCLUSION: Alternative treatments are frequent among adults with asthma or rhinosinusitis and should be taken into account by health-care providers and public health and policy analysts.

The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma.

BACKGROUND: Volume-outcome relations have been established for several complex therapies. However, few studies have examined volume-outcome relations for high-risk procedures in general surgery, such as hepatectomy for hepatocellular carcinoma (HCC). OBJECTIVE: To evaluate the relation between hospital volume and outcome for patients undergoing hepatectomy for HCC. DESIGN: Retrospective cohort study. SETTING: All acute-care hospitals in California. PATIENTS: Hospital discharge data were analyzed for each patient in California who underwent major hepatic resection for HCC from January 1, 1990, through December 31, 1994. Hospitals were grouped according to number of hepatectomies performed at each center during the 5-year study. MAIN OUTCOME MEASURES: Outcome measures included operative mortality and length of hospital stay. Regression analyses were used to adjust for differences in patient mix. RESULTS: Five hundred seven patients underwent hepatectomy for HCC during the study. Hepatic resections were performed in 138 hospitals, with an overall in-hospital mortality rate of 14.8%. Three quarters of patients were treated at hospitals that average 3 or fewer hepatic resections for HCC per year. These low-volume providers represent 97.1% of all hospitals treating patients with HCC statewide. Significant reductions in risk-adjusted operative mortality rates (22.7%-9.4%; P = .002, multiple logistic regression) and risk-adjusted length of stay (14.3-11.3 days; P = .03, multiple linear regression) were observed as hospital volume increased. CONCLUSIONS: Low operative mortality and length of stay were associated with high-volume centers. These data support regionalization of high-risk procedures in general surgery, such as hepatectomy for HCC.

The stresses of rheumatoid arthritis: appraisals of perceived impact and coping efficacy.

OBJECTIVE: This study examined appraisals of the impact of 7 stressors associated with rheumatoid arthritis (RA) and the perceived ability to cope with those stressors. METHODS: Subjects were 446 participants in a panel study of persons with RA. Data were derived from the 1994 annual interview. RESULTS: There were significant differences among mean ratings of the stressors. Taking care of RA, fatigue, pain, and functional impairment were rated as having the greatest impact; perceived coping efficacy was highest for medication side effects and taking care of RA. Appraisals of impact and coping efficacy were negatively correlated. Clinical factors were the strongest predictors of both appraisals. Depressive symptoms and instrumental support were also independently associated with both appraisals for most stressors. CONCLUSIONS: All of the stressors were problematic to some degree, suggesting that coping research should include stressors other than pain and function. Most subjects rated the effects of these stressors as moderate, however. Future examination of the coping responses of these individuals may shed light on adaptation to RA.

The impact of rheumatoid arthritis on life activities.

OBJECTIVE: To examine the proportion of valued activities performed by persons with rheumatoid arthritis (RA) and the change in this proportion over a 5-year period and to compare the performance and loss of valued activities of persons with and without RA. METHODS: Data were drawn from a longitudinal panel study of persons with RA. Valued activities were assessed using a standardized questionnaire. RESULTS: Over a 5-year period, persons with RA lost approximately 10% of the activities they had valued. Losses were noted in every domain of activity. The greatest losses were seen in work-related, service, nurturant, cultural and leisure, and social participation activities. Compared to persons without arthritis, persons with RA performed fewer valued activities at baseline, and lost more valued activities over the 5-year period. CONCLUSIONS: RA takes a considerable toll on the ability of people with the disease to perform valued life activities. Other research has shown that the loss of valued activities is a strong risk factor for the development of depressive symptoms among women with RA.

Differences in symptom reports between men and women with rheumatoid arthritis.

OBJECTIVE: To determine if differences exist between men and women in their reports and evaluations of rheumatoid arthritis (RA) symptoms, and, if so, to identify explanations of those differences. METHOD: Data from a longitudinal panel study of persons with RA were used. Symptom reports were defined as individuals' evaluation of body states, e.g., evaluations of the severity of pain. Analyses were controlled for sociodemographic, clinical, and psychological characteristics. RESULTS: In unadjusted analyses, women were more likely to evaluate their symptoms as severe. Adjustment for sociodemographic and clinical characteristics changed these results very little. Controlling for depressive symptoms decreased the magnitude of associations somewhat. Analyses controlling for additional respondent-reported clinical characteristics (Health Assessment Questionnaire score, number of painful joints) yielded dramatically different results; in no case did women evaluate their symptoms significantly more severely than men. CONCLUSION: Our analyses suggest that women reported more severe symptoms, but that these differences may be due to more severe disease rather than a tendency by women to over-report symptoms or over-rate symptom severity. Future research should examine whether physicians respond to reports or prescribe treatments differently for men and women.

Satisfaction with abilities and well-being: development and validation of a questionnaire for use among persons with rheumatoid arthritis.

OBJECTIVE: To develop a questionnaire to measure satisfaction with abilities and well-being of persons with rheumatoid arthritis (RA). METHODS: We used data from a panel study of persons with RA (n = 446). The 13 items of the Satisfaction with Abilities and Well-Being Scale (SAWS) were based on problematic aspects of RA and domains of life activities. RESULTS: The SAWS demonstrated internal consistency (Cronbach's alpha = 0.93). Two subscales were identified, Satisfaction with Abilities and Satisfaction with Well-Being, which also demonstrated internal consistency (alpha = 0.91 and alpha = 0.82, respectively). Construct validity was supported by significant correlations with psychosocial and clinical variables. After controlling for demographic, psychosocial, and clinical characteristics, there was a significant inverse association between SAWS scores and depressive symptoms scores. CONCLUSIONS: The SAWS appears to be a valid and reliable measure of satisfaction with abilities and well-being among persons with RA. Longitudinal studies will examine the role of satisfaction in the development of depressive symptoms.

Life activities of persons with rheumatoid arthritis with and without depressive symptoms.

OBJECTIVE: Persons with rheumatoid arthritis (RA) report more activity losses than persons without RA. Persons with RA who report depressive symptoms experience lower levels of functioning. We integrated these findings and examined the association of depressive symptoms with the activities in which persons with RA participate. METHODS: We surveyed 726 persons with RA and 192 matched controls. Within each group, we examined the perceived importance and actual performance of 65 life activities by individuals with and without depressive symptoms. RESULTS: Significantly more individuals with RA reported depressive symptoms. Among persons with RA, those who had depressive symptoms performed fewer activities, particularly fewer valued activities. In contrast, among controls, those who were depressed rated fewer activities as important, but exhibited few significant differences in the performance of activities. CONCLUSIONS: Depressive symptoms and life activities are associated differently among persons with RA and controls. The higher rate of depression among persons with RA may be partially due to the inability to perform valued activities.

Education and self-care activities among persons with rheumatoid arthritis.

Associations between low formal education and increased morbidity and mortality have been well established among persons with rheumatoid arthritis (RA) and other conditions. This study attempted to identify a partial explanation for the association between low education and poor outcomes among persons with RA by examining self-care activities performed by persons with different levels of education. Persons with 13+ yr of education were significantly more likely to perform specific self-care activities (e.g., using a heated pool, tub, shower, OR = 2.59; using relaxation methods, OR = 3.00; using stress control methods, OR = 2.41; avoiding certain foods, OR = 1.74). The association between education and performance of self-care activities was not linear. When significant differences were noted, 13 yr of education was usually the point at which performance was significantly different than among lower education groups; individuals with 12 yr of education often exhibited lower frequencies of particular behaviors than did individuals with 9-11 yr of education. The association between higher education and performance of more self-care activities may shed light on previously described associations between education and morbidity. However, low education should not be viewed as the cause of increased morbidity and mortality, but as a proxy for a constellation of factors responsible for poor health outcomes.

The association between occupational factors and adverse health outcomes in chronic obstructive pulmonary disease.

BACKGROUND AND AIMS: Despite recognition that occupational exposures may make a substantive contribution to the aetiology of COPD, little is known about the potential role of work related factors in COPD related health outcomes. METHODS: Prospective cohort study using structured telephone interviews among a random sample of adults aged 55-75 reporting a COPD condition (emphysema, chronic bronchitis, or COPD). Using multivariate models adjusting for smoking and demographic factors, the separate and combined associations were estimated between occupational exposure to vapours, gas, dust, or fumes (VGDF) and leaving work due to lung disease (respiratory related work disability) with health outcomes and utilisation ascertained at one year follow up. RESULTS: Of 234 subjects, 128 (55%) reported exposure to VGDF on their longest held jobs, 58 (25%) reported respiratory related work disability, and 38 (16%) subjects reported both. Combined exposure to VGDF and respiratory related work disability (rather than either factor alone) was associated with the greatest risk at follow up of frequent (everyday) restricted activity days attributed to a breathing or lung condition (OR 3.8; 95% CI 1.4 to 10.1), emergency department (ED) visit (OR 3.9; 95% CI 1.4 to 10.5), and hospitalisation (OR 7.6; 95% CI 1.8 to 32). CONCLUSIONS: Among persons with COPD, past occupational exposures and work disability attributed to lung disease, particularly in combination, appear to be risk factors for adverse health related outcomes.

A pneumonia practice guideline and a hospitalist-based reorganization lead to equivalent efficiency gains.

OBJECTIVE: To compare the impact of a practice guideline for a common inpatient disorder with that of a hospitalist-based reorganization of an academic medical service. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: In July 1995 we introduced a clinical practice guideline for the treatment of community-acquired pneumonia at University of California San Francisco Moffitt-Long Hospital. Simultaneously, we implemented a structural change for half of the inpatient medical service, requiring earlier and more intensive faculty intervention, primarily by hospitalists. For 1 year, we studied the effect of these interventions on hospital costs, length of stay, and resource use. RESULTS: As reported previously, the hospitalist-based intervention resulted in significant decreases in average adjusted cost ($7777 vs $7007, P = .05) and length of stay (4.9 days vs 4.3 days, P = .01) compared with both concurrent and historical controls. For patients with community-acquired pneumonia, a similar savings occurred when fiscal year 1996 was compared with fiscal year 1995 ($8164 vs $6282, P= .015; 5.0 vs 4.2 days, P= .04). However, the effect was identical for the hospitalist and nonhospitalist groups. The reduced length of stay was associated with a borderline significant reduction in readmission rates (from 4.8% to 0.7%, P = .055) and no change in mortality rates. CONCLUSIONS: In this study, a hospitalist-based reorganization improved efficiency, with its greatest impact on the care of patients with disorders not covered by a practice guideline. The introduction of a guideline for a common diagnosis improved efficiency on both hospitalist- and nonhospitalist-based services. For common diagnoses amenable to practice guidelines, successful implementation of and compliance with guidelines may be an alternative to major organizational change.