The Impact of Parent's Health Literacy on Pediatric Asthma Outcomes.

Background: Health literacy has been associated with health disparities in many disease outcomes, including children's asthma. Parents are responsible for most of children's healthcare. Therefore, parents' health literacy may impact children's health outcomes, including asthma control. This study sought to determine the association between parent health literacy and children's asthma control among a cohort of predominately minority urban children aged between 6 and 12 years. Methods: This cross-sectional study assessed children with asthma and their parents at a single outpatient visit. English-speaking parents and their children, aged between 6 and 12 years with physician-diagnosed asthma, were eligible for this study. Healthcare providers assessed asthma control and severity, and parents completed demographic, health literacy, asthma control, and asthma knowledge measures. Children completed a pulmonary function test as part of the Asthma Control Questionnaire (ACQ) scoring. Results: A total of 281 parent-child dyads provided data, with the majority of parents being mothers and African American, with a high school level education or less. Lower parent health literacy was associated with worse asthma control as rated both by the provider (p=0.007) and the ACQ (p=0.013), despite only moderate concordance between ratings (ρ=0.408, p<0.0001). Lower parent health literacy also was associated with less asthma knowledge, which was associated with worse asthma control. Conclusions: Higher parent health literacy was associated with more parent asthma knowledge and better child asthma control. Pediatric providers should consider tailoring education or treatment plans or utilizing universal precautions for low health literacy.

Differences in Electronic Cigarette Awareness, Use History, and Advertisement Exposure Between Black and White Hospitalized Cigarette Smokers.

E-cigarette use has increased rapidly over the past decade. There is growing concern about e-cigarette use and advertising given limited regulation of these products. This cross-sectional study reports on data collected at baseline from hospitalized cigarette smokers (N=944) recruited in monthly cohorts between December 2012 and September 2013. Participants were queried regarding e-cigarette awareness and use, and number and sources of e-cigarette advertisement exposures in the previous 6 months. Most Whites (99%) reported ever hearing of an e-cigarette compared to 96% of Blacks (p<0.001). Over two thirds (64%) of Whites reported ever using an e-cigarette compared to 30% of Blacks (p<0.001). There were significant trends in increasing e-cigarette use for both racial groups with an average increase of 13% each month (p<0.005) and in increasing e-cigarette advertisement exposure reported for the previous 6 months, with a 14% increase each month (p<0.0001). Whites reported 56% greater advertisement exposure than Blacks (mean=25 vs. 8 in month 1 to 79 vs. 45 in month 9, respectively; p<0.0001). For Blacks, advertisement exposure was significantly associated with e-cigarette use (p<0.001). Whites reported more advertisement exposure from stores and the Internet, and Blacks reported more advertisement exposure from radio or television. Results suggest that e-cigarette marketing is beginning to breach the Black population who are, as a consequence, "catching up" with Whites with regard to e-cigarette use. Given the significant disparities for smoking-related morbidity and mortality between Blacks and Whites, these findings identify new areas for future research and policy.

Web-based smoking cessation intervention that transitions from inpatient to outpatient: study protocol for a randomized controlled trial.

BACKGROUND: E-health tools are a new mechanism to expand patient care, allowing supplemental resources to usual care, including enhanced patient-provider communication. These applications to smoking cessation have yet to be tested in a hospitalized patient sample. This project aims to evaluate the effectiveness and cost-effectiveness of a tailored web-based and e-message smoking cessation program for current smokers that, upon hospital discharge, transitions the patient to continue a quit attempt when home (Decide2Quit). DESIGN: A randomized two-arm follow-up design will test the effectiveness of an evidence- and theoretically-based smoking cessation program designed for post-hospitalization. METHODS: A total of 1,488 patients aged 19 or older, who smoked cigarettes in the previous 30 days, are being recruited from 27 patient care areas of a large urban university hospital. Study-eligible hospitalized patients receiving usual tobacco cessation usual care are offered study referral. Trained hospital staff assist the 744 patients who are being randomized to the intervention arm with registration and orientation to the intervention website. This e-mail and web-based program offers tailored messages as well as education, self-assessment and planning aids, and social support to promote tobacco use cessation. Condition-blind study staff assess participants for tobacco use history and behaviors, tobacco use cost-related information, co-morbidities and psychosocial factors at 0, 3, 6, and 12 months. The primary outcome is self-reported 30-day tobacco abstinence at 6 months follow-up. Secondary outcomes include 7-day point prevalence quit rates at 3-, 6-, and 12-month follow-up, 30-day point prevalence quit rates at 3 and 12 months, biologically confirmed tobacco abstinence at 6-month follow-up, and multiple point-prevalence quit rates based on self-reported tobacco abstinence rates at each follow-up time period. Healthcare utilization and quality of life are assessed at baseline, and 6- and 12-month follow-up to measure program cost-effectiveness from the hospital, healthcare payer, patient, and societal perspectives. DISCUSSION: Given the impact of tobacco use on medical resources, establishing feasible, cost-effective methods for reducing tobacco use is imperative. Given the minimal hospital staff burden and the automated transition to a post-hospitalization tailored intervention, this program could be an easily disseminated approach. TRIAL REGISTRATION: Current Intervention Trial NCT01277250.

A survey of clergy practices associated with premarital financial counseling.

The purpose of this exploratory study was to gain an understanding of the state of clergy-led premarital financial counseling. Clergy respondents (n = 223) indicated that they often include a financial component in their formal premarital counseling. The most frequently discussed financial topics are budgeting, managing debt and credit, and saving. The most frequently cited obstacles to providing premarital financial counseling are lack of time and lack of subject matter expertise.

Cost-effectiveness of school-based asthma screening in an urban setting.

BACKGROUND: Much has been done to promote population-based childhood asthma screening; however, concerns remain regarding its cost-effectiveness. OBJECTIVES: To conduct a cost-effectiveness analysis of school-based asthma screening strategies. METHODS: A 5 health state Markov approach (symptom-free, symptom, exacerbation recovery, emergency department, and hospitalization day) was used to evaluate school-based screening in a simulated population of urban elementary-age school children. Two questionnaire and 2 multistage strategies incorporating spirometry or spirometry with exercise testing were evaluated from the societal perspective by using 365 daily cycles. The outcome was 2006 dollars per quality-adjusted life year (QALY). RESULTS: The most efficient strategy identified children with previously diagnosed but poorly controlled asthma at a cost of $150,000 per QALY (95% CI, $65,800-$318,000). Uncertainty surrounding the cost-effectiveness estimate was primarily a result of the symptom day preference weight estimate (44%), the probability of confirmation after screening (17%), the adequacy of asthma control in the population (9%), and the estimated treatment effect on symptoms (6%). Screening generated an additional 21 symptom-free day equivalents per child identified with previously diagnosed but not well controlled asthma and led to $85.55, $12.36, and $2.58 in additional screening, daily treatment, and indirect costs and $5.01 less in emergency department and hospitalization costs. CONCLUSION: Population-based asthma screening is not cost-effective at $50,000 per QALY and has only a 20% chance of being cost-effective at $100,000 per QALY. The most efficient approach is to screen for previously diagnosed but poorly controlled asthma. Linking screening with better treatment, and long-term adherence strategies might yield future cost-effective approaches.

Development and validation of the Chronic Obstructive Pulmonary Disease Assessment Questionnaire (COPD-AQ).

AIMS: To develop a practical patient-completed chronic obstructive pulmonary disease assessment questionnaire (COPD-AQ) to improve COPD assessment and management in primary care, based on the concept of COPD stability. METHODS: An Expert Working Group defined parameters of COPD stability and a 10-item Physician's Global Assessment was established. A 21-item COPD-AQ was developed and validated in a cross-sectional, non-randomised study of patients with COPD (n=395). Items most discriminative of stability status (stable/unstable) were selected to produce a 5-item COPD-AQ, which was then validated. RESULTS: In the development sample, internal consistency reliability of the 5-item COPD-AQ was 0.74 (n=296). The COPD-AQ discriminated between stability groups based on physician assessment (F=44.26; p<0.0001) and post-bronchodilator spirometry measures (F=2.92; p<0.05). A questionnaire score >20 (range: 5.0-25.0) had a specificity of 82.9% and sensitivity of 64.7%. CONCLUSIONS: The 5-item COPD-AQ proved a practical tool for assessing COPD status and was sufficiently simple for routine clinical use. However, overall validation was limited by small numbers of patients in the validation sample. Difficulties also existed over using the term 'stability' to define COPD status. COPD-AQ was not progressed further, but this work will prove valuable in the future development of a global questionnaire to improve COPD management in primary care.

Targeted tuberculosis contact investigation saves money without sacrificing health.

BACKGROUND: Health departments require an efficient strategy to investigate individuals exposed to Mycobacterium tuberculosis. The contact priority model (CPM) uses a decision rule to minimize testing of low-risk contacts; however, its impact on costs and disease control is unknown. METHODS: A cost-effectiveness analysis compared the CPM with the traditional concentric circle approach (CCA) in a simulated population of 1000 healthy, community-dwelling adults with a 10% background rate of latent tuberculosis (TB) infection. The analysis was conducted from the perspective of the Alabama Department of Public Health. Model inputs were derived from the literature and the Alabama Department of Public Health. Lifetime costs (2004 dollars) and outcomes were discounted 3 percent annually. Incremental cost-effectiveness ratios were used to compare the strategies. RESULTS: Over the lifetime of 1000 simulated contacts, the CPM saved $45,000 but led to 0.5 additional TB cases and 0.24 fewer years of life. The CCA is more effective than the CPM, but it costs $92,934 to prevent one additional TB case and $185,920 to gain one additional life year. CONCLUSIONS: The CPM reduces costs with minimal loss of disease control and is a viable alternative to the CCA under most conditions.

Long-term oxygen treatment in chronic obstructive pulmonary disease: recommendations for future research: an NHLBI workshop report.

Long-term oxygen treatment (LTOT) prolongs life in patients with chronic obstructive pulmonary disease (COPD) and severe resting hypoxemia. Although this benefit is proven by clinical trials, scientific research has not provided definitive guidance regarding who should receive LTOT and how it should be delivered. Deficiencies in knowledge and in current research activity related to LTOT are especially striking in comparison to the importance of LTOT in the management of COPD and the associated costs. The National Heart, Lung, and Blood Institute, in collaboration with the Centers for Medicare and Medicaid Services, convened a working group to discuss research on LTOT. Participants in this meeting identified specific areas in which further investigation would likely lead to improvements in the care of patients with COPD or reductions in the cost of their care. The group recommended four clinical trials in subjects with COPD: (1) efficacy of ambulatory O(2) supplementation in subjects who experience oxyhemoglobin desaturation during physical activity but are not severely hypoxemic at rest; (2) efficacy of LTOT in subjects with severe COPD and only moderate hypoxemia; (3) efficacy of nocturnal O(2) supplementation in subjects who show episodic desaturation during sleep that is not attributable to obstructive sleep apnea; and (4) effectiveness of an activity-dependent prescription for O(2) flow rate that is based on clinical tests performed at rest, during exercise, and during sleep.

A decision tree for tuberculosis contact investigation.

The University of Alabama at Birmingham and the Alabama Department of Public Health recently developed a logistic regression model showing those variables that are most likely to predict a positive tuberculin skin test in contacts of tuberculosis cases. However, translating such a model into field application requires a stepwise approach. This article describes a decision tree developed to assist public health workers in determining which contacts are most likely to have a positive tuberculin skin test. The Classification and Regression Tree analysis was performed on 292 consecutive cases and their 2,941 contacts seen by the Alabama Department of Public Health from January 1, 1998, to October 15, 1998. Several decision trees were developed and were then tested using prospectively collected data from 366 new tuberculosis cases and their 3,162 contacts from October 15, 1998, to April 30, 2000. Testing showed the trees to have sensitivities of 87-94%, specificities of 22-28%, and false-negative rates between 7 and 10%. The use of the decision trees would decrease the number of contacts investigated by 17-25% while maintaining a false-negative rate that was close to that of the presumed background rate of latent tuberculosis infection in the state of Alabama.

Murder and capital punishment: some further evidence.

The literature relating homicide and capital punishment is reviewed briefly. Despite the "presumed conclusiveness" of the evidence against the death penalty, most studies are shown to suffer from a number of theoretical and methodological shortcomings. To provide a more theoretically sound and comprehensive examination of the question, this paper analyzes alternative data for first and second degree murder and homicide in death penalty and abolition states. Results are essentially consistent with those of earlier investigations.