A Model-Based Cost-Effectiveness Analysis of an Exercise Program for Lung Cancer Survivors After Curative-Intent Treatment.

OBJECTIVE: The cost-effectiveness of exercise interventions in lung cancer survivors is unknown. We performed a model-based cost-effectiveness analysis of an exercise intervention in lung cancer survivors. DESIGN: We used Markov modeling to simulate the impact of the Lifestyle Interventions and Independence for Elders exercise intervention compared with usual care for stage I-IIIA lung cancer survivors after curative-intent treatment. We calculated and considered incremental cost-effectiveness ratios of less than US $100,000/quality-adjusted life-year as cost-effective and assessed model uncertainty using sensitivity analyses. RESULTS: The base-case model showed that the Lifestyle Interventions and Independence for Elders exercise program would increase overall cost by US $4740 and effectiveness by 0.06 quality-adjusted life-years compared with usual care and have an incremental cost-effectiveness ratio of US $79,504/quality-adjusted life-year. The model was most sensitive to the cost of the exercise program, probability of increasing exercise, and utility benefit related to exercise. At a willingness-to-pay threshold of US $100,000/quality-adjusted life-year, Lifestyle Interventions and Independence for Elders had a 71% probability of being cost-effective compared with 27% for usual care. When we included opportunity costs, Lifestyle Interventions and Independence for Elders had an incremental cost-effectiveness ratio of US $179,774/quality-adjusted life-year, exceeding the cost-effectiveness threshold. CONCLUSIONS: A simulation of the Lifestyle Interventions and Independence for Elders exercise intervention in lung cancer survivors demonstrates cost-effectiveness from an organization but not societal perspective. A similar exercise program for lung cancer survivors may be cost-effective.

Association of systemic inflammation, adiposity, and metabolic dysregulation with asthma burden among Hispanic adults.

RATIONALE: Obesity-related asthma is associated with higher disease burden than normal-weight asthma among Hispanics. Adiposity, metabolic dysregulation, and inflammation are all implicated in pathogenesis of obesity-related asthma, but their independent contributions are poorly understood. OBJECTIVE: To examine the independent contributions of body fat distribution, metabolic abnormalities and inflammation on asthma symptoms and pulmonary function among Hispanics. METHODS: Participants of the Hispanic Community Health Study/Study of Latinos with doctor-diagnosed asthma who completed an asthma symptom questionnaire and performed a valid spirometry were included in the analysis (n = 1126). Multivariate analysis was used to examine the independent association of general adiposity (assessed using body mass index), truncal adiposity (assessed by waist circumference), metabolic dysregulation (presence of insulin resistance and low HDL) and inflammation (high-sensitivity C-Reactive Protein≥3 mg/L) with reported asthma symptoms or pulmonary function measures (FEV1, and FVC) while adjusting for demographic and clinical covariates. RESULTS: Of the 1126 participants, 334 (29.5%) were overweight, and 648 (57.8%) were obese. FEV1 and FVC were lower in obese compared to normal-weight asthmatics. In analyses controlling for metabolic and adiposity factors, high hs-CRP (>7 mg/L) was associated with more symptoms (prevalence-ratio 1.27 (95%CI 1.05, 1.54), and lower FVC (ß -138 ml (95%CI -27 ml, -249 ml)) and FEV1 (ß -155 ml (95% CI -38 ml, -272 ml). Low HDL was also associated with lower FVC (ß -111 ml (-22 ml, -201 ml) and FEV1 (ß -100 ml (-12 ml, -188 ml)). Results were similar in men and women. CONCLUSIONS: Our findings suggest that hs-CRP and low HDL, rather than general and truncal adiposity, are associated with asthma burden among overweight and obese Hispanic adults.

An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis.

In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.

Quality of life as an outcome measure in pulmonary diseases.

Chronic obstructive pulmonary disease is a serious debilitating condition that is a major cause of death and disability in the modern world. There is no medical or surgical cure for chronic obstructive pulmonary disease and rehabilitation has become an accepted component of disease management and recommended in practice guidelines. Pulmonary rehabilitation programs are designed to restore patients to their highest level of functioning. Traditional physiological measures of lung function are of limited value in the evaluation of outcomes from rehabilitation and rarely capture the benefits of intervention. This review considers quality-of-life outcome measures. There are 2 major approaches to quality-of-life assessment: psychometric and decision theory. The psychometric approach is used to offer a profile summarizing different dimensions of quality of life. The decision theory approach attempts to weight the different dimensions of health in order to provide a single expression of health status. Measures can be classified as either generic or disease targeted. Generic measures can be used with any population, whereas disease-targeted measures are used for patients with a particular diagnosis. Finally, measures can be categorized by their probable uses. Most measures can be used to characterize populations and to study clinical change. However, only generic, decision theory-based measures can be used to evaluate cost-effectiveness. In this article, we review measures for chronic lung diseases in these different categories and identify those more suitable for particular purposes. We devote particular attention to methods designed for use in cost-effectiveness analysis.

Physician and patient perceptions in COPD: the COPD Resource Network Needs Assessment Survey.

PURPOSE: Chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States, has received disproportionately little attention from physicians and institutions. National data are lacking on patient and physician perceptions of and patterns of care for COPD. METHODS: Linked surveys were administered to national samples of patients with COPD, primary care physicians, and pulmonologists to evaluate perceptions of COPD severity and quality of life, attitudes about COPD, health insurance barriers to COPD care, sources of information, and knowledge about COPD diagnosis and treatment. RESULTS: Overall, 1023 patients with COPD and 1051 primary care physicians and pulmonologists responded to the surveys. Despite experiencing significant symptoms and high health care use, the majority of patients were satisfied with their care. Eighty-eight percent of physicians agreed with the statement that COPD is a "self-inflicted" disease, and more than one third were nihilistic about the treatment of patients who continued to smoke. Patients and physicians reported that insurance problems impeded access to therapies. Patients were generally uninformed about COPD; 54% of primary care physicians were aware of any COPD guidelines. Both patient and physician surveys demonstrated continued confusion about the diagnosis of COPD and treatment choices. There was frequent use of regular oral steroids despite demonstrated lack of efficacy and under-use of pulmonary rehabilitation despite proven efficacy. CONCLUSIONS: Patients with COPD have a high prevalence of activity limitations. Although most physicians believed that proper treatment can slow progression, inadequate knowledge and poor adherence to practice guidelines, together with insurance impediments, negatively impact COPD care.