Comparing asthma control assessment using the Asthma Control Test and the Asthma APGAR in African American/Black and Hispanic/Latinx populations.

INTRODUCTION: The objective of this analysis was to compare the Asthma Control Test (ACT) and the Asthma APGAR asthma control assessment tools in African-Ancestry/Black (AA/B) and Hispanic/Latinx (H/L) adults with moderate to severe asthma. METHODS: This pre-planned sub-study of the PREPARE clinical trial compares the baseline ACT and Asthma APGAR scores for the PREPARE populations using correlation coefficients, generalized linear modeling and receiver operating curve (ROC) analyses. Correlations were also assessed for both control tests and the Asthma Symptom Utility Index (ASUI). RESULTS: Among the 1201 adults (603 AA/B and 598 H/L) with moderate to severe asthma, most had uncontrolled asthma by both the ACT and the Asthma APGAR. Correlation coefficients between the ACT, Asthma APGAR and ASUI were strong and did not differ significantly by race/ethnicity. The ACT consistently assessed more patients as uncontrolled compared with the Asthma APGAR. The differences in ACT and Asthma APGAR scores did not differ by age, gender, race/ethnicity, self-reported health literacy or medication adherence but did differ by education level. Both the ACT and Asthma APGAR had similar ROCs for predicting an asthma exacerbation in the next 3 months. CONCLUSIONS: Both the ACT and the Asthma APGAR can be used for asthma control assessment in AA/B and H/L populations with moderate to severe asthma, providing comparable rates of uncontrolled asthma and similar limited ability to predict exacerbations. Further work is required to better understand the basis and clinical implications of the higher rates of uncontrolled asthma identified using the ACT.

Increased Health Care Resource Utilization and Costs Associated with Herpes Zoster Among Patients Aged ≥50 Years with Chronic Obstructive Pulmonary Disease in the United States.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are potentially at increased risk of herpes zoster (HZ). Little is known about the impact of an HZ episode on health care resource utilization (HRU) and costs among patients with COPD. METHODS: This retrospective cohort study of individuals aged ≥50 years in the United States (US) used administrative claims data from Optum's de-identified Clinformatics Data Mart Database for commercially insured and Medicare Advantage members (2013-2018). Two cohorts of patients with COPD, with HZ (COPD+/HZ+) and without HZ (COPD+/HZ-), were identified. All-cause and COPD-related HRU rates and costs (2018 US dollars) were compared between cohorts for up to 12 months of follow-up. Comparisons were controlled for baseline differences through propensity score adjustment. RESULTS: A total of 3415 COPD+/HZ+ and 35,360 COPD+/HZ- patients (mean ages 73.2 ± 9.0 and 72.4 ± 9.4 years, respectively) were identified. Patients in the COPD+/HZ+ versus COPD+/HZ- cohort had increased use of all-cause (adjusted incidence rate ratio [aIRR] 1.17; 95% confidence interval [CI] 1.14, 1.21) and COPD-related (aIRR 1.27; 95% CI 1.21, 1.34) medical services (both P<0.001) and higher mean total all-cause ($4140 versus $3749 per person per month [PPPM]; adjusted cost difference +$313 PPPM) and COPD-related ($1541 versus $1231 PPPM; +$152 PPPM) costs (both P<0.004) in the year after HZ. CONCLUSIONS: HRU and cost burden is higher in patients with COPD with vs without HZ. These results could help to estimate the potential cost benefits of HZ vaccination among patients with COPD.

A systematic literature review of herpes zoster incidence worldwide.

We conducted a systematic review to characterize the incidence rate of herpes zoster (HZ) in the general population, specifically in individuals ≥50 years of age. A total of 69 publications were included in the review. We found a cumulative incidence of HZ ranging from 2.9-19.5 cases per 1,000 population and an incidence rate of HZ ranging from 5.23-10.9 cases per 1,000 person-years. The cumulative incidence (3.22-11.2 versus 2.44-8.0 cases per 1,000 population) and incidence rates (6.05-12.8 versus 4.30-8.5 cases per 1,000 person-years) were higher in females than males. Studies revealed a trend of increasing incidence of HZ with increasing age and over time. Variations in incidence estimates can be attributed to the various study designs, case ascertainments, age distributions of the population and year of the study. HZ is associated with a substantial disease burden and is expected to increase due to population aging.

Protocol Summary of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) Validation in Primary Care Study.

Chronic obstructive pulmonary disease (COPD) often remains undiagnosed and untreated. To date, COPD screening/case finding has not been designed to identify clinically significant COPD, disease ready for therapies beyond smoking cessation. Herein, we describe the ongoing prospective, pragmatic cluster-randomized controlled trial to assess specificity and sensitivity of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) tool consisting of 5 questions and peak expiratory flow. The tool is designed to identify clinically significant COPD (forced expiratory volume in 1 second [FEV1] to forced vital capacity [FVC] ratio <.70 plus FEV1% predicted <60% or increased risk for exacerbation) and the trial will explore the impact of CAPTURE-based screening on COPD diagnosis and treatment rates in primary care patients. Of a total planned enrollment of 5000 English- or Spanish-speaking patients 45 to 80 years of age without a prior COPD diagnosis from 100 primary care practices, a total of 68 practices and 3064 patients have been enrolled in the study. Practices are centrally randomized to either usual care or clinician receipt of patient-level CAPTURE results. All clinicians receive basic COPD education with those in intervention practices also receiving CAPTURE interpretation education. In a single visit, patient participants complete a CAPTURE screening, pre- and post-bronchodilator spirometry and baseline demographic and health questionnaires to validate CAPTURE sensitivity, specificity, and predictive value of identifying undiagnosed, clinically significant COPD. One-year follow-up chart reviews and participant surveys assess the impact of sharing versus not sharing CAPTURE results with clinicians on clinical outcomes including level of respiratory symptoms and events and clinicians' initiation of recommendation-concordant COPD care. This is one of the first U.S. studies to validate and assess impact of a simple COPD screening tool in primary care.

Analysis of Vascular Event Risk After Herpes Zoster From 2007 to 2014 US Insurance Claims Data.

OBJECTIVE: To estimate the risk of transient ischemic attack (TIA), stroke, and myocardial infarction in periods covering 4 weeks before to 52 weeks after herpes zoster (HZ) diagnosis in US adults. PATIENTS AND METHODS: This retrospective study (GSK study identifier: HO-15-15771) with matched cohorts used the Truven Health MarketScan Commercial and Medicare claims data set linked with obesity and smoking status information. Patients 18 years and older at the date of HZ diagnosis and 1-year pre- and post-HZ diagnosis continuous insurance enrollment (from January 1, 2007, through December 31, 2014) were propensity score matched to controls in terms of demographic characteristics, risk factors for vascular events, other comorbid disorders, general health, obesity, and smoking status. A post hoc sensitivity analysis was performed not matching for obesity and smoking status information. Adjusted incidence rate ratios (IRRs) were estimated using multivariate Poisson models during an aggregate period (1-month before and after the index date). RESULTS: A total of 23,339 patients with HZ were matched to 46,378 controls (mean age, 56 years; 45,173 [65%] women). During the aggregate period, patients with HZ were statistically significantly more likely to suffer a TIA: IRRs for all patients and patients aged 18 to 49 years were 1.56 (95% confidence interval [CI], 1.13-2.15) and 5.12 (95% CI, 1.37-19.10), respectively (P<.05); the respective IRRs for stroke were 1.40 (95% CI, 0.93-2.11) and 8.12 (95% CI, 0.93-71.27). In the sensitivity analysis, IRRs for TIA and stroke were statistically significantly increased regardless of age. CONCLUSION: Herpes zoster was associated with an increased risk of composite events, TIA, and stroke in adults in the period around diagnosis. More research on the HZ and vascular risk association is needed. GSK STUDY IDENTIFIER: HO-15-15771.

Cost-effectiveness of an adjuvanted recombinant zoster vaccine in older adults in the United States who have been previously vaccinated with zoster vaccine live.

Zoster Vaccine Live (ZVL) is marketed in the US since 2008, and a non-live adjuvanted Recombinant Zoster Vaccine (RZV) was approved in 2017. Literature suggests that waning of ZVL efficacy may necessitate additional vaccination. The Advisory Committee on Immunization Practices recommended vaccination with RZV in immunocompetent adults aged 50+ years old, including those previously vaccinated with ZVL. The objective of this study was to determine the cost-effectiveness of vaccinating US adults aged 60+ years old, previously vaccinated with ZVL. The ZOster ecoNomic Analysis (ZONA) model, a deterministic Markov model, was adapted to follow a hypothetical 1 million(M)-person cohort of US adults previously vaccinated with ZVL. Model inputs included demographics, epidemiology, vaccine characteristics, utilities and costs. Costs and quality-adjusted life-years (QALYs) were presented over the lifetimes of the cohort from the year of additional vaccination, discounted 3% annually. The model estimated that, vaccination with RZV 5 years after previous vaccination with ZVL, would reduce disease burden compared with no additional vaccination, resulting in a gain of 1,633 QALYs at a total societal cost of $96M (incremental cost-effectiveness ratio: $58,793/QALY saved). Compared with revaccinating with ZVL, vaccination with RZV would result in a gain of 1,187 QALYs and societal cost savings of almost $84M. Sensitivity, scenario, and threshold analyses demonstrated robustness of these findings. Vaccination with RZV is predicted to be cost-effective relative to no additional vaccination, assuming a threshold of $100,000/QALY, and cost-saving relative to ZVL revaccination of US adults aged 60+ years old who have been previously vaccinated with ZVL.

COPD in Primary Care: Key Considerations for Optimized Management: Treatment Options for Stable Chronic Obstructive Pulmonary Disease: Current Recommendations and Unmet Needs.

Primary care physicians manage the care of approximately 80% of patients with chronic obstructive pulmonary disease (COPD). This provides the opportunity to engage patients in management goal-setting that facilitates more tailored treatments, and can improve adherence to therapy, which is historically poor in patients with COPD, thereby improving outcomes.

Developing a standardized healthcare cost data warehouse.

BACKGROUND: Research addressing value in healthcare requires a measure of cost. While there are many sources and types of cost data, each has strengths and weaknesses. Many researchers appear to create study-specific cost datasets, but the explanations of their costing methodologies are not always clear, causing their results to be difficult to interpret. Our solution, described in this paper, was to use widely accepted costing methodologies to create a service-level, standardized healthcare cost data warehouse from an institutional perspective that includes all professional and hospital-billed services for our patients. METHODS: The warehouse is based on a National Institutes of Research-funded research infrastructure containing the linked health records and medical care administrative data of two healthcare providers and their affiliated hospitals. Since all patients are identified in the data warehouse, their costs can be linked to other systems and databases, such as electronic health records, tumor registries, and disease or treatment registries. RESULTS: We describe the two institutions' administrative source data; the reference files, which include Medicare fee schedules and cost reports; the process of creating standardized costs; and the warehouse structure. The costing algorithm can create inflation-adjusted standardized costs at the service line level for defined study cohorts on request. CONCLUSION: The resulting standardized costs contained in the data warehouse can be used to create detailed, bottom-up analyses of professional and facility costs of procedures, medical conditions, and patient care cycles without revealing business-sensitive information. After its creation, a standardized cost data warehouse is relatively easy to maintain and can be expanded to include data from other providers. Individual investigators who may not have sufficient knowledge about administrative data do not have to try to create their own standardized costs on a project-by-project basis because our data warehouse generates standardized costs for defined cohorts upon request.

Assessing health disparities in children using a modified housing-related socioeconomic status measure: a cross-sectional study.

OBJECTIVES: Socioeconomic status (SES) is a well-established risk factor for many health outcomes. Recently, we developed an SES measure based on 4 housing-related characteristics (termed HOUSES) and demonstrated its ability to assess health disparities. In this study, we aimed to evaluate whether fewer housing-related characteristics could be used to provide a similar representation of SES. STUDY SETTING AND PARTICIPANTS: We performed a cross-sectional study using parents/guardians of children aged 1-17 years from 2 US Midwestern counties (n=728 in Olmsted County, Minnesota, and n=701 in Jackson County, Missouri). PRIMARY AND SECONDARY OUTCOME MEASURES: For each participant, housing-related characteristics used in the formulation of HOUSES (assessed housing value, square footage, number of bedrooms and number of bathrooms) were obtained from the local government assessor's offices, and additional SES measures and health outcomes with known associations to SES (obesity, low birth weight and smoking exposure) were collected from a telephone survey. Housing characteristics with the greatest contribution for predicting the health outcomes were added to formulate a modified HOUSES index. RESULTS: Among the 4 housing characteristics used in the original HOUSES, the strongest contributions for predicting health outcomes were observed from assessed housing value and square footage (combined contribution ranged between 89% and 96%). Based on this observation, these 2 were used to calculate a modified HOUSES index. Correlation between modified HOUSES and other SES measures was comparable to the original HOUSES for both locations. Consistent with the original HOUSES formula, the strongest association with modified HOUSES was observed with smoking exposure (OR=0.24 with 95% CI 0.11 to 0.49 for comparing participants in highest HOUSES vs lowest group; overall p<0.001). CONCLUSIONS: The modified HOUSES requires only 2 readily available housing characteristics thereby improving the feasibility of using this index as a proxy for SES in multiple communities, especially in the US Midwestern region.

Adherence to Asthma Guidelines in Children, Tweens, and Adults in Primary Care Settings: A Practice-Based Network Assessment.

OBJECTIVE: To assess primary care adherence to 2007 US asthma guidelines. PATIENTS AND METHODS: Patients with persistent asthma aged 5 to 65 years from 22 primary care participating practices provided the data for this analysis of baseline information from the pragmatic randomized clinical trial the Asthma Tools Study. Using a combination of abstracted medical record data and patient-reported demographic information, we assessed the medical record documentation for elements of the 2007 US asthma guidelines. Elements assessed included documentation of (1) assessment of control, (2) factors that affect control (medication adherence evaluation, inhaler technique education, and evaluation for triggers), (3) self-management support (action plan), and (4) asthma medications prescribed (short-acting ß-agonists and daily maintenance therapy). The baseline data was collected from March 16, 2009, to May 1, 2014. RESULTS: In 1176 patients (285 children, 211 tweens, and 680 adults) from 16 family medicine and 6 pediatric practices across the United States, documented guideline adherence was highest for prescription of medications (88.0% for short-acting ß-agonists and 70.4% for maintenance medications) and lowest for an asthma action plan (3.1%). Documentation of control (15.0%) and factors that affect control (inhaler technique education, 7.6%; medication adherence assessment, 32.5%; and allergy evaluation, 32.5%) was not common and even less common for adults compared with children. A total of 22.2% of the enrolled patients had no asthma-related visit in the year before enrollment. Adherence to the nonmedication elements were higher in practices located in cities of more than 250,000 people and cities that used electronic medical records. Older patient age was negatively associated with guideline adherence. CONCLUSION AND RELEVANCE: Adherence to asthma guidelines is poor in primary care practices, leaving many opportunities for improvement.

Risk of Stroke and Myocardial Infarction After Herpes Zoster in Older Adults in a US Community Population.

OBJECTIVE: To assess the risk of stroke and myocardial infarction (MI) after herpes zoster in a US community population of older adults. PATIENTS AND METHODS: We performed a community cohort study (January 1, 1986, to October 1, 2011) comparing the risk of stroke and MI in 4862 adult residents of Olmsted County, Minnesota, 50 years and older with and without herpes zoster and 19,433 sex- and age-matched individuals with no history of herpes zoster. Odds ratios are presented for MI and stroke at 3, 6, 12, and 36 months after index herpes zoster plus hazard ratios for long-term risk (up to 28.6 years). RESULTS: Individuals with herpes zoster had more risk or confounding factors for MI and stroke, suggesting that they had worse health status overall. When controlling for the multiple risk factors, those with herpes zoster were at increased risk for stroke at 3 months after herpes zoster compared with those without a history of herpes zoster (odds ratio, 1.53; 95% CI, 1.10-2.33; P=.04). The association between herpes zoster and MI at 3 months was not robust across analytic methods. Herpes zoster was not associated with an increased risk of stroke or MI at any point beyond 3 months. CONCLUSIONS: Herpes zoster was associated with only a short-term increased risk of stroke, which may be preventable with the prevention of herpes zoster.

Concordance between Individual vs. Area-Level Socioeconomic Measures in an Urban Setting.

Area-level socioeconomic status (SES) measures have been used as a proxy in child health research when individual SES measures are lacking, yet little is known about their validity in an urban setting. We assessed agreement between census block-group and individual-level SES measures obtained from a caregiver telephone survey in Jackson County, Missouri. Associations with prevalence of childhood overweight (OW), low birth weight (LBW), and household smoking exposure were examined using logistic regression models. Seven hundred eighty-one households were surveyed: 49% male, 76% White, mean child age 9.4 years. We found misclassification rates of 20-35% between individual vs. area-level measures of education and income; Kappa indices ranged from 0.26-0.36 indicating poor agreement. Both SES measures showed an inverse association with LBW and smoking exposure. Area-level SES measures may reflect a construct inclusive of neighborhood resources; routine substitution of these measures should be interpreted with caution, despite similar correlations with health outcomes.

Obesity, low levels of physical activity and smoking present opportunities for primary care asthma interventions: an analysis of baseline data from The Asthma Tools Study.

BACKGROUND: Asthma prevalence, severity and outcomes are associated with various patient characteristics and lifestyle choices. AIMS: To identify potentially modifiable factors associated with poor asthma outcomes among US primary care patients. METHODS: Using baseline data from the Asthma Tools Study, we calculated cross-sectional frequencies of activity levels, smoking, secondhand smoke exposure and the presence of obesity, as well as rates of out-of-control asthma and asthma exacerbations. Frequencies were stratified by sex, and into three age groups: 5-11 years, 12-18 years and 19 years and older. Logistic regression was used to identify factors associated with each of the asthma outcomes. RESULTS: In the 901 individuals enrolled in this asthma study, tobacco smoke exposure, obesity, low activity levels, poverty, inadequately controlled asthma and high asthma-related health-care utilisation were common. Across all age groups, obesity was associated with poorer asthma outcomes: either poor asthma control (odds ratio (OR)=2.3, 95% confidence interval (CI) 1.1-4.7 in 5- to 11-year-olds and OR=1.5, 95% CI 1.1-2.2 in adults) or asthma exacerbations (OR 2.9, 95% CI 1.6-5.1 in 12- to 18-year-olds and OR 1.7, 95% CI 1.1-2.5 in adults). Among adults, smoking was associated with both measures of poorer asthma outcomes; inadequate asthma control (OR=2.3, 95% CI 1.5-3.5), and asthma exacerbations (OR 1.7, 95% CI 1.1-2.6), and low physical activity were associated with poor asthma control (OR=1.5, 95% CI 1.1-2.2). CONCLUSIONS: Obesity, low levels of physical activity and smoking are common, and they are associated with poor asthma outcomes in a sample of primary care patients, suggesting important targets for intervention.

Depressive symptoms and access to mental health care in women screened for postpartum depression who lose health insurance coverage after delivery: findings from the Translating Research into Practice for Postpartum Depression (TRIPPD) effectiveness study.

OBJECTIVE: To determine the impact of losing health insurance coverage on perceived need for and access to mental health care in women screened for postpartum depression (PPD) in primary care settings. PATIENTS AND METHODS: The study sample included 2343 women enrolled in a 12-month, multisite, randomized trial that compared clinical outcomes of a comprehensive PPD screening and management program with usual care (March 1, 2006, through August 31, 2010). Screening for PPD occurred at the first postpartum visit (5-12 weeks) using the Edinburgh Postnatal Depression Scale followed by the 9-item Patient Health Questionnaire. Insurance status during the prenatal period, at delivery, and during the first postpartum year and perceived need for and access to mental health care during the first postpartum year were assessed via questionnaires completed by individual patients and participating practices. RESULTS: Rates of uninsured increased from 3.8% during pregnancy and delivery (n=87 of 2317) to 10.8% at the first postpartum visit (n=253 of 2343) and 13.7% at any subsequent visit to the practice after 2 months post partum (n=226 of 1646) (P<.001, both comparisons vs baseline). For patients with data on insurance type during follow-up, insurance loss occurred primarily in Medicaid beneficiaries. Nine-item Patient Health Questionnaire scores and self-reported need for mental health care did not differ significantly between patients who remained insured and those who lost insurance during the first postpartum year. However, of patients who reported the need for mental health care, 61.1% of the uninsured (n=66 of 108) vs 27.1% of the insured (n=49 of 181) reported an inability to obtain mental health care (P<.001). CONCLUSION: Loss of insurance during the first postpartum year did not significantly affect depressive symptoms or perceived need for mental health care but did adversely affect self-reported ability to obtain mental health care.

Introducing the COPD Foundation Guide for Diagnosis and Management of COPD, recommendations of the COPD Foundation.

The increasing number of treatment options for managing patients with chronic obstructive pulmonary disease (COPD) promises to improve the outcomes for COPD patients. However, determining which treatments are appropriate for individual patients has become increasingly complex. The COPD Foundation Guide for Diagnosis and Management of COPD was developed to be a practical, easy to use tool for clinicians. The Guide includes specific recommendations for diagnostic studies and treatments based on specific diagnostic criteria. This manuscript describes the rationale for the development of the Guide, the process used, the rationale for the specific recommendations and the plans for further development. The current recommendations of the COPD Foundation have been summarized in the form of Pocket Cards, which may be obtained from the Foundation at no charge (1-866-316-COPD (2673), www.copdfoundation.org).

'They leave at least believing they had a part in the discussion': understanding decision aid use and patient-clinician decision-making through qualitative research.

OBJECTIVE: This study explores how patient decision aids (DAs) for antihyperglycemic agents and statins, designed for use during clinical consultations, are embedded into practice, examining how patients and clinicians understand and experience DAs in primary care visits. METHODS: We conducted semistructured in-depth interviews with patients (n=22) and primary care clinicians (n=19), and videorecorded consultations (n=44). Two researchers coded all transcripts. Inductive analyses guided by grounded theory led to the identification of themes. Video and interview data were compared and organized by themes. RESULTS: DAs used during consultations became flexible artifacts, incorporated into existing decision making roles for clinicians (experts, authority figures, persuaders, advisors) and patients (drivers of healthcare, learners, partners). DAs were applied to different decision making steps (deliberation, bargaining, convincing, case assessment), and introduced into an existing knowledge context (participants' literacy regarding shared decision-making (SDM) and DAs). CONCLUSION: DAs' flexible use during consultations effectively provided space for discussion, even when SDM was not achieved. DAs can be used within any decision-making model. PRACTICE IMPLICATIONS: Clinician training in DA use and SDM practice may be needed to facilitate DA implementation and promote more ideal-type forms of sharing in decision making.

Comparison of individual-level versus area-level socioeconomic measures in assessing health outcomes of children in Olmsted County, Minnesota.

BACKGROUND: Socioeconomic status (SES) is an important determinant of health, but SES measures are frequently unavailable in commonly used datasets. Area-level SES measures are used as proxy measures of individual SES when the individual measures are lacking. Little is known about the agreement between individual-level versus area-level SES measures in mixed urban-rural settings. METHODS: We identified SES agreement by comparing information from telephone self-reported SES levels and SES calculated from area-level SES measures. We assessed the impact of this agreement on reported associations between SES and rates of childhood obesity, low birth weight <2500 g and smoking within the household in a mixed urban-rural setting. RESULTS: 750 households were surveyed with a response rate of 62%: 51% male, 89% Caucasian; mean child age 9.5 years. Individual-level self-reported income was more strongly associated with all three childhood health outcomes compared to area-level SES. We found significant disagreement rates of 22-31%. The weighted Cohen's κ indices ranged from 0.15 to 0.22, suggesting poor agreement between individual-level and area-level measures. CONCLUSION: In a mixed urban-rural setting comprised of both rural and urbanised areas, area-level SES proxy measures significantly disagree with individual SES measures, and have different patterns of association with health outcomes from individual-level SES measures. Area-level SES may be an unsuitable proxy for SES when individual rather than community characteristics are of primary concern.

Tracking health disparities through natural-language processing.

Health disparities and solutions are heterogeneous within and among racial and ethnic groups, yet existing administrative databases lack the granularity to reflect important sociocultural distinctions. We measured the efficacy of a natural-language-processing algorithm to identify a specific immigrant group. The algorithm demonstrated accuracy and precision in identifying Somali patients from the electronic medical records at a single institution. This technology holds promise to identify and track immigrants and refugees in the United States in local health care settings.