Cardiopulmonary interactions with beta-blockers and inhaled therapy in COPD.

BACKGROUND: Beta-blockers remain underused in patients with chronic obstructive pulmonary disease (COPD) and cardiovascular disease. AIM: We compared how different inhaled therapies affect tolerability of bisoprolol and carvedilol in moderate to severe COPD. DESIGN: A randomized, open label, cross-over study. METHODS: We compared the cardiopulmonary interactions of bisoprolol 5 mg qd or carvedilol 12.5 mg bid for 6 weeks in conjunction with: (i) triple: inhaled corticosteroid/long acting beta-agonist/long acting muscarinic antagonist (ICS + LABA + LAMA), (ii) dual: ICS + LABA and (iii) ICS alone. RESULTS: Eighteen patients completed, all ex-smokers, mean age 65 years, forced expiratory volume in 1 s (FEV1) 52% predicted. Bisoprolol and carvedilol produced comparable significant reduction in resting and exercise heart rate. FEV1, forced vital capacity and lung compliance (AX) were significantly lower with carvedilol vs. bisoprolol while taking concomitant ICS/LABA (P < 0.05) but not ICS/LABA/LAMA. CONCLUSIONS: In summary, bisoprolol was better tolerated than carvedilol on pulmonary function at doses which produced equivalent cardiac beta-1 blockade. Worsening of pulmonary function with carvedilol was mitigated by concomitant inhaled LAMA (tiotropium) with LABA (formoterol), but not LABA alone. Registered at clinicaltrials.gov: NCT01656005.

Physician judgement is a crucial adjunct to pneumonia severity scores in low-risk patients.

This study investigates the reasons for hospitalisation in patients with low-risk (CURB-65 score 0-1) community-acquired pneumonia (CAP), with a view to identifying the potential for improving outpatient management. As part of a prospective observational study of CAP, we evaluated reasons for hospitalisation in these low-risk patients. 565 patients had low-risk CAP and 420 of these were admitted (for >12 h). 39.3% had additional markers of severity justifying admission, 29.5% of the admissions were required for further management that could not be provided rapidly in the community, 11.9% had unsafe social circumstances and 19.3% had no clinical reason justifying hospitalisation. 30-day mortality was increased in patients with additional severity markers (6.7%), which was significantly higher compared with 0% for patients awaiting investigations (p=0.009) and 0% without a clear indication for hospitalisation (p=0.04). In a logistic regression analysis, parameters associated with 30-day mortality were chronic cardiac comorbidity (adjusted odds ratio (aOR) 5.73, 95% CI 1.52-21.6; p=0.01), acidosis (aOR 5.14, 95% CI 1.44-18.3; p=0.01), hypoxia (aOR 9.86, 95% CI 2.39-40.7; p=0.002) and multilobar chest radiograph shadowing (aOR 4.54, 95% CI 1.21-17.1; p=0.03). This study supports recommendations from international guidelines that pneumonia severity scores should be used as an adjunct to clinical judgement, when deciding on hospitalisation.

Disconnect between standardized field-based testing and mannitol challenge in Scottish elite swimmers.

BACKGROUND: Elite swimmers have high rates of rhinoconjunctivitis and exercise-induced bronchoconstriction. Moreover, exposure to chlorine and chlorine metabolites is known to induce bronchial hyper-reactivity. OBJECTIVE: To assess the early and late effects of chlorine and exercise on the unified airway of elite swimmers, and to compare the response to mannitol and field-based exercise challenge. METHODS: The Scottish national squad underwent exhaled tidal (FE(NO)) and nasal (N(NO)) nitric oxide measurement, peak nasal inspiratory flow (PNIF), and forced expiratory volume in 1 s before, immediately after, and 4-6 h post-swimming. A sport-specific exercise test was carried out during an intensive lactate set (8 min at >/=80% maximum hear rate). All swimmers underwent mannitol challenge, and completed a health questionnaire. RESULTS: N=61 swimmers were assessed: 8/59 (14%) of swimmers had a positive mannitol challenge. Nine out of 57 (16%) of swimmers had a positive exercise test. Only one swimmer was positive to both. Swimmers with a positive mannitol had a significantly higher baseline FE(NO) (37.3 vs. 18.0 p.p.b., P=0.03) than those with a positive exercise challenge. A significant decrease in FE(NO) was observed pre vs. immediate and delayed post-chlorine exposure: mean (95% CI) 18.7 (15.9-22.0) p.p.b. vs. 15.9 (13.3-19.1) p.p.b. (P<0.01), and 13.9 (11.5-16.7) p.p.b. (P<0.01), respectively. There were no significant differences in N(NO.) Mean PNIF increased from 142.4 L/min (5.8) at baseline to 162.6 L/min (6.3) immediately post-exposure (P<0.01). Delayed post-exposure PNIF was not significantly different from pre-exposure. CONCLUSIONS: No association was found between mannitol and standardized field-based testing in elite swimmers. Mannitol was associated with a high baseline FE(NO); however, exercise/chlorine challenge was not. Thus, mannitol may identify swimmers with a 'traditional' inflammatory asthmatic phenotype, while field-based exercise/chlorine challenge may identify a swimmer-specific bronchoconstrictor response. A sustained fall in FE(NO) following chlorine exposure suggests that a non-cellular, perhaps neurogenic, response may be involved in this group of athletes.

Effects of chlorine and exercise on the unified airway in adolescent elite Scottish swimmers.

BACKGROUND: Chlorine metabolites and high training load may produce exercise-induced bronchospasm (EIB) in elite swimmers. The aim of this study was to assess the combined effects of chlorine and exercise on the unified airway of adolescent elite swimmers. METHODS: The Scottish Midlands District squad were assessed during an indoor pool session at the National Swimming Academy. Athletes trained at least 8 h per week. Subjects underwent tidal (T(NO)) and nasal (N(NO)) exhaled NO and peak nasal inspiratory flow (PNIF) pre and post a 2 h session. A physiological exercise challenge assessed EIB in n = 36 swimmers (>10% fall in forced expiratory volume in 1 s (FEV(1))). RESULTS: Combined and free chlorine levels (mg/l) were 1.66 and 0.3 respectively. n = 36 swimmers (mean age 13.3 years) were assessed: n = 8 (22%) had known asthma; n = 13 (36%) had a positive physiological challenge; 18 (50%) complained of symptoms suggestive of EIB. n = 10/28 (36%) who did not have asthma were found to have a positive exercise challenge. There was no significant association between reported exercise symptoms and positive exercise test. There was no significant change in T(NO) or N(NO) for pre vs postexposure, irrespective of asthma diagnosis or AHR. n = 15 (42%) swimmers complained of worsening nasal symptoms postexposure, but only n = 7 (14%) had a demonstrable fall in PNIF (mean 33 l/min). No significant association was found between PNIF and symptoms. CONCLUSIONS: Combined exposure to chlorine and exercise did not affect surrogate markers of inflammation in the unified airway. There was a high prevalence of undiagnosed EIB.

A comparative study of anticoagulant control in patients on long-term warfarin using home and hospital monitoring of the international normalised ratio.

BACKGROUND: Capillary whole-blood point-of-care prothrombin-INR (PT-INR) testing at home is an alternative to hospital-based monitoring for patients on lifelong warfarin. AIM: To retrospectively assess the safety and efficacy of home point-of-care testing for children on long-term warfarin. METHOD: All patients who had been on point-of-care home monitoring for at least 6 months were included in the study. Their warfarin control was assessed while on home monitoring and compared to that achieved in a similar period before changing from hospital monitoring. RESULTS: Thirty-seven patients were studied for a mean of 1.0 year on clinic monitoring and 1.07 years on home monitoring. The clinic monitoring tests were within a therapeutic range for a median 70.0 (inter-quartile range 34.5) and the home monitoring were within range for median 75.0 (inter-quartile range 44.5). There were no major haemorrhagic or thrombotic complications in either group during the study period. Only 2.3% of all tests had an INR greater than 6.0 with no statistical differences seen between the clinic and home monitoring groups. CONCLUSION: Home point-of-care testing in children on lifelong warfarin is safe, effective and offers a number of advantages to the child and family. Ongoing training and support for the families is essential for this service.

Characterization of a Brucella sp. strain as a marine-mammal type despite isolation from a patient with spinal osteomyelitis in New Zealand.

Naturally acquired infection of humans with a marine mammal-associated Brucella sp. has only been reported once previously in a study describing infections of two patients from Peru. We report the isolation and characterization of a strain of Brucella from a New Zealand patient that appears most closely related to strains previously identified from marine mammals. The isolate was preliminarily identified as Brucella suis using conventional bacteriological tests in our laboratory. However, the results profile was not an exact match, and the isolate was forwarded to four international reference laboratories for further identification. The reference laboratories identified the isolate as either B. suis or B. melitensis by traditional bacteriological methods in three laboratories and by a molecular test in the fourth laboratory. Molecular characterization by PCR, PCR-restriction fragment length polymorphism, and DNA sequencing of the bp26 gene; IS711; the omp genes omp25, omp31, omp2a, and omp2b; IRS-PCR fragments I, III, and IV; and five housekeeping gene fragments was conducted to resolve the discrepant identification of the isolate. The isolate was identified to be closely related to a Brucella sp. originating from a United States bottlenose dolphin (Tursiops truncatus) and common seals (Phoca vitulina).

A workable solution for the pre-Medicare population.

Incremental reforms to expand health coverage among older Americans are justified by medical spending that increases with age and enrollment in employer insurance that decreases with age. Older Americans are also at risk of unexpected changes in health, access to health insurance, and earnings that could leave them poorly positioned financially for their retirement years. We propose offering universal access to Medicare at a community-rated premium, with premium vouchers for those with a history of low lifetime earnings and tax-preferred savings accounts to help everyone with the increased cost of insurance at older ages. These subsidies are available for coverage obtained from sources other than Medicare. We would set the eligibility age for the buy-in at 62. However, because enrollment in employer insurance does not drop precipitously at age 62, we regard the eligibility age as an adjustable design element that could resize the program to fit political and budgetary constraints.

Health plan choice and information about out-of-pocket costs: an experimental analysis.

Many consumers are offered two or more employer-sponsored health insurance plans, and competition among health plans for subscribers is promoted as a mechanism for balancing health care costs and quality. Yet consumers may not receive the information necessary to make informed health plan choices. This study tests the effects on health plan choice of providing supplemental decision-support materials to inform consumers about expected health plan costs. Our main finding is that such information induces consumers to bear more risk, especially those in relatively good health. Thus our results suggest that working-age, privately insured consumers currently may be over-insuring for medical care.

Betwixt and between: targeting coverage reforms to those approaching Medicare.

Recent Medicare buy-in proposals agree on setting eligibility at age sixty-two but disagree on linking eligibility to loss of employer insurance or ability to pay. We examine arguments for targeting incremental coverage for older Americans in these ways. While access to retiree health insurance is declining, we question whether targeting loss of employer insurance can address many older Americans' insurance problems. Furthermore, focusing on persons ages sixty-two to sixty-four misses a large group of persons in poor health with limited resources. Efforts to improve coverage for older Americans should consider trade-offs between defining eligibility by age versus ability to pay.

Do consumer reports of health plan quality affect health plan selection?

OBJECTIVE: To learn whether consumer reports of health plan quality can affect health plan selection. DATA SOURCES: A sample of 311 privately insured adults from Los Angeles County. STUDY DESIGN: The design was a fractional factorial experiment. Consumers reviewed materials on four hypothetical health plans and selected one. The health plans varied as to cost, coverage, type of plan, ability to keep one's doctor, and quality, as measured by the Consumer Assessment of Health Plans Study (CAHPS) survey. DATA ANALYSIS: We used multinomial logistic regression to model each consumer's choice among health plans. PRINCIPAL FINDINGS: In the absence of CAHPS information, 86 percent of consumers preferred plans that covered more services, even though they cost more. When CAHPS information was provided, consumers shifted to less expensive plans covering fewer services if CAHPS ratings identified those plans as higher quality (59 percent of consumers preferred plans covering more services). Consumer choices were unaffected when CAHPS ratings identified the more expensive plans covering more services as higher quality (89 percent of consumers preferred plans covering more services). CONCLUSIONS: This study establishes that, under certain realistic conditions, CAHPS ratings could affect consumer selection of health plans and ultimately contain costs. Other studies are needed to learn how to enhance exposure and use of CAHPS information in the real world as well as to identify other conditions in which CAHPS ratings could make a difference.

Hitting a moving target: income-related health insurance subsidies for the uninsured.

New government health insurance programs are likely to emphasize voluntary purchases in a market setting, with subsidies targeted at low-income populations and stress on managed care. Such programs are best structured with a guaranteed enrollment period that is as long as six months to a year. However, given that incomes change over time, errors will be made in awarding income-related subsidies for that long. These errors are assessed in simulations undertaken with longitudinal data from the Survey of Income and Program Participation. Two allocations of the subsidies, based on current income at the beginning of the enrollment period and on actual income assessed at the end, are compared for a variety of program designs. Prospective determination of subsidies is somewhat biased toward overpayment. Net overpayments amount to 5-10 percent of subsidy costs. However, prospective payment encourages participation in the subsidy program. The simulated participation rate for true eligibles is as high as 73 percent with prospective subsidies, compared to 69 percent with retrospective reconciliation. Net overpayments are slightly reduced by testing income less frequently and over longer periods.

Quality of life assessment in adults with type 1 Gaucher disease.

The effect of enzyme replacement therapy on health-related quality of life in 25 adults with type 1 Gaucher disease was investigated over a 2-year period. Quality of life was assessed using the SF-36 Health Survey (SF-36). Psychological functioning was assessed using the Symptom Checklist--90R. The results indicated significant improvement in 7 of 8 SF scale scores beginning at 18 months of therapy (P < 0.05 to 0.001). The SF scale showing improvement first was Vitality (energy level and fatigue) at 6 months of therapy (P < 0.01). The SF-36 scales showing the largest improvements were Role-Physical and Social Functioning (P < 0.001). Compared to the general US adult population, the study population's health profile was significantly lower prior to starting therapy but by 24 months of therapy there were no differences between the two. No differences were found in psychological functioning compared to a US adult normative group at the start of therapy. However, within the study population there was significant improvement in mood and global functioning and fewer psychological symptoms reported at 24 months of therapy. The findings indicate that enzyme replacement therapy for type 1 Gaucher disease has a positive impact on health-related quality of life from the patient's perspective.

Pesticide use in the U.S. and policy implications: a focus on herbicides.

This article examines herbicide use in the United States, providing estimates of poundage, land surface covered, distribution, and recent trends based on federal and state figures. Herbicides are by far the most widely used class of pesticide in the US, where 556 million lbs of herbicide active ingredients (AIs) were applied in 1995. Agriculture accounts for the majority of herbicide use, totaling 461 million lbs of AIs in 1995. Over 60% of the poundage of all agricultural herbicides consist of those that are capable of disrupting the endocrine and/or reproductive systems of animals. In addition, at least 17 types of 'inert ingredients,' which can equal 90% or more of a pesticide product, have been identified as having potential endocrine-disrupting effects. Atrazine is the predominant herbicide used according to poundage, with 68-73 million lbs of AIs applied in 1995. However, 2,4-D is the most widespread herbicide, covering 78 million acres for agricultural uses alone. Both of these herbicides are reported endocrine disruptors. Acetolactate synthase (ALS) inhibitors, namely the sulfonylureas and imidazolinones, are one of the fastest growing classes of herbicides. Many of these herbicides are 100 times more toxic to select plant species than their predecessors, so they can be applied at rates approximately 100 times lower. Consequently, they can affect plant species at concentration levels so low that no standard chemical protocol can detect them. Due in part to these more potent herbicides, the poundage of herbicides used in the US has decreased since the mid-1980s; however, the available data suggest that the number of treated acres has not significantly declined. A thorough assessment of potential exposure to herbicides by wildlife and humans is limited due to the inaccessibility of production and usage data.

Special issues in assessing care of Medicaid recipients.

OBJECTIVES: The authors describe the process used to develop and test survey items targeted to Medicaid consumers for the Consumer Assessment of Health Plans Study (CAHPS). In addition, the authors highlight the special challenges in locating and surveying Medicaid recipients and provide recommendations for increasing response rates. METHODS: The RAND CAHPS team reviewed the literature and existing questionnaires to identify health care issues and concepts important to Medicaid consumers. Three focus groups and 66 one-on-one cognitive interviews were conducted to test the relevance of our concepts and items and to identify additional concepts important to Medicaid consumers. After the cognitive interviews, the CAHPS Medicaid consumer survey was field tested using a sample of 930 adults and children receiving both Medicaid and Aid to Families with Dependent Children in Los Angeles County and Oklahoma. To determine if one particular mode were preferable for surveying a Medicaid population, our field test sample was divided randomly into a telephone-mode sample, a mixed-mode sample, and a second telephone-mode sample with enhanced locating procedures. Before finalizing the CAHPS 1.0 surveys, the full CAHPS item set was subjected to a formal literacy review. RESULTS: The results of the focus groups and cognitive testing informed iterative versions of the list of concepts addressed by the Medicaid-targeted items. Concepts that were not relevant to Medicaid consumers or that consumers were unable to accurately attribute to a health plan were discarded. New concepts addressing important aspects of health care and the health care experience of Medicaid consumers were identified and added. Item wording and format were revised and refined based on the findings from focus groups, cognitive testing, the field test, and the formal literacy review. In the field test, the mixed-mode method achieved the best results with a 56% completion rate. CONCLUSIONS: The testing and formatting efforts described in this article, in combination with a formal literacy review, led to the development of a Medicaid questionnaire that measures the important health care experiences of Medicaid consumers in a format that is "respondent-friendly." Our recommendations for surveying Medicaid recipients can benefit any survey of a Medicaid population.

Epilogue: Early lessons from CAHPS Demonstrations and Evaluations. Consumer Assessment of Health Plans Study.

OBJECTIVES: The Consumer Assessment of Health Plans Study (CAHPS) was developed to provide an integrated set of tested, standardized surveys to obtain meaningful information from health plan enrollees and their experiences. Many organizations began to implement CAHPS in 1997. Formal evaluations of the experiences of three demonstration sites with implementing CAHPS (ie, process evaluations) and the impact of CAHPS on consumer's choices (ie, outcome evaluations) were conducted. This article reports on the early findings and feedback from our process evaluations about the sites' experiences with using CAHPS. Results are presented from the first round demonstration sites, including the lessons learned during the demonstrations. Our plans for future demonstrations and evaluations are included. METHODS: A similar evaluation design and instruments were used across demonstration sites. The process evaluation to monitor program intervention included on-site interviews, off-site review of documents, and focus groups with consumers. RESULTS: There are 4 early results from the CAHPS demonstrations: (1) the CAHPS survey covers topics of importance to sponsors, is of reasonable length, and can be administered quickly; (2) the report templates are being used effectively, but sponsors vary widely in their preferences for summarizing and presenting CAHPS ratings; (3) standardized or off-the-shelf products are aspects of CAHPS that sponsors value highly, while emphasizing need for further development; and (4) because surveys like CAHPS require multiple within-plan samples to make plan comparisons, they require a substantial investment and may be affordable only for large sponsors. CONCLUSION: The first round CAHPS demonstrations highlighted the strengths of the integrated surveys and the areas for improving the products and the implementation process.

Single women and the dynamics of Medicaid.

OBJECTIVE: To investigate transitions in and out of Medicaid for a cohort of single adult women of childbearing age in order to address questions that arise as policymakers try to encourage transitions from welfare to work. DATA SOURCES: Longitudinal data from Waves 2 through 8 of the 1990 panel of the Survey of Income and Program Participation, a nationally representative survey of American adults covering May 1990-1992. STUDY DESIGN: We estimate a series of discrete-time logit models with duration dependence to obtain transition probabilities among Medicaid, privately insured, and uninsured spells. Explanatory variables in the models include prior insurance history, income limits on Medicaid by state, and important socioeconomic and demographic characteristics. We use these models to characterize insurance spells for a cohort of single women. PRINCIPAL FINDINGS: Most Medicaid spells are relatively short. Over half end in a year or less; only one spell out of seven lasts longer than five years. Two-thirds of Medicaid disenrollees become uninsured. Former welfare recipients are prone to frequent changes in insurance status. In states with more generous income limits for AFDC, women stay on Medicaid longer, but they do not move into the program at a faster rate. CONCLUSIONS: Imposing time limits on Medicaid eligibility would affect only a small proportion of Medicaid spells but would eliminate a significant proportion of the caseload at a point in time. In considering changes in Medicaid that would encourage transitions from welfare to work and would alter the dynamics of Medicaid, policymakers need to consider how transitions both in and out of private insurance and Medicaid would be affected.