Caribbean Latinx with moderate-severe asthma bear greater asthma morbidity than other Latinx.

BACKGROUND: Hispanic/Latinx (HL) ethnicity encompasses racially and culturally diverse subgroups. Studies suggest that Puerto Ricans (PR) may bear greater asthma-related morbidity than Mexicans, but these were conducted in children or had limited clinical characterization. OBJECTIVES: This study sought to determine whether disparities in asthma morbidity exist among HL adult subgroups. METHODS: Adults with moderate-severe asthma were recruited from US clinics, including from Puerto Rico, for the Person Empowered Asthma Relief (PREPARE) trial. Considering the shared heritage between PR and other Caribbean HL (Cubans and Dominicans [C&D]), the investigators compared baseline self-reported clinical characteristics between Caribbean HL (CHL) (PR and C&D: n = 457) and other HLs (OHL) (Mexicans, Spaniards, Central/South Americans; n = 141), and between CHL subgroups (C&D [n = 56] and PR [n = 401]). This study compared asthma morbidity measures (self-reported exacerbations requiring systemic corticosteroids, emergency department/urgent care (ED/UC) visits, hospitalizations, health care utilization) through negative binomial regression. RESULTS: CHL compared to OHL were similar in age, body mass index, poverty status, blood eosinophils, and fractional exhaled nitric oxide but were prescribed more asthma controller therapies. Relative to OHL, CHL had significantly increased odds of asthma exacerbations (odds ratio [OR]: 1.84; 95% CI: 1.4-2.4), ED/UC visits (OR: 1.88; 95% CI: 1.4-2.5), hospitalization (OR: 1.98; 95% CI: 1.06-3.7), and health care utilization (OR: 1.91; 95% CI: 1.44-2.53). Of the CHL subgroups, PR had significantly increased odds of asthma exacerbations, ED/UC visits, hospitalizations, and health care utilization compared to OHL, whereas C&D only had increased odds of exacerbations compared to OHL. PR compared to C&D had greater odds of ED/UC and health care utilization. CONCLUSIONS: CHL adults, compared with OHL, adults reported nearly twice the asthma morbidity; these differences are primarily driven by PR. Novel interventions are needed to reduce morbidity in this highly impacted population.

Reliever-Triggered Inhaled Glucocorticoid in Black and Latinx Adults with Asthma.

BACKGROUND: Black and Latinx patients bear a disproportionate burden of asthma. Efforts to reduce the disproportionate morbidity have been mostly unsuccessful, and guideline recommendations have not been based on studies in these populations. METHODS: In this pragmatic, open-label trial, we randomly assigned Black and Latinx adults with moderate-to-severe asthma to use a patient-activated, reliever-triggered inhaled glucocorticoid strategy (beclomethasone dipropionate, 80 µg) plus usual care (intervention) or to continue usual care. Participants had one instructional visit followed by 15 monthly questionnaires. The primary end point was the annualized rate of severe asthma exacerbations. Secondary end points included monthly asthma control as measured with the Asthma Control Test (ACT; range, 5 [poor] to 25 [complete control]), quality of life as measured with the Asthma Symptom Utility Index (ASUI; range, 0 to 1, with lower scores indicating greater impairment), and participant-reported missed days of work, school, or usual activities. Safety was also assessed. RESULTS: Of 1201 adults (603 Black and 598 Latinx), 600 were assigned to the intervention group and 601 to the usual-care group. The annualized rate of severe asthma exacerbations was 0.69 (95% confidence interval [CI], 0.61 to 0.78) in the intervention group and 0.82 (95% CI, 0.73 to 0.92) in the usual-care group (hazard ratio, 0.85; 95% CI, 0.72 to 0.999; P = 0.048). ACT scores increased by 3.4 points (95% CI, 3.1 to 3.6) in the intervention group and by 2.5 points (95% CI, 2.3 to 2.8) in the usual-care group (difference, 0.9; 95% CI, 0.5 to 1.2); ASUI scores increased by 0.12 points (95% CI, 0.11 to 0.13) and 0.08 points (95% CI, 0.07 to 0.09), respectively (difference, 0.04; 95% CI, 0.02 to 0.05). The annualized rate of missed days was 13.4 in the intervention group and 16.8 in the usual-care group (rate ratio, 0.80; 95% CI, 0.67 to 0.95). Serious adverse events occurred in 12.2% of the participants, with an even distribution between the groups. CONCLUSIONS: Among Black and Latinx adults with moderate-to-severe asthma, provision of an inhaled glucocorticoid and one-time instruction on its use, added to usual care, led to a lower rate of severe asthma exacerbations. (Funded by the Patient-Centered Outcomes Research Institute and others; PREPARE ClinicalTrials.gov number, NCT02995733.).

Socioeconomic impact of COVID-19 and willingness to be vaccinated in African American/Black and Hispanic/Latinx adults.

PURPOSE: To describe the socioeconomic and healthcare-related effects of the COVID-19 pandemic, and willingness to receive a free COVID-19 vaccine, among African American/Black (AA/B) and Hispanic/Latinx (H/L) adults with asthma currently enrolled in a large trial. METHODS: The present analysis is a sub-study of the PeRson EmPowered Asthma RElief (PREPARE) study, a pragmatic study of 1201 AA/B and H/L adults with asthma. A monthly questionnaire was completed by a subset of PREPARE participants (n = 325) during May-August, 2020. The 5-item questionnaire assessed self-reported impact of COVID-19 on respondents' ability to obtain asthma medications, medical care quality, employment, income and ability to pay bills; and willingness to get a free COVID-19 vaccine. Bivariate analysis and multivariate logistic regression were performed to investigate factors associated with vaccine hesitancy. RESULTS: Of 325 survey respondents (25% AA/B, 75% H/L), the majority reported no impact of COVID-19 on medical care or ability to get asthma medications. Approximately half of employed respondents experienced a lower level of employment or job loss, and approximately half reported having difficulty paying bills during the pandemic. Thirty-five percent of respondents reported unwillingness and 31% reported being somewhat likely to receive a free COVID-19 vaccine. AA/B race/ethnicity and poorer reported physical health were associated with a higher likelihood of COVID-19 vaccine hesitancy. CONCLUSION: AA/B and H/L adults with asthma may experience changes in the quality of their asthma care and increased socioeconomic stressors as a result of the COVID-19 pandemic and may be hesitant or unwilling to receive a COVID-19 vaccine.

A randomized, open-label, pragmatic study to assess reliever-triggered inhaled corticosteroid in African American/Black and Hispanic/Latinx adults with asthma: Design and methods of the PREPARE trial.

BACKGROUND: Asthma prevalence, morbidity, and mortality disproportionately impact African American/Black (AA/B) and Hispanic/Latinx (H/L) communities. Adherence to daily inhaled corticosteroid (ICS), recommended by asthma guidelines in all but the mildest cases of asthma, is generally poor. As-needed ICS has shown promise as a patient-empowering asthma management strategy, but it has not been rigorously studied in AA/B or H/L patients or in a real-world setting. Design and Aim The PeRson EmPowered Asthma RElief (PREPARE) Study is a randomized, open-label, pragmatic study which aims to assess whether a patient-guided, reliever-triggered ICS strategy called PARTICS (Patient-Activated Reliever-Triggered Inhaled CorticoSteroid) can improve asthma outcomes in AA/B and H/L adult patient populations. In designing and implementing the study, the PREPARE research team has relied heavily on advice from AA/B and H/L Patient Partners and other stakeholders. Methods PREPARE is enrolling 1200 adult participants (600 AA/Bs, 600H/Ls) with asthma. Participants are randomized to PARTICS + Usual Care (intervention) versus Usual Care (control). Following a single in-person enrollment visit, participants complete monthly questionnaires for 15 months. The primary endpoint is annualized asthma exacerbation rate. Secondary endpoints include asthma control; preference-based quality of life; and days lost from work, school, or usual activities. Discussion The PREPARE study features a pragmatic design allowing for the real-world assessment of a patient-centered, reliever-triggered ICS strategy in AA/B and H/L patients. Outcomes of this study have the potential to offer powerful evidence supporting PARTICS as an effective asthma management strategy in patient populations that suffer disproportionately from asthma morbidity and mortality.

Effect of 2 Clinical Decision Support Strategies on Chronic Kidney Disease Outcomes in Primary Care: A Cluster Randomized Trial.

Importance: Information is needed about optimal strategies to improve evidence-based treatment of chronic kidney disease (CKD) in primary care. Objective: To determine whether a multimodal intervention delays annualized loss of estimated glomerular filtration rate (eGFR) in stages 3 and 4 CKD. Design, Setting, and Participants: This pragmatic cluster randomized clinical trial enrolled 42 primary care practices located in nonhospital settings with electronic health record systems. Practices were recruited through the American Academy of Family Physicians National Research Network. The study was conducted January 2013 through January 2016. Interventions: Practices were randomized at the organization level to either the clinical decision support (CDS) plus practice facilitation (PF) group (n = 25) or CDS group (n = 17) using covariate constrained randomization. Both groups received point-of-care CDS to prompt screening, diagnosis, and treatment of CKD; the intervention group also received PF based on the 9-point TRANSLATE model (target, use point-of-care reminder systems, get administrative buy-in, network information systems using registries, site coordination, local physician champion, audit and feedback, team approach, and education). Main Outcomes and Measures: The primary outcome measure was eGFR over time. Secondary outcome measures were systolic blood pressure over time, change in hemoglobin A1c (HbA1c) over time, avoidance of nonsteroidal anti-inflammatory medications, use of angiotensin converting enzyme inhibitor or angiotensin-renin blocker medication, early recognition and diagnosis of CKD, blood pressure control, and smoking cessation. Results: In this cluster randomized trial of 30 primary care practices comprising 6699 patients, there were 1685 patients in the control group (10 practices) and 5014 patients in the intervention group (20 practices). The final sample of practices differed from the original set of randomized practices owing to dropout. Patients in the practices were similar at baseline for age (mean [SD], 71.3 [9.6] years), sex (2716 male [40.5%]), and eGFR. There was a significant difference in eGFR slopes for patients in the intervention vs control group practices. The mean (SE) annualized loss of eGFR was 0.95 (0.19) in the control group in propensity-adjusted longitudinal analyses and 0.01 (0.12) in the intervention group (mean [SE] difference in slopes, 0.93 [0.23]; P < .001). Among patients with HbA1c measures, slopes differed significantly for patients in intervention vs control practices, with a mean (SE) annualized increase of 0.14 (0.03) in HbA1c for patients in control practices and a mean (SE) decline of 0.009 (0.02) for patients in intervention practices. There was a significant difference in HbA1c slopes for patients in the intervention compared with control group practices (control vs intervention, -0.14; P < .001), but no difference in the other secondary outcomes. Conclusions and Relevance: A multimodal intervention in primary care, based on the TRANSLATE model, slowed annualized loss of eGFR. This study had several important strengths, weaknesses, and lessons learned regarding the implementation of pragmatic interventions in primary care to improve CKD outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT01767883.

Do professional development programs for Maintenance of Certification (MOC) affect quality of patient care?

OBJECTIVE: The objective of this study was to examine the relationship between physicians' completion of American Board of Family Medicine (ABFM) Maintenance of Certification (MOC) modules and the quality of medical care delivered. METHODS: Physicians from the Electronic National Quality Improvement and Research Network (eNQUIRENet) were enrolled. Data from their electronic health records were compared before and after they completed one or more MOC modules for family physicians (Self-Assessment Module [Part II MOC] and Performance in Practice Module [Part IV MOC]; SAM/PPM). Process data and other quantitative clinical measures for all adult patients with a diagnosis of type 2 diabetes were gathered from each study physician. General linear mixed effects models were used to analyze data before and after the MOC modules, adjusting for clustering of patients within physicians. RESULTS: Physicians participating in SAM/PPM activities demonstrated greater improvements over time in 11 of 24 measures in process and intermediate outcome measures related to type 2 diabetes care compared with non-SAM/PPM participants. All groups demonstrated improvements over time. CONCLUSION: Participation in SAM/PPM activities is associated with greater improvements in care, but the association between activity undertaken and specific improvements is difficult to demonstrate.

Outcomes of biomarker feedback on physical activity, eating habits, and emotional health: from the Americans in Motion-Healthy Intervention (AIM-HI) study.

PURPOSE: The purpose of this article was to test whether physical activity, healthy eating, and emotional well-being would improve if patients received feedback about biomarkers that have been shown to be responsive to changes in weight and fitness. METHODS: Patients were randomized to limited feedback (weight, body mass index [BMI], and blood pressure at 4 and 10 months) or enhanced feedback (weight, BMI, blood pressure, homeostatic insulin resistance, and nuclear magnetic resonance lipoprotein profiles at 2, 4, 7, and 10 months). Repeated measures mixed effects multivariate regression models were used to determine whether BMI, fitness, diet, and quality of life changed over time. RESULTS: Major parameters were similar in both groups at baseline. BMI, measures of fitness, healthy eating, quality of life, and health state improved in both patient groups, but there was no difference between patient groups at 4 or 10 months. Systolic blood pressure improved in the enhanced feedback group, and there was a difference between the enhanced and limited feedback groups at 10 months (95% confidence interval, -6.011 to -0.5113). CONCLUSIONS: Providing patients with enhanced feedback did not dramatically change outcomes. However, across groups, many patients maintained or lost weight, suggesting the need for more study of nondiet interventions.

Effectiveness of 2 methods of promoting physical activity, healthy eating, and emotional well-being with the americans in motion--healthy interventions approach.

PURPOSE: An increasing number of Americans are putting their health at risk from being overweight. We undertook a study to compare patient-level outcomes of 2 methods of implementing the Americans In Motion-Healthy Interventions (AIM-HI) approach to promoting physical activity, healthy eating, and emotional well-being. METHODS: We conducted a randomized trial in which 24 family medicine practices were randomized to (1) an enhanced practice approach in which clinicians and office staff used AIM-HI tools to make personal changes and created a healthy environment, or (2) a traditional practice approach in which physicians and staff were trained and asked to use the tools with patients. Of the 610 patients enrolled, 331 were in healthy practices, and 279 were in traditional practices. At 0, 4, and 10 months we assessed blood pressure, body mass index, fasting blood glucose and insulin levels, nuclear magnetic resonance lipoprotein profiles, fitness, dietary intake, physical activity, and emotional well-being. Outcome data were analyzed using linear, mixed-effects multivariate models, adjusting for practices as a random effect. RESULTS: Regardless of patient group, 16.2% of patients who completed a 10-month visit (n = 378 patients, 62% of enrollees) and 10% of all patients enrolled lost 5% or more of their body weight; 16.7% of patients who completed a 10-month visit (10.3% of all enrollees) had a 2-point or greater increase in their fitness level; and 29.2% of 10-month completers (18.0% of all enrollees) lost 5% or more of their body weight and/or increased their fitness level by 2 or more points. There were no significant differences in these outcomes between groups. CONCLUSIONS: There was no difference between the 2 groups in the primary and most secondary outcomes. Both patient groups were able to show significant before-after improvements in selected patient-level outcomes.

Clinician suspicion of an alcohol problem: an observational study from the AAFP National Research Network.

PURPOSE: In clinical practice, detection of alcohol problems often relies on clinician suspicion instead of using a screening instrument. We assessed the sensitivity, specificity, and predictive values of clinician suspicion compared with screening-detected alcohol problems in patients. METHODS: We undertook a cross-sectional study of 94 primary care clinicians' office visits. Brief questionnaires were completed separately after a visit by both clinicians and eligible patients. The patient's anonymous exit questionnaire screened for hazardous drinking based on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and for harmful drinking (alcohol abuse or dependence) based on 2 questions from the Diagnostic and Statistical Manual of Mental Disorders. After the visit, clinicians responded to the question, "Does this patient have problems with alcohol?" with answer options including "yes, hazardous drinking" and "yes, alcohol abuse or dependence." Analyses assessed the associations between patients' responses to screening questions and clinician's suspicions. RESULTS: Of 2,518 patients with an office visit, 2,173 were eligible, and 1,699 (78%) completed the exit questionnaire. One hundred seventy-one (10.1%) patients had a positive screening test for hazardous drinking (an AUDIT-C score of 5 or greater) and 64 (3.8%) for harmful drinking. Clinicians suspected alcohol problems in 81 patients (hazardous drinking in 37, harmful drinking in 40, and both in 4). The sensitivity of clinician suspicion of either hazardous or harmful drinking was 27% and the specificity was 98%. Positive and negative predictive values were 62% and 92%, respectively. CONCLUSION: Clinician suspicion of alcohol problems had poor sensitivity but high specificity for identifying patients who had a positive screening test for alcohol problems. These data support the routine use of a screening tool to supplement clinicians' suspicions, which already provide reasonable positive predictive value.

Use of the Americans in Motion-Healthy Intervention (AIM-HI) to create a culture of fitness in family practice.

BACKGROUND: Americans in Motion-Healthy Interventions (AIM-HI) is an initiative designed to assist family physicians with positioning fitness (physical activity, nutrition, and emotional well-being) as the treatment of choice for prevention and management of chronic disease. We investigated whether the concept of a culture of fitness would benefit office personnel and carry over to patient care. METHODS: This randomized, controlled trial provided an intervention based on the AIM-HI curriculum to 12 enhanced offices with support for office activities, while 12 traditional offices received only AIM-HI tools with encouragement for use with patients. Before intervention, at 4 months, and at 14 months, we measured the practice personnel's dietary behavior (PrimeScreen), physical activity (International Physical Activity Questionnaire), self-determined (intrinsic) motivation (Treatment Self-Regulation Questionnaire [TSRQ]), perceived ability to carry out health behaviors (Perceived Competence Scale), and readiness to improve and/or maintain health behaviors (Stages of Change). RESULTS: From 24 practices we enrolled 470 subjects; 21 practices completed the study, and data from 341 patients were analyzed. Differential change from baseline between the enhanced and traditional offices was not evident for behavior changes. An overall decrease from baseline in self-reported total physical activity measured as metabolic equivalent-minutes for all surveyed groups occurred over the study time period (4-month ß = -11.97; 14-month ß = -9.01; P = .003). A statistically significant increase occurred at 4 months among participants from the enhanced practices for the TSRQ outcomes of Healthy Eating (baseline, 3.00 ± 0.12; 4 months, 3.26 ± 0.13; P = .013). Among clinicians, TSRQ Healthy Eating scores increased from 3.19 ± 0.13 at baseline to 3.52 ± 0.14 at 4 months (P = .005). However, increases in TSRQ Eating scores were not sustained by 14 months. Stages of Change scores decreased from baseline to 4 months in enhanced group offices. There was also a decrease in Stages of Change scores among staff from baseline to 14 months. CONCLUSIONS: Primary care clinicians and office staff are resistant to health behavior change. External motivation did not seem to help them change. The effect of this intervention on patient care is not yet known.

Alcohol and sleep problems in primary care patients: a report from the AAFP National Research Network.

PURPOSE: Hazardous and harmful drinking and sleep problems are common, but their associations among patients seen in primary care have not been examined. We hypothesized that greater levels of alcohol consumption would be associated with several self-reported sleep problems. METHODS: In a cross-sectional survey in primary care practices, 94 participating clinicians recruited up to 30 consecutive adult patients, and both clinicians and patients completed anonymous postvisit questionnaires. Patients were asked questions on demographics, alcohol consumption, cardinal symptoms of alcohol use disorders, sleep quality, insomnia, sleep apnea, and symptoms of restless leg syndrome. Multivariate analyses explored the associations of drinking status (none, moderate, or hazardous) and sleep problems, adjusting for demographics and clustering of patients within physician. RESULTS: Of 1,984 patients who responded, 1,699 (85.6%) provided complete data for analysis. Respondents' mean age was 50.4 years (SD 17.4 years), 67% were women, and 72.9% were white. Of these, 22.3% reported hazardous drinking, 47.8% reported fair or poor overall sleep quality, and 7.3% reported a diagnosis or treatment of sleep apnea. Multivariate analyses showed no associations between drinking status and any measure of insomnia, overall sleep quality, or restless legs syndrome symptoms. Moderate drinking was associated with lower adjusted odds of sleep apnea compared with nondrinkers (OR = 0.61; 95% CI, 0.38-1.00). Using alcohol for sleep was strongly associated with hazardous drinking (OR = 4.58; 95% CI, 2.97-7.08, compared with moderate drinking). CONCLUSIONS: Moderate and hazardous drinking were associated with few sleep problems. Using alcohol for sleep, however, was strongly associated with hazardous drinking relative to moderate drinking and may serve as a prompt for physicians to ask about excessive alcohol use.

Patients' question-asking behavior during primary care visits: a report from the AAFP National Research Network.

PURPOSE: The Ask Me 3 (AM3) health communication program encourages patients to ask specific questions during office visits with the intention of improving understanding of their health conditions and adherence to treatment recommendations. This study evaluated whether implementing AM3 improves patients' question-asking behavior and increases adherence to prescription medications and lifestyle recommendations. METHODS: This randomized trial involved 20 practices from the American Academy of Family Physicians National Research Network that were assigned to an AM3 intervention group or a control group. Forty-one physicians in the practices were each asked to enroll at least 20 patients. The patients' visits were audio recorded, and recordings were reviewed to determine whether patients asked questions and which questions they asked. Patients were interviewed 1 to 3 weeks after the visit to assess their recall of physicians' recommendations, rates of prescription filling and taking, and attempts at complying with lifestyle recommendations. RESULTS: The study enrolled 834 eligible patients in 20 practices. There were no significant difference between the AM3 and control patients in the rate of asking questions, but this rate was high (92%) in both groups. There also were no differences in rates of either filling or taking prescriptions, although rates of these outcomes were fairly high, too. Control patients were more likely to recall that their physician recommended a lifestyle change, however (68% vs 59%, P = .04). CONCLUSIONS: In a patient population in which asking questions already occurs at a high rate and levels of adherence are fairly high, we found no evidence that the AM3 intervention results in patients asking specific questions or more questions in general, or in better adherence to prescription medications or lifestyle recommendations.

Stress and quitting among African American smokers.

This study examined the relationship between stress and the likelihood of quitting among 300 urban African American smokers enrolled in the placebo arm of a controlled randomized trial assessing the efficacy of bupropion for smoking cessation. Participants were predominantly female, middle-aged, and of lower income. Participants received 7 weeks of placebo treatment and counseling as well as a self-help guide. Quit status and stress, measured with the Perceived Stress Scale and an adapted Hassles Index, were assessed at baseline, end of treatment, and 6 month follow-up. Results indicated that although baseline stress did not predict quitting at later visits, higher concurrent stress levels were associated with not being abstinent. Furthermore, changes (reductions) in perceived stress from baseline also predicted abstinence at the end of treatment. Results suggest that methods to help African Americans cope with stress as they attempt to quit smoking may prevent relapse to smoking.