Effect of Lung Transplantation on Health-Related Quality of Life in the Era of the Lung Allocation Score: A U.S. Prospective Cohort Study.

Under the U.S. Lung Allocation Score (LAS) system, older and sicker patients are prioritized for lung transplantation (LT). The impact of these changes on health-related quality of life (HRQL) after transplant has not been determined. In a single-center prospective cohort study from 2010 to 2016, we assessed HRQL before and repeatedly after LT for up to 3 years using the SF12-Physical and Mental Health, the respiratory-specific Airway Questionnaire 20-Revised, and the Euroqol 5D/Visual Analog Scale utility measures by multivariate linear mixed models jointly modeled with death. We also tested changes in LT-Valued Life Activities disability, BMI, allograft function, and 6-min walk test exercise capacity as predictors of HRQL change. Among 211 initial participants (92% of those eligible), LT improved HRQL by all 5 measures (p < 0.05) and all but SF12-Mental Health improved by threefold or greater than the minimally clinically important difference. Compared to younger participants, those aged ≥65 improved less in SF12-Physical and Mental Health (p < 0.01). Improvements in disability accounted for much of the HRQL improvement. In the LAS era, LT affords meaningful and durable HRQL improvements, mediated by amelioration of disability. Identifying factors limiting HRQL improvement in selected subgroups, especially those aged ≥65, are needed to maximize the net benefits of LT.

Validity of a self-administered version of the brief index of lupus damage in a predominantly African American systemic lupus erythematosus cohort.

OBJECTIVE: To assess the reliability and criterion and construct validity of the self-administered Brief Index of Lupus Damage (SA-BILD), a patient-reported measure of organ damage in systemic lupus erythematosus (SLE). METHODS: The validity of the SA-BILD was assessed using data from the Georgians Organized Against Lupus (GOAL) survey. GOAL is a longitudinal cohort of SLE patients predominantly derived from the Georgia Lupus Registry, a population-based registry established in Atlanta, Georgia. In total, 711 participants with documented SLE completed the SA-BILD. To test reliability, the SA-BILD was readministered to 32 patients. Criterion validity was examined in 150 respondents for whom the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) was also completed. Construct validity was assessed among 711 GOAL participants by dividing the SA-BILD scores into quartiles and examining the association with demographics, health status, and health care utilization. RESULTS: The test-retest correlation score was 0.93 (P < 0.0001), the item-by-item agreement with the SDI was >80% for most SA-BILD items, and the Spearman's rho correlation coefficient for the SDI and SA-BILD was moderately high (ρ = 0.59, P < 0.0001). SA-BILD scores showed significant associations in the expected directions with age, disease duration, disease activity, overall health, comorbidity index, and physician visits. CONCLUSION: The SA-BILD was reliable and had very good or good criterion validity compared with the SDI when tested in a predominantly African American cohort of US SLE patients. Associations of SA-BILD scores with sociodemographics and health status were consistent with previous studies. These findings support the use of the SA-BILD as a valid measure of patient-reported damage in SLE.

Comparison of cardiac and pulmonary-specific quality-of-life measures in pulmonary arterial hypertension.

Studies systematically comparing the performance of health-related quality-of-life (HRQoL) instruments in pulmonary arterial hypertension (PAH) are lacking. We sought to address this by comparing cardiac and respiratory-specific measures of HRQoL in PAH. We prospectively assessed HRQoL in 128 patients with catheterisation-confirmed PAH at baseline and at 6, 12 and post-24 month follow-up visits. Cardiac-specific HRQoL was assessed using the Minnesota Living with Heart Failure Questionnaire (LHFQ); respiratory-specific HRQoL was assessed using the Airways Questionnaire 20 (AQ20); and general health status was assessed using the 36-item Short Form physical component summary (SF-36 PCS). The LHFQ and AQ20 were highly intercorrelated. Both demonstrated strong internal consistency and converged with the SF-36 PCS. Both discriminated patients based on World Health Organization (WHO) functional class, 6-min walking distance (6MWD) and Borg dyspnoea index (BDI), with the exception of a potential floor effect associated with low 6MWD. The LHFQ was more responsive than the AQ20 to changes over time in WHO functional class, 6MWD and BDI. In multivariate analyses, the LHFQ and AQ20 were each longitudinal predictors of general health status, independent of functional class, 6MWD and BDI. In conclusion, both cardiac-specific and respiratory-specific measures appropriately assess HRQoL in most patients with PAH. Overall, the LHFQ demonstrates stronger performance characteristics than the AQ20.

Socioeconomic status, race and COPD health outcomes.

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) is a common cause of death and disability, little is known about the effects of socioeconomic status (SES) and race-ethnicity on health outcomes. METHODS: The aim of this study is to determine the independent impacts of SES and race-ethnicity on COPD severity status, functional limitations and acute exacerbations of COPD among patients with access to healthcare. Data were used from the Function, Living, Outcomes and Work cohort study of 1202 Kaiser Permanente Northern California Medical Care Plan members with COPD. RESULTS: Lower educational attainment and household income were consistently related to greater disease severity, poorer lung function and greater physical functional limitations in cross-sectional analysis. Black race was associated with greater COPD severity, but these differences were no longer apparent after controlling for SES variables and other covariates (comorbidities, smoking, body mass index and occupational exposures). Lower education and lower income were independently related to a greater prospective risk of acute COPD exacerbation (HR 1.5; 95% CI 1.01 to 2.1; and HR 2.1; 95% CI 1.4 to 3.4, respectively). CONCLUSION: Low SES is a risk factor for a broad array of adverse COPD health outcomes. Clinicians and disease management programs should consider SES as a key patient-level marker of risk for poor outcomes.

Occupational exposures and the risk of COPD: dusty trades revisited.

BACKGROUND: The contribution of occupational exposures to chronic obstructive pulmonary disease (COPD) and, in particular, their potential interaction with cigarette smoking remains underappreciated. METHODS: Data from the FLOW study of 1202 subjects with COPD (of which 742 had disease classified as stage II or above by Global Obstructive Lung Disease (GOLD) criteria) and 302 referent subjects matched by age, sex and race recruited from a large managed care organisation were analysed. Occupational exposures were assessed using two methods: self-reported exposure to vapours, gas, dust or fumes on the longest held job (VGDF) and a job exposure matrix (JEM) for probability of exposure based on occupation. Multivariate analysis was used to control for age, sex, race and smoking history. The odds ratio (OR) and adjusted population attributable fraction (PAF) associated with occupational exposure were calculated. RESULTS: VGDF exposure was associated with an increased risk of COPD (OR 2.11; 95% CI 1.59 to 2.82) and a PAF of 31% (95% CI 22% to 39%). The risk associated with high probability of workplace exposure by JEM was similar (OR 2.27; 95% CI 1.46 to 3.52), although the PAF was lower (13%; 95% CI 8% to 18%). These estimates were not substantively different when the analysis was limited to COPD GOLD stage II or above. Joint exposure to both smoking and occupational factors markedly increased the risk of COPD (OR 14.1; 95% CI 9.33 to 21.2). CONCLUSIONS: Workplace exposures are strongly associated with an increased risk of COPD. On a population level, prevention of both smoking and occupational exposure, and especially both together, is needed to prevent the global burden of disease.

Performance of self-reported occupational exposure compared to a job-exposure matrix approach in asthma and chronic rhinitis.

OBJECTIVES: Self-reported exposure to vapours, gas, dust or fumes (VGDF) has been widely used as an occupational exposure metric in epidemiological studies of chronic lung diseases. Our objective was to characterise the performance of VGDF for repeatability, systematic misclassification, and sensitivity and specificity against exposure likelihood by a job-exposure matrix (JEM). METHODS: We analysed data from two interviews, 24 months apart, of adults with asthma and chronic rhinitis. Using distinct job as the unit of analysis, we tested a single response item (exposure to VGDF) against assignment using a JEM. We further analysed VGDF and the JEM among a subset of 199 subjects who reported the same job at both interviews, using logistic regression analysis to test factors associated with VGDF inconsistency and discordance with the JEM. RESULTS: VGDF was reported for 193 (44%) of 436 distinct jobs held by the 348 subjects studied; moderate to high exposure likelihood by JEM was assigned to 120 jobs (28%). The sensitivity and specificity of VGDF against JEM were 71% and 66%, respectively. Among 199 subjects with the same job at both interviews, 32% had a discordant VGDF status (kappa = 0.35). Those with chronic rhinitis without concomitant asthma compared to asthma alone were more likely to have a VGDF report discordant with the JEM (OR 3.6, 95% CI 1.4 to 9.0; p = 0.01). Rhinitis was also associated with reported VGDF in a job classified by the JEM as low exposure (OR 3.9, 95% CI 1.6 to 9.4; p = 0.003). CONCLUSION: The VGDF item is moderately sensitive measured against JEM as a benchmark. The measure is a useful assessment method for epidemiological studies of occupational exposure risk.

Negative life events and quality of life in adults with asthma.

BACKGROUND: The relationship between stress and quality of life in adults with asthma has not been well studied. Stress, quantified by negative life events, may be linked to quality of life in asthma through multiple pathways, including increase in disease severity and adverse effects on socioeconomic status (SES). METHODS: The responses to a self-completed questionnaire assessing negative life events (NLEs) in the previous 12 months (from a 24-item checklist) among 189 adults with asthma from a well-characterised cohort were analysed. The relationship between the number of NLEs reported and asthma-specific quality of life (AQOL) was measured with the Marks instrument. General linear modelling was used to test the conjoint effects of NLEs, SES and disease severity based on the Severity of Asthma Score, a validated acute and chronic disease measure. RESULTS: Those with annual family incomes < 60,000 dollars reported significantly more NLEs than those with higher incomes (p = 0.03). The number of NLEs did not differ significantly between those with forced expiratory volume in 1 s <80% predicted and those with >80% predicted, nor among those with lower compared with higher Severity of Asthma Score. The frequency of NLEs was associated with poorer (higher numerical score) AQOL (p = 0.002). When studied together in the same model, combinations of income level and asthma severity (greater or lesser Severity of Asthma Score; p < 0.001) and number of NLEs (p = 0.03) were both significantly associated with AQOL. CONCLUSION: NLEs are associated with quality of life among adults with asthma, especially among those of lower SES. Clinicians should be aware of this relationship, especially in vulnerable patient subsets.

Area-level socio-economic status and health status among adults with asthma and rhinitis.

Socio-economic status (SES) may affect health status in airway disease at the individual and area level. In a cohort of adults with asthma, rhinitis or both conditions, questionnaire-derived individual-level SES and principal components analysis (PCA) of census data for area-level SES factors were used. Regression analysis was utilised to study the associations among individual- and area-level SES for the following four health status measures: severity of asthma scores and the Short Form-12 Physical Component Scale (SF-12 PCS) (n = 404); asthma-specific quality of life (QoL) scores (n = 340); and forced expiratory volume in one second (FEV1) per cent predicted (n = 218). PCA yielded a two-factor solution for area-level SES. Factor 1 (lower area-level SES) was significantly associated with poorer SF-12 PCS and worse asthma QoL. These associations remained significant after adding individual-level SES. Factor 1 was also significantly associated with severity of asthma scores, but not after addition of the individual-level SES. Factor 2 (suburban area-level SES) was associated with lower FEV1 per cent predicted in combined area-level and individual SES models. In conclusion, area-level socio-economic status is linked to some, but not all, of the studied health status measures after taking into account individual-level socio-economic status.

Prevalence and predictors of disability in valued life activities among individuals with rheumatoid arthritis.

OBJECTIVE: To identify the prevalence of disability in a wide range of life activities and identify factors associated with such disability using the Verbrugge and Jette disablement model as a framework. METHODS: Data were from a panel study of 548 individuals with rheumatoid arthritis, interviewed annually by telephone. Valued life activity (VLA) disability was assessed using a 26-item scale rating difficulty in carrying out each activity. Three types of summary measure were calculated: activities unable to perform, activities affected, and mean difficulty. Subscale scores were also calculated, corresponding to obligatory, committed, and discretionary activities, as defined in the disablement model. Disease status measures were examined as predictors of VLA disability using multiple regression analyses. RESULTS: Half the subjects were unable to do at least one VLA. Approximately 2%, 31.3%, and 40.2% were unable to do at least one obligatory, committed, and discretionary activity, respectively. Almost all (95%) reported at least one VLA affected by rheumatoid arthritis; 68.4%, 91.4%, and 92.5% reported at least one obligatory, committed, and discretionary activity, respectively, affected. Disease status measures were robust predictors of VLA disability, accounting for 22-47% of the variation in VLA disability (with one exception). Adding the health assessment questionnaire (HAQ) to these models increased (p<0.0001) all model R2 values. HAQ score mediated the effects of many disease measures, consistent with the disablement model. CONCLUSION: VLA disability was common, with more disability noted in committed and discretionary than obligatory activities. Because VLA disability has been linked to psychological wellbeing in previous studies, identification of factors that may protect against such disability is important.

The association between occupational factors and adverse health outcomes in chronic obstructive pulmonary disease.

BACKGROUND AND AIMS: Despite recognition that occupational exposures may make a substantive contribution to the aetiology of COPD, little is known about the potential role of work related factors in COPD related health outcomes. METHODS: Prospective cohort study using structured telephone interviews among a random sample of adults aged 55-75 reporting a COPD condition (emphysema, chronic bronchitis, or COPD). Using multivariate models adjusting for smoking and demographic factors, the separate and combined associations were estimated between occupational exposure to vapours, gas, dust, or fumes (VGDF) and leaving work due to lung disease (respiratory related work disability) with health outcomes and utilisation ascertained at one year follow up. RESULTS: Of 234 subjects, 128 (55%) reported exposure to VGDF on their longest held jobs, 58 (25%) reported respiratory related work disability, and 38 (16%) subjects reported both. Combined exposure to VGDF and respiratory related work disability (rather than either factor alone) was associated with the greatest risk at follow up of frequent (everyday) restricted activity days attributed to a breathing or lung condition (OR 3.8; 95% CI 1.4 to 10.1), emergency department (ED) visit (OR 3.9; 95% CI 1.4 to 10.5), and hospitalisation (OR 7.6; 95% CI 1.8 to 32). CONCLUSIONS: Among persons with COPD, past occupational exposures and work disability attributed to lung disease, particularly in combination, appear to be risk factors for adverse health related outcomes.

The occupational burden of chronic obstructive pulmonary disease.

Although chronic obstructive pulmonary disease (COPD) is attributed predominantly to tobacco smoke, occupational exposures are also suspected risk factors for COPD. Estimating the proportion of COPD attributable to occupation is thus an important public health need. A randomly selected sample of 2,061 US residents aged 55-75 yrs completed telephone interviews covering respiratory health, general health status and occupational history. Occupational exposure during the longest-held job was determined by self-reported exposure to vapours, gas, dust or fumes and through a job exposure matrix. COPD was defined by self-reported physician's diagnosis. After adjusting for smoking status and demography, the odds ratio for COPD related to self-reported occupational exposure was 2.0 (95% confidence interval (CI) 1.6-2.5), resulting in an adjusted population attributable risk (PAR) of 20% (95% CI 13-27%). The adjusted odds ratio based on the job exposure matrix was 1.6 (95% CI 1.1-2.5) for high and 1.4 (95% CI 1.1-1.9) for intermediate probability of occupational dust exposure; the associated PAR was 9% (95% CI 3-15%). A narrower definition of COPD, excluding chronic bronchitis, was associated with a PAR based on reported occupational exposure of 31% (95% CI 19-41%). Past occupational exposures significantly increased the likelihood of chronic obstructive pulmonary disease, independent of the effects of smoking. Given that one in five cases of chronic obstructive pulmonary disease may be attributable to occupational exposures, clinicians and health policy-makers should address this potential avenue of chronic obstructive pulmonary disease causation and its prevention.

Exposure to indoor combustion and adult asthma outcomes: environmental tobacco smoke, gas stoves, and woodsmoke.

BACKGROUND: Because they have chronic airway inflammation, adults with asthma may be particularly susceptible to indoor air pollution. Despite widespread exposure to environmental tobacco smoke (ETS), gas stoves, and woodsmoke, the impact of these exposures on adult asthma has not been well characterised. METHODS: Data were used from a prospective cohort study of 349 adults with asthma who underwent structured telephone interviews at baseline and 18 month follow up. The prospective impact of ETS, gas stove, and woodsmoke exposure on health outcomes was examined. RESULTS: ETS exposure at baseline interview was associated with impaired health status at longitudinal follow up. Compared with respondents with no baseline self-reported exposure to ETS, higher level exposure (>/=7 hours/week) was associated with worse severity of asthma scores at follow up, controlling for baseline asthma severity, age, sex, race, income, and educational attainment (mean score increment 1.5 points; 95% CI 0.4 to 2.6). Higher level baseline exposure to ETS was also related to poorer physical health status (mean decrement -4.9 points; 95% CI -8.4 to -1.3) and asthma specific quality of life (mean increase 4.4 points; 95% CI -0.2 to 9.0) at longitudinal follow up. Higher level baseline ETS exposure was associated with a greater risk of emergency department visits (OR 3.4; 95% CI 1.1 to 10.3) and hospital admissions for asthma at prospective follow up (OR 12.2; 95% CI 1.5 to 102). There was no clear relationship between gas stove use or woodstove exposure and asthma health outcomes. CONCLUSION: Although gas stove and woodstove exposure do not appear negatively to affect adults with asthma, ETS is associated with a clear impairment in health status.

Risk factors for hospitalization among adults with asthma: the influence of sociodemographic factors and asthma severity.

BACKGROUND: The morbidity and mortality from asthma have markedly increased since the late 1970s. The hospitalization rate, an important marker of asthma severity, remains substantial. METHODS: In adults with health care access, we prospectively studied 242 with asthma, aged 18-50 years, recruited from a random sample of allergy and pulmonary physician practices in Northern California to identify risk factors for subsequent hospitalization. RESULTS: Thirty-nine subjects (16%) reported hospitalization for asthma during the 18-month follow-up period. On controlling for asthma severity in multiple logistic regression analysis, non-white race (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.1-8.8) and lower income (OR, 1.1 per $10,000 decrement; 95% CI, 0.9-1.3) were associated with a higher risk of asthma hospitalization. The severity-of-asthma score (OR, 3.4 per 5 points; 95%, CI 1.7-6.8) and recent asthma hospitalization (OR, 8.3; 95%, CI, 2.1-33.4) were also related to higher risk, after adjusting for demographic characteristics. Reliance on emergency department services for urgent asthma care was also associated with a greater likelihood of hospitalization (OR, 3.2; 95% CI, 1.0-9.8). In multivariate analysis not controlling for asthma severity, low income was even more strongly related to hospitalization (OR, 1.2 per $10,000 decrement; 95% CI, 1.02-1.4). CONCLUSION: In adult asthmatics with access to health care, non-white race, low income, and greater asthma severity were associated with a higher risk of hospitalization. Targeted interventions applied to high-risk asthma patients may reduce asthma morbidity and mortality.

Alternative therapies among adults with a reported diagnosis of asthma or rhinosinusitis : data from a population-based survey.

BACKGROUND: Asthma and rhinosinusitis are common medical conditions among adults. Alternative treatments could have important impacts on health status among those individuals with these conditions, but specific prevalence data for these treatments are limited. OBJECTIVE: To estimate the prevalence of specific alternative treatment modalities, including herbal agents, ingestion of caffeinated beverages, homeopathy, acupuncture, and massage therapies. DESIGN: Random population telephone sample. SETTING: Northern California. PARTICIPANTS: Three hundred adults aged 18 to 50 years with self-report of a physician diagnosis of asthma (n = 125) or rhinosinusitis without concomitant asthma (n = 175). MEASUREMENTS: Structured telephone interviews covering demographics and clinical variables, including the following alternative treatments used in the previous 12 months: herbal agents; caffeine-containing products; homeopathy; acupuncture; aromatherapy; reflexology; and massage. RESULTS: Any alternative practice was reported by 127 subjects (42%; 95% confidence interval [CI], 36 to 48%). Of these, 33 subjects (26%; 95% CI, 21 to 31%) were not current prescription medication users. Herbal use was reported by 72 subjects (24%), caffeine treatment by 54 subjects (18%), and other alternative treatments by 66 subjects (22%). Taking into account demographic variables, subjects with asthma were more likely than those with rhinitis alone to report caffeine self-treatment for their condition (odds ratio, 2.5; 95% CI, 1.4 to 4.8%), but herbal use and other alternative treatments did not differ significantly by condition group. CONCLUSION: Alternative treatments are frequent among adults with asthma or rhinosinusitis and should be taken into account by health-care providers and public health and policy analysts.

Measurement of environmental tobacco smoke exposure among adults with asthma.

Because the morbidity and mortality from adult asthma have been increasing, the identification of modifiable environmental exposures that exacerbate asthma has become a priority. Limited evidence suggests that exposure to environmental tobacco smoke (ETS) may adversely affect adults with asthma. To study the effects of ETS better, we developed a survey instrument to measure ETS exposure in a cohort of adults with asthma living in northern California, where public indoor smoking is limited. To validate this survey instrument, we used a passive badge monitor that measures actual exposure to ambient nicotine, a direct and specific measure of ETS. In this validation study, we recruited 50 subjects from an ongoing longitudinal asthma cohort study who had a positive screening question for ETS exposure or potential exposure. Each subject wore a passive nicotine badge monitor for 7 days. After the personal monitoring period, we readministered the ETS exposure survey instrument. Based on the survey, self-reported total ETS exposure duration ranged from 0 to 70 hr during the previous 7 days. Based on the upper-range boundary, bars or nightclubs (55 hr) and the home (50 hr) were the sites associated with greatest maximal self-reported exposure. As measured by the personal nicotine badge monitors, the overall median 7-day nicotine concentration was 0.03 microg/m(3) (25th-75th interquartile range 0-3.69 microg/m(3)). Measured nicotine concentrations were highest among persons who reported home exposure (median 0.61 microg/m(3)), followed by work exposure (0.03 microg/m(3)), other (outdoor) exposure (0.025 microg/m(3)), and no exposure (0 microg/m(3); p = 0.03). The Spearman rank correlation coefficient between self-reported ETS exposure duration and directly measured personal nicotine concentration during the same 7-day period was 0.47, supporting the survey's validity (p = 0.0006). Compared to persons with no measured exposure, lower-level [odds ratio (OR) 1.9; 95% confidence interval (CI), 0.4-8.8] and higher-level ETS exposures (OR 6.8; 95% CI, 1.4-32.3) were associated with increased risk of respiratory symptoms. A brief, validated survey instrument can be used to assess ETS exposure among adults with asthma, even with low levels of exposure. This instrument could be a valuable tool for studying the effect of ETS exposure on adult asthma health outcomes.

Does satisfaction with abilities mediate the relationship between the impact of rheumatoid arthritis on valued activities and depressive symptoms?

OBJECTIVE: Both impact of rheumatoid arthritis (RA) on valued life activities and dissatisfaction with abilities have been linked to depression among individuals with RA. We integrated these concepts by examining the hypothesis that satisfaction with one's abilities may explain the mechanism by which the impact of RA on valued activities leads to depression. METHODS: Data were collected over 2 years (1997 and 1998) through interviews with the University of California, San Francisco, RA panel. Analyses examined whether activity impairment in 1997 predicted later (1998) dissatisfaction with abilities and depression. RESULTS: Greater impact on activities predicted dissatisfaction with abilities, which in turn was associated with higher depression scores. There was no direct relationship between activity impact and depression when satisfaction with abilities was considered. CONCLUSION: Satisfaction with abilities mediated the relationship between the impact of RA on valued activities and an increase in depressive symptoms, suggesting a need to assess not only physical decline but also individuals' interpretation of the decline.

The work impact of asthma and rhinitis: findings from a population-based survey.

Asthma and rhinitis are common chronic conditions that affect adults of working age. Little is known about their relative impacts on work loss and decreased productivity. Using random digit telephone dialing, we carried out a population-survey of adults in Northern California aged 18-50 years. We interviewed 125 persons with asthma (with or without concomitant rhinitis) and 175 persons with rhinitis alone. Study eligibility was based on subject report of a physician's diagnosis of asthma and/or a rhinitis-related condition. Any adult labor force participation since condition onset was lower among those with asthma (88%) than among those with rhinitis alone (97%) (P = 0.002). In contrast, among those still employed, decreased job effectiveness was more frequently reported in the rhinitis group (43 of 121; 36%) compared to those with asthma (14 of 72; 19%) (P = 0.02). Condition-attributed lost work was common in both groups, with more than 20% reporting one or more complete or partial work days lost in the 4 weeks previous to interview. Taking into account age, gender, race, and smoking status, those with asthma were more likely to have no labor force participation after diagnosis (OR = 3.0; 95% CI 1.1-7.7) and less likely to report decreased job effectiveness among those remaining employed (OR = 0.4; 95% CI 0.2-0.9). Excluding subjects from the rhinitis group most likely to have unreported asthma based on past medication use had little impact on these associations. Both asthma and rhinitis negatively affect work productivity. Those with asthma are less likely to be employed at all, while among those remaining on the job, rhinitis is a more potent cause of decreased work effectiveness. The economic impact of asthma and rhinitis and related conditions may be under-appreciated.

Activity loss and the onset of depressive symptoms: do some activities matter more than others?

OBJECTIVE: This study continues an investigation into the role of decline in performance of valued life activities in the development of depressive symptoms among persons with rheumatoid arthritis (RA). We examined whether declines in specific types of activities are important in the onset of depressive symptoms or whether the important factor is simply the overall burden of activity decline. METHODS: Data from a longitudinal study of persons with RA, for which individuals are interviewed annually, were used. Two analyses (n = 344 and 310) were conducted because of differences in the way life activities were assessed over time. Each analysis covered 4 interviews (1989-1992 and 1995-1998). Analyses were structured so that the decline in performance of life activities clearly preceded the development of depressive symptoms. The outcome variable was the presence of depressive symptoms at time 4; primary independent variables were activity decline between time 2 and time 3. Individuals with high levels of depressive symptoms prior to time 4 were excluded from the analyses. RESULTS: In both analyses, total decline in performance of life activities was an important predictor of subsequent high levels of depressive symptoms. However, some activity domains were more closely linked to the onset of new depressive symptoms than others. In particular, declines in the ability to perform recreational activities and engage in social interactions were linked to the onset of new depressive symptoms. CONCLUSION: Declines in the ability to engage in recreational activities and social interactions appear to significantly increase the risk of new depressive symptoms. These findings can give direction to both clinical inquiries into patients' functioning and interventions intended to enhance functioning.

A pneumonia practice guideline and a hospitalist-based reorganization lead to equivalent efficiency gains.

OBJECTIVE: To compare the impact of a practice guideline for a common inpatient disorder with that of a hospitalist-based reorganization of an academic medical service. STUDY DESIGN: Retrospective cohort study. PATIENTS AND METHODS: In July 1995 we introduced a clinical practice guideline for the treatment of community-acquired pneumonia at University of California San Francisco Moffitt-Long Hospital. Simultaneously, we implemented a structural change for half of the inpatient medical service, requiring earlier and more intensive faculty intervention, primarily by hospitalists. For 1 year, we studied the effect of these interventions on hospital costs, length of stay, and resource use. RESULTS: As reported previously, the hospitalist-based intervention resulted in significant decreases in average adjusted cost ($7777 vs $7007, P = .05) and length of stay (4.9 days vs 4.3 days, P = .01) compared with both concurrent and historical controls. For patients with community-acquired pneumonia, a similar savings occurred when fiscal year 1996 was compared with fiscal year 1995 ($8164 vs $6282, P= .015; 5.0 vs 4.2 days, P= .04). However, the effect was identical for the hospitalist and nonhospitalist groups. The reduced length of stay was associated with a borderline significant reduction in readmission rates (from 4.8% to 0.7%, P = .055) and no change in mortality rates. CONCLUSIONS: In this study, a hospitalist-based reorganization improved efficiency, with its greatest impact on the care of patients with disorders not covered by a practice guideline. The introduction of a guideline for a common diagnosis improved efficiency on both hospitalist- and nonhospitalist-based services. For common diagnoses amenable to practice guidelines, successful implementation of and compliance with guidelines may be an alternative to major organizational change.