Reducing the Risk of Mortality in Chronic Obstructive Pulmonary Disease With Pharmacotherapy: A Narrative Review.

In 2020, chronic obstructive pulmonary disease (COPD) was the fifth leading cause of death in the United States excluding COVID-19, and its mortality burden has been rising since the 1980s. Smoking cessation, long-term oxygen therapy, noninvasive ventilation, and lung volume reduction surgery have had a beneficial effect on mortality; however, until recently, the effects of pharmacologic therapies on all-cause mortality have been unclear. Inhaled pharmacologic treatments for patients with COPD include combinations of long-acting muscarinic receptor antagonists (LAMAs), long-acting-ß2-agonists (LABAs), and inhaled corticosteroids (ICS). The recent IMPACT and ETHOS clinical trials reported mortality benefits with ICS/LAMA/LABA triple therapy compared with LAMA/LABA dual therapy. In IMPACT, fluticasone furoate/umeclidinium/vilanterol therapy significantly reduced the risk of on-/off-treatment all-cause mortality vs umeclidinium/vilanterol (hazard ratio, 0.72; 95% CI, 0.53 to 0.99; P=.042). The ETHOS trial found a reduction in the risk of on-/off-treatment all-cause mortality in patients treated with budesonide/glycopyrrolate/formoterol vs glycopyrrolate/formoterol (hazard ratio, 0.51 [0.33 to 0.80]; nominal P=.0035). Both trials included populations of patients with symptomatic COPD at high risk of future exacerbations, and a post hoc analysis of the final retrieved vital status data suggested that the observed mortality benefits are conferred by the ICS component. In conclusion, triple therapy reduces the risk of mortality in patients with symptomatic COPD characterized by moderate or severe airflow obstruction and a recent history of moderate or severe exacerbations. This benefit is likely to be driven by reductions in exacerbations. Future research efforts should focus on improving the long-term prognosis of patients living with COPD.

GOLD in Practice: Chronic Obstructive Pulmonary Disease Treatment and Management in the Primary Care Setting.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Early detection and appropriate treatment and management of COPD can lower morbidity and perhaps mortality. Clinicians in the primary care setting provide the majority of COPD care and are pivotal in the diagnosis and management of COPD. In this review, we provide an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 report, with a focus on the management of COPD in the primary care setting. We discuss the pathophysiology of COPD; describe COPD risk factors, signs, and symptoms that may facilitate earlier diagnosis of COPD; and reinforce the importance of spirometry use in establishing the diagnosis of COPD. Disease monitoring, as well as a review of the 2020 GOLD treatment recommendations, is also discussed. Patients and families are important partners in COPD management; therefore, we outline simple steps that may assist them in caring for those affected by COPD. Finally, we discuss nonpharmacological treatment options for COPD, COPD monitoring tools that may aid in the evaluation of disease progression and response to therapy, and the importance of developing a COPD action plan on an individualized basis.

Role of the Kidney in Type 2 Diabetes and Mechanism of Action of Sodium Glucose Cotransporter-2 Inhibitors.

The aim of this supplement is to discuss the important role of the kidney in glucose homeostasis. It produces glucose via gluconeogenesis, it filters glucose from the blood, and reabsorbs the filtered glucose in the proximal tubule, mainly via the sodium-glucose cotransporter-2 (SGLT-2). SGLT-2 is paradoxically upregulated in individuals with type 2 diabetes (T2D), which results in increased glucose reabsorption and hyperglycemia. This core defect in the pathophysiology of T2D provides the rationale for the use of SGLT-2 inhibitors to increase urinary glucose excretion and reduce hyperglycemia in an insulin-independent manner. Benefits of SGLT-2 inhibitor use in patients with T2D, in addition to improved glycemic control, include modest weight loss, decreased systolic blood pressure, reduced serum uric acid, and reduced risk of cardiovascular events. Common adverse events are urinary tract infection and genital mycotic infections. The risk of hypoglycemia is low with SGLT-2 inhibitors, particularly when they are given as monotherapy.

Changes in medical students' exposure to and attitudes about drug company interactions from 2003 to 2012: a multi-institutional follow-up survey.

PURPOSE: To ascertain whether changes occurred in medical student exposure to and attitudes about drug company interactions from 2003-2012, which factors influence exposure and attitudes, and whether exposure and attitudes influence future plans to interact with drug companies. METHOD: In 2012, the authors surveyed 1,269 third-year students at eight U.S. medical schools. Items explored student exposure to, attitudes toward, and future plans regarding drug company interactions. The authors compared 2012 survey data with their 2003 survey data from third-year students at the same schools. RESULTS: The 2012 response rate was 68.2% (866/1,269). Compared with 2003, in 2012, students were significantly less frequently exposed to interactions (1.6/month versus 4.1/month, P < .001), less likely to feel entitled to gifts (41.8% versus 80.3%, P < .001), and more apt to feel gifts could influence them (44.3% versus 31.2%, P < .001). In 2012, 545/839 students (65.0%) reported private outpatient offices were the main location of exposure to pharmaceutical representatives, despite spending only 18.4% of their clerkship-rotation time there. In 2012, 310/703 students (44.1%) were unaware their schools had rules restricting interactions, and 467/837 (55.8%) planned to interact with pharmaceutical representatives during residency. CONCLUSIONS: Students in 2012 had less exposure to drug company interactions and were more likely to have skeptical attitudes than students in 2003. These changes are consistent with national organizations' recommendations to limit and teach about these interactions. Continued efforts to study and influence students' and physician role models' exposures to and attitudes about drug companies are warranted.

The effect of resident duty-hours restrictions on internal medicine clerkship experiences: surveys of medical students and clerkship directors.

UNLABELLED: PHENOMENON: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students' and clerkship directors' perceptions of the effects of the 2011 DHR on internal medicine clerkship students' experiences with teaching, feedback and evaluation, and patient care. APPROACH: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. FINDINGS: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. INSIGHTS: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student-patient relationship and students' clinical skills acquisition.

Saxagliptin versus glipizide as add-on therapy to metformin: assessment of hypoglycemia.

OBJECTIVE: To compare characteristics of hypoglycemic episodes in patients with type 2 diabetes receiving saxagliptin or glipizide add-on therapy to metformin. PATIENTS AND METHODS: This was a post hoc analysis of an international, randomized, parallel-group, double-blind, active-controlled, phase 3 trial. The 52-week trial and 52-week extension were conducted from December 2007 to August 2010. Patients aged ≥18 years with glycated hemoglobin (HbA1c) >6.5% to 10.0% receiving stable metformin doses (≥1500 mg/d) were randomized 1:1 to add-on therapy with saxagliptin 5 mg/d or glipizide 5 to 20 mg/d (titrated to optimal effect or highest tolerable dose during the initial 18 weeks). Hypoglycemic episodes were recorded in patient diaries. Confirmed hypoglycemic events were defined as fingerstick glucose ≤50 mg/dL (≤2.8 mmol/L) with associated symptoms. RESULTS: Of 858 patients randomized, 428 received saxagliptin + metformin, and 430 received glipizide + metformin. Saxagliptin was noninferior to glipizide in lowering HbA1c. Hypoglycemia with saxagliptin + metformin and glipizide + metformin was reported by 15 (24 events) and 165 (896 events) patients, respectively, through week 104. The mean (SD) number of hypoglycemic events per patient reporting hypoglycemia was lower with saxagliptin + metformin versus glipizide + metformin through weeks 52 (1.5 [SD 0.88] vs 4.8 [SD 4.9], respectively) and 104 (1.6 [SD 0.99] vs 5.4 [SD 5.8]). Most patients receiving glipizide + metformin with hypoglycemia had multiple events (124/165 patients [75%]). Confirmed hypoglycemia, major events, and severe events occurred only with glipizide + metformin. Time to first hypoglycemic event was shorter with glipizide versus saxagliptin. Limitations of this analysis include its post hoc nature, a high rate of study discontinuation, and exclusion of patients with serious comorbidities and complications. CONCLUSION: Saxagliptin + metformin was associated with fewer patients reporting hypoglycemia and fewer and less severe hypoglycemic events in those experiencing hypoglycemia compared with glipizide + metformin. ClinicalTrials.gov registration number: NCT00575588.

Evaluating oral case presentations using a checklist: how do senior student-evaluators compare with faculty?

PURPOSE: Previous studies have shown student-evaluators to be reliable assessors of some clinical skills, but this model has not been studied for oral case presentations (OCPs). The purpose of this study was to examine the validity of student-evaluators in assessing OCP by comparing them with faculty. METHOD: In 2010, the authors developed a dichotomous checklist. They trained 30 fourth-year medical students (student-evaluators) to use it to assess 170 second-year medical students' OCPs in real time during a year-end objective structured clinical examination. Ten faculty physicians then scored videos of a random sample of these OCPs. After discarding items with poor faculty reliability, the authors assessed agreement between faculty and student-evaluators on 18 individual items, total scores, and pass/fail decisions. RESULTS: The total score correlation between student-evaluators and faculty was 0.84 (P < .001) and was somewhat better than the faculty-faculty intraclass correlation (r = 0.71). Using a 70% pass/fail cutoff, faculty and student-evaluator agreement was 74% (Kappa = 0.46; 95% CI, 0.20-0.72). Overall, student-evaluator scores were more lenient than faculty scores (72% versus 56% pass rates; P = .03). CONCLUSIONS: Senior student-evaluators were able to reliably assess second-year medical students' OCP skills. The results support the use of student-evaluators for peer assessment of OCPs in low-stakes settings, but evidence of leniency compared with faculty assessment suggests caution in using student-evaluators in high-stakes settings. Extending peer assessment to OCPs provides a practical approach for low-resource evaluation of this essential skill.

Developing a national collaborative of medical educators who lead clinical skills courses.

BACKGROUND: The majority of US medical schools now have pre-clerkship clinical skills (PCCS) courses. Course directors for these often logistically complicated courses may be in different medical specialties and, historically, have had few formal opportunities for communication and collaboration with their counterparts at other institutions. As such, we hypothesized that leaders of PCCS courses would benefit from a national network. SUMMARY: In this paper, we outline the methodology used to form a national collaborative from grass roots interest. Over three years, a self-identified eleven-person task force with national representation has created an organization for PCCS course directors from US medical schools called Directors Of Clinical Skills courses (DOCS) that meets annually. CONCLUSIONS: Through iterative presentations at regional and national medical education meetings, we have produced an inventory of educational issues for those developing, administering, and evaluating PCCS courses. Further development of this nascent organization is ongoing. Our process is generalizable.

Analysis and publication rates of Clerkship Directors in Internal Medicine (CDIM) annual meeting abstracts 1995-2005.

BACKGROUND: Abstracts presented at meetings may be a reflection of the meeting's quality. SUMMARY: The goal is to determine purpose, content areas, research design, and subsequent publication rates of abstracts presented at Clerkship Directors in Internal Medicine's annual meetings. Abstracts presented in 1995-2005 were analyzed. A total of 201 abstracts were analyzed and coded. The purpose of the majority of the studies was description (155, 77%), 44 (22%) were justification studies, and 2 (1%) were clarification studies. In all, 109 (54%) assessed the relationship between teaching and student performance. Seven (4%) were studies about how students learn, study, solve problems, obtain medical knowledge, and think critically. Nineteen (10%) were studies about students' noncognitive skills, professionalism, interpersonal skills, and well-being studies. In all, 29 (14%) were measurement studies assessing reliability or validity of assessments. Twenty (10%) focused on career or faculty development pertaining to either faculty or residents. Research design of most studies was descriptive or pre-experimental (175, 87%), some were quasi-experimental (13, 7%), and two thirds (135, 66%) were not published as full articles in peer-reviewed journals. and there was an upward trend in publication rates. CONCLUSIONS: These findings may serve as an indicator of the quality of the educational meeting. It may further stimulate efforts to develop programs to help program attendees achieve scholarly publications for work presented and serve as a benchmark against which future meetings may be judged.

Prevalence of airway obstruction assessed by lung function questionnaire.

OBJECTIVE: To estimate the prevalence of unidentified chronic obstructive pulmonary disease (COPD) and determine the screening accuracy of the Lung Function Questionnaire (LFQ). PATIENTS AND METHODS: Cigarette smokers who had a smoking history of 10 or more pack-years and were aged 30 years or older were recruited from 36 centers from February 18, 2009, to May 29, 2009. A total of 1575 patients completed a Web-based survey including the 5-item LFQ. Spirometry was performed on patients with an LFQ total score of 18 or less and on a subset scoring more than 18. The primary outcome was the proportion of patients at risk of airflow obstruction as measured by the LFQ (score, ≤ 18) in whom an airflow obstruction was confirmed by spirometry. RESULTS: Of the patients who completed the LFQ, 849 (54%) had standardized spirometry data available. On the basis of LFQ and spirometry results, the estimated prevalence of possible COPD was 17.9% (95% confidence interval, 15.3%-20.6%). At a cut point of 18 or less, sensitivity, specificity, positive predictive value, and negative predictive value of the LFQ were 88%, 25%, 21%, and 90%, respectively. Approximately 1 in 5 patients (21%) aged 30 years or older and 1 in 4 (26%) aged 50 years or older scored 18 or less on the LFQ and had a ratio of forced expiratory volume in the first second of expiration to forced vital capacity less than 0.70. CONCLUSION: On the basis of postbronchodilator spirometry results using weighted estimates, approximately 1 in 5 patients (21%) aged 30 years or older with a smoking history of 10 or more pack-years seen in a primary care setting is likely to have COPD. The LFQ could be a helpful COPD case-finding tool for clinicians to identify patients who need further evaluation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01013948.

Development of the Lung Function Questionnaire (LFQ) to identify airflow obstruction.

OBJECTIVE: To describe the item-selection and item-reduction for the Lung Function Questionnaire (LFQ), being developed to help clinicians identify patients appropriate for diagnostic evaluation for chronic obstructive pulmonary disease (COPD) using spirometry. METHODS: Item selection and reduction were based on information from 387 > or =40-year-old respondents to the third National Health and Nutrition Examination Survey who had self-reported chronic bronchitis. Item reduction involved stepwise logistic regression. The accuracy of the final subset of items for identifying individuals with airflow obstruction (forced expiratory volume in one second/forced vital capacity <0.70) versus those without it was assessed with receiver operating characteristic analysis. Content and face validity were assessed using focus groups of primary care physicians (n = 16) and interviews with COPD patients (n = 16). RESULTS: The model with all five items (age; smoking history; the presence of wheeze, dyspnea, and phlegm) compared with models with combinations of fewer items had the highest classification accuracy (area under the curve [AUC] = 0.720) with sensitivity and specificity of 73.2% and 58.2%, respectively. The presence of three or more factors yielded the highest AUC, a result suggesting that three or more affirmative answers is the most appropriate criterion indicating presence of airflow obstruction. CONCLUSIONS: The five-item LFQ retained sufficient accuracy, sensitivity, and specificity in identifying individuals with COPD for further validation testing.

Perspective: are we teaching racial profiling? The dangers of subjective determinations of race and ethnicity in case presentations.

Physicians make subjective visual assessments concerning the race and/or ethnicity of their patients and document these assessments in patient histories every day. Medical students learn this practice through textbooks and the example set by their educators. Although physicians may believe that they are helping their patients, the practice of using visual clues concerning race and/or ethnicity to determine whether a patient is at risk of certain diseases lacks scientific rigor and may put the patient at significant risk of receiving substandard medical care. The authors argue that if the patient's race or ethnicity is of critical importance, the data should be collected through more objective, scientifically rigorous means, such as genetic testing. In this article, the authors call for the widespread transformation of the way medical schools teach tomorrow's physicians about the role of race and ethnicity in taking medical histories, and they challenge physicians to change their current practices.

Psychometric validation of the rhinitis control assessment test: a brief patient-completed instrument for evaluating rhinitis symptom control.

BACKGROUND: Allergic rhinitis is common, but a validated tool for comprehensive assessment of disease control is not available. OBJECTIVE: To develop a simple patient-completed instrument (the Rhinitis Control Assessment Test [RCAT]) to help detect problems with control of rhinitis symptoms. METHODS: During a visit to an allergy specialist, 410 patients with allergic rhinitis completed a Total Nasal Symptom Score (TNSS) assessment and the 26-item developmental RCAT. Physicians also completed a global assessment of rhinitis symptom control for each patient. RESULTS: Stepwise regression methods identified 6 items from the developmental RCAT (frequency of nasal congestion, sneezing, and watery eyes; sleep interference; activity avoidance; and self-assessed control) that were most predictive of the allergist's global rating of rhinitis symptom control. A summated rating scale from these 6 items showed good convergent validity (r > 0.70) with scale scores from the TNSS. The discriminant validity of the 6-item scale was demonstrated as mean RCAT scale scores differed significantly across groups of patients differing in physician-rated disease severity (F = 54.4), TNSS severity (F = 193.8), and physician-recommended change in therapy (F = 50.6) (P < .001 for all). CONCLUSIONS: The RCAT, a 6-item patient-completed instrument, has satisfactory psychometric properties and seems to be a valid tool for assessing control of allergic rhinitis. Further validation studies will provide confirmation.

Predicting risk of airflow obstruction in primary care: Validation of the lung function questionnaire (LFQ).

The Lung Function Questionnaire (LFQ) is being developed as a case finding tool to identify patients who are appropriate for spirometry testing to confirm the diagnosis of chronic obstructive pulmonary disease (COPD). The cross-sectional study reported herein was conducted to validate the LFQ, to identify item-response scales associated with the best accuracy, and to determine the impact on accuracy of the addition of another item on activity limitations (AL). Patients >or= 40 years old seen at 2 primary care offices completed the LFQ, a demographic questionnaire followed by spirometry. Of the 837 evaluable patients, 18.6% had airflow obstruction (forced expiratory volume in 1 s/forced vital capacity [FEV(1)/FVC] < 0.70). The 5 items (age, wheeze, dyspnea, smoking, and cough) previously identified in initial LFQ development predicted airflow obstruction and showed good evidence of screening accuracy. Screening accuracy was significantly better with 5-point ordinal item-response scales (78%) than binary (yes/no) item-response scales (74%)(p < 0.05). Screening accuracy was good regardless of whether airflow obstruction was defined as FEV(1)/FVC < 0.70 or FEV(1)/FVC < 0.70 and FEV(1) < 80% of predicted. Based on

Qualitative Development of the Rhinitis Control Assessment Test (RCAT), an Instrument for Evaluating Rhinitis Symptom Control.

BACKGROUND: : Effective management of allergic rhinitis requires ongoing monitoring of its control. This article describes the qualitative phase of development of a patient-completed instrument, the Rhinitis Control Assessment Test (RCAT), designed to assist patients and providers in the detection of problems with rhinitis symptom control. OBJECTIVE: : To identify concepts to be measured and to develop initial questionnaire items to be tested further in the next phase of development. METHODS: : A literature review and input from patient focus groups were utilized to generate concepts to be measured in the draft questionnaire. The draft items were subjected to cognitive testing to ensure that the items were understood by patients and to eliminate ambiguity as well as to select an optimal recall period and meaningful response scales. Patients aged ≥18 years self-reporting a rhinitis diagnosis who had experienced rhinitis symptoms in the past 12 months were eligible for participation in the focus groups (n = 39) and the cognitive interviews (n = 23). RESULTS: : This qualitative process yielded a draft instrument with 26 items assessing five constructs of rhinitis symptom control: frequency and bothersomeness of nasal and non-nasal symptoms, symptom impact, activity interference, symptom control, and medication use. A five-point Likert response scale and a 1-week recall period for each item were adopted based on patient input. CONCLUSION: : The qualitative phase of development of the RCAT produced constructs and items for an instrument that is anticipated to facilitate accurate assessment of rhinitis control and improve the quality of care for patients with allergic rhinitis.

Relationships between drug company representatives and medical students: medical school policies and attitudes of student affairs deans and third-year medical students.

OBJECTIVES: The authors sought to ascertain the details of medical school policies about relationships between drug companies and medical students as well as student affairs deans' attitudes about these interactions. METHODS: In 2005, the authors surveyed deans and student affairs deans at all U.S. medical schools and asked whether their schools had a policy about relationships between drug companies and medical students. They asked deans at schools with policies to summarize them, queried student affairs deans regarding their attitudes about gifts, and compared their attitudes with those of students who were studied previously. RESULTS: Independently of each other, 114 out of 126 deans (90.5%) and 114 out of 126 student affairs deans (90.5%) responded (identical numbers are not misprints). Ten schools had a policy regarding relationships between medical students and drug company representatives. Student affairs deans were much more likely than students to perceive that gifts were inappropriate. CONCLUSION: These 2005 policies show trends meriting review by current medical schools in considering how to comply with the 2008 Association of American Medical Colleges recommendations about relationships between drug companies and medical students or physicians.

Use of electronic medical records by physicians and students in academic internal medicine settings.

PURPOSE: Electronic medical records (EMRs) have been touted as one method to improve quality and safety in medical care, and their use has recently increased. The purpose of this study is to describe current use of EMRs by medical students at U.S. and Canadian medical schools. METHOD: In 2006 the authors performed a cross-sectional survey of the Clerkship Directors in Internal Medicine institutional members at U.S. and Canadian academic health centers. Outcome measures included implementation of EHRs, EHR use by students, and the challenges of having students use EMRs. RESULTS: Of 110 members, 82 (74.5%) responded. Of those 82, 48 (58%) reported using an EMR in the ambulatory setting (excluding Veterans' Affairs medical centers) of their institutions, and only 21 of those 48 (44%) had policies regarding medical student documentation of progress notes in the EMR during the ambulatory internal medicine (IM) clerkship. Schools were dichotomously split; about half (23/48, 48%) required and about half (25/48, 52%) prohibited allowing students to document in the EMR. The programs that prohibited medical students from documenting in the EMR primarily cited billing concerns. Other issues regarding student use of EMRs included student access, faculty concerns, and note quality. CONCLUSIONS: Use of EMRs by IM clerkship students is common, yet many institutions do not have policies regarding student use. Where policies do exist, they vary, and many prohibit students from using EMRs. Concerns about documentation as it relates to billing seem to be a significant factor in prohibiting students' use of EMRs.

Medical informatics in the internal medicine clerkship: Results of a national survey.

BACKGROUND: Medical Informatics (MI) is increasingly a critical aspect of medical education and patient care. AIMS: This study assessed the status of MI training, perception of needs and barriers for the implementation of MI curricula and utilization of information technology (IT) in patient care and medical education. METHOD: The MI questionnaire was a part of the 2006 Clerkship Directors in Internal Medicine survey of 110 institutional members. Descriptive statistics were calculated using Statistical Package for the Social Sciences (SPSS), version 12 and all p-values are two-tailed. RESULTS: Eighty-three (75%) members responded. Out of this, 52, 32.5 and 12% report that students receive MI training for patient care activities during pre-clinical years, third-year internal medicine clerkship or intersession, respectively. House staff critiques (46.4%), patient billing (44.1%), radiographic imaging (40.8%), accessing clinical data (37.3%), and student evaluations (36.1%) were areas in which 35% of respondents use IT 'all the time.' Fifty-one percent of respondents rate the adequacy of training in MI as average. Cost, time and lack of trained faculty were primary barriers for the implementation. CONCLUSIONS: Significant variations exist in timing of MI curricula. IT is utilized more frequently for non-patient activities. Studies are needed to examine the needs, processes and outcomes of MI curricula.

Patients' and primary care physicians' beliefs about asthma control and risk.

Patients' and physicians' knowledge of asthma control and risks can affect long-term outcomes. The Asthma General Awareness and Perceptions II (Asthma GAP II) survey sought to assess the beliefs and behaviors of asthma patients and their physicians. In the United States, a telephone survey was conducted among 1885 adults with asthma (representative population sample [n = 1001] plus additional black [n = 436] and Hispanic samples [n = 448]) who took asthma medication in the previous year. An online survey included 300 primary care physicians. Most patients (66, 84, and 78% of national, black, and Hispanic samples, respectively) and physicians (80%) considered asthma a very or extremely serious condition. In contrast to current guidelines, most patients (69, 72, and 70%) believed that quick-relief medications could be taken daily. Many patients (42, 52, and 60%) and some physicians (22%) stated controller medications could be taken less regularly when symptoms decrease, although most patients (92, 92, and 89%) and physicians (95%) indicated that controller medications are most effective when taken daily. Of patients who discontinued controller medications (21%), 71% discontinued when symptoms abated. Most physicians (87%) believed that patients discontinued controller medications without their advice. After controller medication cessation, more black (22%) and Hispanic patients (22%) than patients in the national sample (15%) experienced serious health consequences after an asthma attack. Gaps exist between patients' understanding of asthma control and their use of controller and quick-relief medications. Many patients and physicians fail to recognize that, even with symptom abatement, serious asthma risks remain.