World Trade Center workers with asthma and post-traumatic stress disorder perceive airflow limitation more accurately.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a major risk factor for increased asthma morbidity among World Trade Center (WTC) workers. OBJECTIVE: To investigate whether differences in perception of airflow limitation mediate the association of PTSD with worse asthma control in WTC workers. METHODS: We collected data from WTC workers on asthma control (Asthma Control Questionnaire and Asthma Quality of Life Questionnaire) and daily peak expiratory flow (PEF) measures over 6 weeks. Perception of airway limitation was assessed by comparing guessed vs actual PEF values. Post-traumatic stress disorder was diagnosed using the Structured Clinical Interview. We used unadjusted and adjusted models to compare PEF and perception measures in WTC workers with PTSD with those of workers without PTSD. RESULTS: Overall, 25% of 224 participants had PTSD. Post-traumatic stress disorder was associated with worse Asthma Control Questionnaire (2.2±0.8 vs 1.1±0.9, P < .001) and Asthma Quality of Life Questionnaire (3.9±1.1 vs 5.4±1.1, P < .001) scores. Adjusted analyses showed no significant differences in PEF between WTC workers with (351.9±143.3 L/min) and those without PTSD (364.6±131.6 L/min, P = .55). World Trade Center workers with PTSD vs those without PTSD had increased proportion of accurate perception (67.0±37.2% vs 53.5±38.1%, P = .01) and decreased underperception (23.3.0±32.1% vs 38.9±37.5%, P = .004) of airflow limitation during periods of limitation. Similar results were obtained in adjusted analyses. CONCLUSION: This study indicates that differences in perception of airflow limitation may mediate the relationship of PTSD and increased asthma symptoms, given WTC workers with PTSD have worse self-reported asthma control, an increased proportion of accurate perception, and decreased underperception, despite no differences in daily PEF measures.

Asthma Beliefs and Overuse of Short-Acting Beta-adrenergic Receptor Agonists Among Older Adults.

Objective Short-acting Beta-adrenergic Receptor Agonists (SABA) carry a risk of worse asthma outcomes when overused. Beliefs about asthma controller medications are associated with medication-taking behaviors in older adults, but the association of medication beliefs with SABA use has not been previously examined. We aimed to investigate the association of asthma and controller medication beliefs with SABA use among older patients with asthma.Methods We performed a cross-sectional analysis of data on adults ≥ 60 years with moderate to severe asthma in New York City, NY (n = 234). SABA overuse was defined as the average of ≥1 inhalation per day and controller medication adherence as ≥80% of expected inhalations, measured electronically. Illness and medication beliefs were measured using the Brief-Illness Perception Questionnaire and Beliefs about Medications Questionnaire, respectively. The associations of medication-taking behaviors with beliefs were examined in multivariable logistic regression models.Results The mean age was 67.6 ± 6.5 years, 84% were female, 26% were Black and 53% were Hispanic. 35% of participants overused SABA and 21% had adequate controller medication adherence. Overuse of SABA was not significantly associated with controller medication beliefs (Necessity: odds ratio [OR] 1.04, 95% confidence interval [CI] [0.97-1.12], p = 0.28, Concerns: OR 0.95 [95% CI 0.88, 1.03], p = 0.23) or asthma beliefs (OR 1.06 [95% CI 0.99, 1.15], p = 0.11). SABA overuse was also not significantly associated with controller medication adherence (OR 2.20 [95% CI 0.88, 5.51], p = 0.09).Conclusions SABA overuse was common among older adults with asthma and was not significantly associated with asthma controller medication or illness beliefs.

The relationships between Physical activity and asthma control and Body Mass Index (BMI) in patients with asthma.

OBJECTIVE: Asthma is one of the most common chronic conditions in developed countries. We examined whether physical activity (PA) is related to asthma control and body mass index (BMI) in asthma patients. METHODS: Cross-sectional data collected on PA (ActiGraph GT3X-BT), asthma control (the Asthma Control Questionnaire; ACQ), and BMI were examined in 206 adults (mean[sd] age 47.2[13.8] years; 49.5% had an obese BMI) with clinically diagnosed asthma. Relationships between PA and continuous BMI and asthma control were assessed using linear regression. Differences in PA across obesity (non-obese: <30 Kg/m2/obese: ≥30 Kg/m2) and asthma control categories (controlled: ≤0.75/uncontrolled: >0.75 ACQ score) were also examined. RESULTS: Median (p25, p75) steps counts and peak cadence were 6035 (4248, 8461) steps/day and 123 (115, 133) steps in a minute, respectively. There were nearly 2000 fewer steps/day among those with uncontrolled asthma versus controlled and among those with obese BMI versus nonobese, respectively (both p < 0.05). In regression models adjusted for relevant covariates each 1-unit increase in ACQ score was associated with -686 [95%CI -997, -13] (p ≤ 0.05) average steps/day. The statistical significance of these findings was attenuated (p ≥ 0.05) when BMI was added to the model. However, the point estimate was not reduced (-766 [95%CI -1060, 34]. CONCLUSIONS: Overall step counts were low in this population despite peak cadence values suggesting that most participants could perform moderate intensity activity. Increasing step counts should be considered an important lifestyle intervention goal in obese and non-obese asthma patients with low PA levels.

Assessing the interrelationship between asthma and obesity self-management behaviors.

Asthma and obesity are common coexisting conditions with increasing prevalence and substantial morbidity. This study examines the inter-relationship between illness and treatment beliefs in asthma and obesity and how they influence self-management behaviors. Overweight and obese adults ≥ 18 years with asthma were recruited from primary care and pulmonary practices in New York, NY and Denver, CO (n = 219). Path analysis was used to examine the relationship between asthma, weight and exercise-related illness and medication beliefs and SMB. Necessity beliefs about asthma medications and diet were associated with better medication adherence and healthier dietary behaviors (ß = 0.276, p = < 0.001, ß = 0.148, p = 0.018 respectively) whereas concerns about these self-care activities were associated with poorer adherence and worse dietary behaviors (ß = - 0.282, p < 0.001, ß = - 0.188, p = 0.003 respectively). We found no statistically significant association of exercise behaviors with any other weight or asthma illness or treatment beliefs. Our study demonstrates that necessity and concerns about treatment are associated with adherence in asthma and obesity. The lack of association of exercise behaviors with any asthma or weight related beliefs may reflect limited awareness of the impact of weight on asthma and warrants additional research.

Rates of Undiagnosed Cognitive Impairment and Performance on the Montreal Cognitive Assessment Among Older Adults in Primary Care.

BACKGROUND: The number of adults in the USA with cognitive impairment is increasing; however, few studies report prevalence rates of undiagnosed cognitive impairment among older adults in primary care. OBJECTIVE: To determine the prevalence of undiagnosed cognitive impairment among adults ages 55 years and older in primary care settings and provide normative data for the Montreal Cognitive Assessment in this context. DESIGN: Single interview, observational study. PARTICIPANTS: English-speaking adults ages 55 years and older without diagnoses of cognitive impairment recruited from primary care practices in New York City, NY, and Chicago, IL (n = 872). MAIN MEASURES: Montreal Cognitive Assessment (MoCA). Undiagnosed cognitive impairment was defined by age and education adjusted z-scores more than 1.0 and 1.5 standard deviations below published norms, corresponding to mild or moderate to severe cognitive impairment, respectively. KEY RESULTS: The mean age was 66.8 (8.0) years, 44.7% were male, 32.9% were Black or African-American, and 29.1% were Latinx. Undiagnosed cognitive impairment was identified in 20.8% of subjects (mild impairment, 10.5%; moderate-severe impairment, 10.3%). Impairment at any level of severity was associated in bivariate analyses with several patient characteristics, most notably for race and ethnicity (White, non-Latinx, 6.9% vs. Black, non-Latinx, 26.8%, Latinx, 28.2%, other race, 21.9%; p < 0.0001), place of birth (US 17.5% vs. non-US 30.7%, p < 0.0001), depression (33.1% vs. no depression, 18.1%; p < 0.0001), and impairment in activities of daily living (≥ 1 ADL impairment, 34.0% vs. no ADL impairment, 18.2%; p < 0.0001). CONCLUSIONS: Undiagnosed cognitive impairment is common among urban dwelling older adults attending primary care practices, and was associated with several patient characteristics, including non-White race and ethnicity and depression. Normative data for the MoCA from this study may serve as a useful resource for studies of similar patient populations.

The relationship between social support, self-efficacy, and asthma outcomes in older adults.

OBJECTIVE: There has been a call for research examining factors that influence asthma outcomes in older adults because of the notable disparities observed in this age group. Social support and self-efficacy are resources that factor into asthma outcomes. The current study aimed to examine the relationship between these resources (independently and jointly) and asthma control and quality of life. METHODS: Older adults with moderate-severe asthma were recruited from NYC. Data were obtained during in-person interviews via validated measures of social support, asthma self-efficacy, asthma control, and asthma quality of life. Linear regression evaluated self-efficacy in the relationship between social support and asthma outcomes. RESULTS: In a sample of 359 older adults (M = 68.04, 47.9% Hispanic, 26.5% Black, and 25.6% other), social support had an inverse association with asthma control. As social support increased, asthma control decreased (ß = 0.95, t(356) = -3.13, p = .002). Self-efficacy significantly moderated this relationship (ß = 0.01, t(356) = 2.37, p = .018). For individuals with low or moderate asthma self-efficacy, more received social support was associated with worse asthma control (ß = -0.33, t(356) = -4.66, p < .0001; ß = -0.20, t(356) = -3.21, p = .0014, respectively). For individuals with high self-efficacy, no relationship was found between received social support and asthma control (ß = -0.10, t(356)= -1.20, p =.23). For asthma quality of life, higher levels of received social support were associated with worse quality of life (ß = -0.88, t(356) = -2.64, p = .009), but this association was not significantly moderated by self-efficacy (ß = 0.01, t(356) = 1.90, p = .0582). CONCLUSIONS: For older adults with asthma, receiving more social support is associated with worse asthma outcomes, especially for older adults with lower asthma self-efficacy.

The indirect influence of 'invisible' support on pulmonary function among adults with chronic obstructive pulmonary disease.

Individuals living with chronic obstructive pulmonary disease (COPD) often require support from family or friends. We examined whether invisible support - support that is provided but goes unnoticed - is related to pulmonary function, and whether this association is mediated by depressive symptoms and illness perceptions. Sixty-six dyads of individuals with COPD and their informal caregivers reported on receipt and provision of support, respectively. Those with COPD completed measures of depressive symptoms, illness perceptions and pulmonary function. Although invisible support was not directly related to pulmonary function, mediation analyses revealed a combined indirect effect through lower depressive symptoms and less negative illness perceptions. Interventions teaching skillful delivery of support to caregivers may reduce depressive symptoms and threatening illness cognitions, which may contribute to improvements in symptom burden among patients with COPD.

Differences in L-arginine metabolism and asthma morbidity among asthma patients with and without obstructive sleep apnea.

BACKGROUND: Imbalance in L-arginine and nitric oxide (NO) metabolism has been implicated in the pathophysiology of asthma and obstructive sleep apnea (OSA), and both diseases impact the other's morbidity. We sought to determine whether L-arginine/NO metabolism differs between adults with asthma with or without comorbid OSA, and its association with asthma morbidity. METHODS: This is a cross-sectional study of 322 adults with asthma recruited in Denver, CO and New York City, NY. Data were collected on OSA status, spirometry, and metrics of asthma control and morbidity. L-Arginine metabolites were quantified in patient serum. Bivariate analyses and multiple regression were performed to determine differences between L-arginine metabolism, OSA and association with asthma morbidity. RESULTS: Among the 322 participants, 92 (28.5%) had OSA. The cohort was 81.6% female, 23.4% identified as Black and 30.6% as Latino. Patients with asthma and OSA had significantly higher serum concentrations of NO synthase inhibitor asymmetric dimethylarginine (ADMA) (p-value = 0.019), lower L-arginine to ornithine ratios (p-value = 0.003), and increased ornithine (p-value = 0.001) and proline levels (p-value < 0.001) compared to those without OSA. In adjusted models, OSA was associated with worse asthma control, adjusted mean difference in asthma control questionnaire of 0.36 (95% confidence interval [CI]: 0.06 to 0.65), and asthma quality of life questionnaire, adjusted mean difference: - 0.53 (95% CI: - 0.85 to - 0.21), after adjusting for relevant covariates including body mass index and L-arginine metabolites. CONCLUSIONS: Adults with asthma and OSA had increased ADMA, an inhibitor of nitric oxide synthase, and greater metabolism of L-arginine via the arginase pathway compared to those with asthma alone, indicating a possible shared pathophysiological mechanism of these diseases.

Cognition, symptom perception, and medication non-adherence in older adults with asthma.

BACKGROUND: Cognitive impairment (CI) is highly prevalent in elderly asthmatics and is associated with worse asthma self-management (SM) and outcomes. CI may also explain why older adults may under-perceive asthma symptoms. We hypothesized that CI would be associated with low medication adherence and asthma symptom under-perception (ASP). We also hypothesized that ASP would mediate the relationship between CI and medication adherence. METHODS: Participants of this longitudinal cohort study were asthmatics (N = 334) ≥60 years (51% Hispanic, 25% Black). Cognitive measures assessed general cognition, attention, processing speed, executive functioning, memory, and language. Measures of SM were self-reported and electronically measured adherence to controller medications. ASP was assessed for 6 weeks by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter, followed by PEF blows. Participants were blinded to actual PEF values. Percentage of time that participants were in the over-perception zone was calculated as an average. RESULTS: In regression analyses, those with impairments in memory and general cognition had lower odds ratios (OR) for self-reported non-adherence (OR: 0.96, 95% CI 0.93 - 0.98 & OR: 0.90, 95% CI 0.83 - 0.96, respectively). CI was not associated with electronically measured non-adherence or ASP. In structural equation modeling, while CI was associated with adherence (ß = 0.04, SE = 0.021, p = 0.04), ASP did not mediate this relationship. CONCLUSIONS: While results confirmed the importance of cognition in asthma SM, these findings were not linked to ASP. Future analyses are needed to understand the role of confounding factors.

Comorbidities and depressive symptoms among older adults with asthma.

OBJECTIVE: Depression is associated with poor outcomes among older adults with asthma, and the presence of multiple comorbidities may magnify this relationship. We sought to determine the association of comorbidities with depressive symptoms among older adults with asthma. METHODS: Secondary analysis of data from a randomized controlled trial of older adults with poorly controlled asthma and comorbidities. Comorbidities were measured in two ways: (1) as a count of all the patient's chronic diseases, and (2) as a count of chronic illnesses with self-management intensive needs (diabetes, hypertension, congestive heart failure). Depressive symptoms were measured using the PROMIS SF8a scale. Multiple regression analyses tested the relationship between comorbidities and depressive symptoms, adjusting for sociodemographic factors. RESULTS: Overall, 25% of participants had moderate-severe levels of depressive symptoms, 87% had ≥ two comorbidities, and 41% had ≥ one comorbidity with self-management intensive needs. The count of all comorbidities was significantly associated with depressive symptoms (F (8, 330) = 7.7, p < 0.0001, R2 = 0.158) in adjusted models, whereas the count of self-management intensive conditions was not significantly associated with depressive symptoms in adjusted analyses. CONCLUSIONS: In older adults with asthma and multiple comorbidities, depressive symptoms increased with the overall count of comorbidities but not with the count of comorbidities with self-management intensive needs. Given the impact of depression on asthma outcomes for older adults, the mechanisms by which comorbid illness contributes to depressive symptoms in older asthmatics warrants further evaluation.

Patient characteristics associated with retention in an asthma self-management trial for older adults.

OBJECTIVE: New self-management interventions are being developed for older adults who suffer from worse asthma morbidity than their younger counterparts, but high rates of study drop out have hampered these efforts and there is limited literature on what factors may influence retention in behavioral intervention studies with older adults. This study analyzed illness beliefs and patient characteristics that may contribute to retention in an asthma self-management trial for older adults. METHODS: This is a secondary analysis of data from a randomized controlled trial of a self-management support intervention for adults 60 years and older with persistent, uncontrolled asthma. Multivariable logistic regression was used to evaluate the association of medication and illness beliefs, and other subject characteristics with study retention, which was defined as completion of the research study interview at 6 and 12 months. RESULTS: The randomized trial enrolled 388 individuals; 261 (67.3%) completed the 12-month interview. Higher perceived threat of chronic diseases relative to asthma was associated with higher study retention (OR = 1.11, 95% CI = 1.00-1.24) at 12 months. Other variables including asthma beliefs, age, cognitive function, health literacy, and asthma symptoms were not significantly associated with retention. CONCLUSIONS: Concern about non-asthma chronic conditions, but no other illness beliefs, or patient characteristics, were associated with retention in an asthma self-management support intervention. Further research, including qualitative studies, is needed to better understand why patients drop out of asthma behavioral intervention studies.

Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma.

OBJECTIVE: Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function. METHODS: We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average. RESULTS: Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (ß = 0.14, p = .029), worse self-reported asthma control (ß = 0.17, p = .003), and lower asthma-related quality of life (ß = -0.33, p < .001), but not with lung function (ß = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (ß = 0.14, p = .021), but not lung function (ß = -0.05, p = .41). CONCLUSIONS: Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.

Change in Health Literacy over a Decade in a Prospective Cohort of Community-Dwelling Older Adults.

BACKGROUND: Health literacy is often viewed as a static trait in longitudinal studies, which may over or underestimate an individual's ability to manage one's health. OBJECTIVES: We sought to examine health literacy over time among older adults using three widely used measures. DESIGN: A prospective cohort study. PARTICIPANTS: Community-dwelling adults ages 55 to 74 at baseline with at least one follow-up visit (N = 656) recruited from one academic internal medicine clinic and six community health centers in Chicago, IL. MEASURES: Health literacy was measured using the Test of Functional Health Literacy in Adults (TOFHLA), Newest Vital Sign (NVS), and Rapid Estimate of Adult Literacy in Medicine (REALM) at baseline and up to three follow-up time points. RESULTS: In unadjusted analyses, significant changes since baseline were found beginning at the second follow-up (mean (M) = 6.0 years, SD = 0.6) for the TOFHLA (M = - 0.9, SD = 0.95, p = 0.049) and the REALM (M = 0.3, SD = 2.5, p = 0.004) and at the last follow-up (M = 8.6 years, SD = 0.5) for the NVS (M = - 0.2, SD = 1.4, p = 0.02). There were non-linear effects of baseline age on TOFHLA and NVS scores over time (piecewise cubic spline p = 0.01 and p < 0.001, respectively) and no effect on REALM scores (B = 0.02, 95% CI - 0.01 to 0.04, p = 0.17) using multivariable mixed-effects linear regression models, controlling for race, education, income, and comorbidity. CONCLUSION: We found a negative relationship between age and health literacy over time as measured by the TOFHLA and NVS. Health literacy barriers appear to be more prevalent among individuals in later life, when self-care demands are similarly increasing. Clinicians might consider strategies to assess and respond to limited health literacy, particularly among patients 70 and older. REALM performance remained stable over 10 years of follow-up. This questions whether health literacy tools measure the same attribute. Prospective health literacy studies should carefully consider what measures to use, depending on their objective.

Comorbid posttraumatic stress disorder and major depressive disorder are associated with asthma morbidity among World Trade Center workers.

BACKGROUND: World Trade Center (WTC) rescue and recovery workers have a high burden of asthma, comorbid posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). PTSD is associated with worse asthma outcomes. OBJECTIVE: In this study, we evaluated whether the relationship between PTSD and asthma morbidity is modified by the presence of MDD. METHODS: We used data from a cohort of WTC workers with asthma. Asthma control (asthma control questionnaire), resource utilization, and quality of life (asthma quality of life questionnaire) were evaluated. We used regression analyses to evaluate the adjusted association of PTSD and MDD with asthma control, resource utilization, and quality of life. RESULTS: Of the study cohort of 293 WTC workers with asthma, 19% had PTSD alone, 2% had MDD alone, and 12% had PTSD and MDD. Adjusted mean differences (95% confidence interval) in asthma control questionnaire scores were 1.32 (0.85-1.80) for WTC workers with PTSD and MDD, 0.44 (0.03-0.84) for those with PTSD alone, and 0.50 (-0.38 to 1.38) for workers with MDD alone compared with those without MDD or PTSD. WTC workers with PTSD and MDD, PTSD alone, and MDD alone had mean (95% confidence interval) adjusted differences in asthma quality of life questionnaire scores of -1.67 (-2.22 to -1.12), -0.56 (-2.23 to -1.12), and -1.21 (-2.23 to -0.18), respectively, compared with workers without MDD or PTSD. Similar patterns were observed for acute resource utilization. CONCLUSION: PTSD and MDD seem to have a synergistic effect that worsens asthma control and quality of life. Efforts to improve asthma outcomes in this population should address the negative impacts of these common mental health conditions.

Patient characteristics associated with improvements in asthma control and reduction in emergency department visits for older adults with asthma.

OBJECTIVE: To identify patient characteristics associated with improvements in asthma control among older adults with asthma. METHODS: Secondary analysis of data from a randomized controlled trial of an asthma self-management support intervention for adults ages 60 and older with moderate-severe persistent asthma (n = 391). We tested the association of baseline patient characteristics with reduced emergency department (ED) visits and improvement in asthma control equal to or exceeding the minimal clinically important difference (MCID) in asthma control test (ACT) scores (3.0) 12 months. RESULTS: At baseline, the mean age was 68 years, 15.0% were male, 30.3% were black, and 56.5% were Hispanic. Patients with a history of ED visits in the 12 months preceding study enrollment were significantly more likely to experience an ED visit during the study period (adjusted odds ratio [AOR] 6.92, 95% confidence interval [CI] 2.18-21.9, p < .0001). Similarly, those with poorer asthma control (baseline ACT scores <13) had greater odds of achieving improved asthma control (AOR 13.7, 95% CI 5.32-35.1, p < .0001). No other variables had statistically significant associations with the outcomes. CONCLUSIONS: Low scores on the asthma control test and prior ED visits for asthma are strong correlates of later clinically meaningful changes in asthma control among older adults. Health systems preparing for population management of patients with asthma ought to consider incorporating serial collection of data on the ACT into the monitoring and management of older asthmatics, a high-risk patient population.

"I felt useless": a qualitative examination of COVID-19's impact on home-based primary care providers in New York.

Research on professional burnout during the pandemic has focused on hospital-based health care workers. This study examined the psychological impact of the pandemic on home-based primary care (HBPC) providers. We interviewed 13 participants from six HBPC practices in New York City including medical/clinical directors, program managers, nurse practitioners, and social workers and analyzed the transcripts using inductive qualitative analysis approach. HBPC providers experienced emotional exhaustion and a sense of reduced personal accomplishment. They reported experiencing grief of losing many patients at once and pressure to adapt to changing circumstances quickly. They also reported feeling guilty for failing to protect their patients and reduced confidence in their professional expertise. Strategies to combat burnout included shorter on-call schedules, regular condolence meetings to acknowledge patient deaths, and peer support calls. Our study identifies potential resources to improve the well-being and reduce the risk of burnout among HBPC providers.

Natural language processing of electronic health records is superior to billing codes to identify symptom burden in hemodialysis patients.

Symptoms are common in patients on maintenance hemodialysis but identification is challenging. New informatics approaches including natural language processing (NLP) can be utilized to identify symptoms from narrative clinical documentation. Here we utilized NLP to identify seven patient symptoms from notes of maintenance hemodialysis patients of the BioMe Biobank and validated our findings using a separate cohort and the MIMIC-III database. NLP performance was compared for symptom detection with International Classification of Diseases (ICD)-9/10 codes and the performance of both methods were validated against manual chart review. From 1034 and 519 hemodialysis patients within BioMe and MIMIC-III databases, respectively, the most frequently identified symptoms by NLP were fatigue, pain, and nausea/vomiting. In BioMe, sensitivity for NLP (0.85 - 0.99) was higher than for ICD codes (0.09 - 0.59) for all symptoms with similar results in the BioMe validation cohort and MIMIC-III. ICD codes were significantly more specific for nausea/vomiting in BioMe and more specific for fatigue, depression, and pain in the MIMIC-III database. A majority of patients in both cohorts had four or more symptoms. Patients with more symptoms identified by NLP, ICD, and chart review had more clinical encounters. NLP had higher specificity in inpatient notes but higher sensitivity in outpatient notes and performed similarly across pain severity subgroups. Thus, NLP had higher sensitivity compared to ICD codes for identification of seven common hemodialysis-related symptoms, with comparable specificity between the two methods. Hence, NLP may be useful for the high-throughput identification of patient-centered outcomes when using electronic health records.

Validity of the Medication Adherence Rating Scale for Adherence to Inhaled Corticosteroids among Older Adults with Asthma or Chronic Obstructive Pulmonary Disease.

Regular use of inhaled corticosteroids (ICS) is the standard of care for patients with persistent asthma and chronic obstructive pulmonary disease (COPD). Adherence to ICS is measured using the 10-item Medication Adherence Report Scale (MARS), a self-reported medication adherence assessment. However, data on the validity of this measure are limited. Data were obtained from two cohort studies that examined the association of health literacy with self-management behaviors among adults ages 65 and older with asthma and adults ages 40 and older with COPD. ICS adherence was objectively measured over a 4-week period using electronic monitoring devices. Adequate adherence by MARS assessment was defined as a score ≥4.5, and by electronic monitoring as ≥80% of doses prescribed. We assessed the criterion validity using correlations between self-reported adherence and electronic adherence. Receiver Operating Characteristic (ROC) curve analysis was performed between the two measures. Among patients with asthma, the continuous values for adherence measured by self-report and electronically were weakly correlated (r = 0.33, p < 0.001); similarly, the agreement between the dichotomized measures was weak (kappa 0.30, p=.49). Findings were similar for COPD patients: r = 0.26, p = 0.003; kappa 0.19, p = .60. Area under curve (AUC) values generated from ROC analysis was 0.69 and 0.61, for asthma and COPD patients, respectively. Commonly used measure for adherence performed weakly compared to electronic monitoring in separate populations of patients with asthma and COPD. Investigators measuring self-reported medication adherence among patients with these pulmonary diseases should consider using alternative instruments or using objective measures exclusively.

Homebound Status and the Critical Role of Caregiving Support.

The homebound population relies on both paid and family caregivers to meet their complex care needs. In order to examine the association between intensity of caregiving support and leaving the home, we identified a population of community-dwelling, homebound Medicare beneficiaries age ≥65 (n = 1,852) enrolled in the 2015 National Health and Aging Trends Study and measured the support they received from paid and family caregivers. Those who had ≥20 h of caregiving support per week had 50% less odds of being "exclusively homebound" (rarely or never leave home) (OR 0.56, p < .01). Policies that facilitate increased support for family caregivers and better access to paid caregivers may allow homebound individuals who would otherwise be isolated at home to utilize existing community-based long-term care services and supports.