Linking smokers to a quitline: randomized controlled effectiveness trial of a support person intervention that targets non-smokers.

Evidence-based treatments (e.g. quitlines) are greatly underutilized by smokers limiting their public health impact. A three-session phone intervention for nonsmoking family members and friends (i.e. support persons) was successful for increasing smoker quitline enrollment. To enhance the intervention's potential translatability, in this study, we delivered treatment for the non-smoker within ongoing quitline services and compared the efficacy of the three-call intervention to a streamlined version (one call). A total of 704 adult non-smokers (85% female, 95% White) wanting to help a smoker quit and recruited statewide in Minnesota participated in this randomized controlled trial with parallel groups. Non-smokers received mailed written materials and were randomly assigned to a control condition (no additional treatment, n = 235), or to a one- (n = 233) or three-call (n = 236) intervention delivered by quitline coaches. The main outcome was smoker quitline enrollment through 7-month follow-up. Smoker quitline enrollment was similar for those linked to non-smokers in the one- and three-call interventions (14.6% [34/233] and 14.8% [35/236]), and higher than for smokers linked to control participants (6.4% [15/235]), P = 0.006. Just one quitline coaching call delivered to non-smokers increased treatment enrollment among smokers. The reach of quitlines could be enhanced by targeting the social support network of smokers.

Characteristics of American Indian/Alaskan Native Quitline Callers Across 14 States.

BACKGROUND: American Indians and Alaska Natives (AI/AN) have the highest smoking prevalence (29.2%) of any other racial/ethnic group in the United States and lower quit rates. Comprehensive health care services, including commercial tobacco cessation treatments, are difficult to access for many AI/AN individuals due to poverty, the rural distribution of tribal territories, cultural barriers and the lack of funding for these programs. Due, in part, to these health care gaps, AI/AN communities are disproportionally affected by nicotine dependence and associated chronic medical and psychiatric conditions. METHODS: We report on data from National Jewish Health that provides telephonic tobacco cessation services for 14 states in the United States. We examine how AI/AN callers who were predominately AI callers differ from their counterparts (i.e., callers identifying as other ethnic groups) in terms of demographic characteristics, commercial tobacco use history, rates of emotional or mental health issues, and rates of chronic illness. RESULTS: Findings from the quitline analyses show a higher rate of preadolescent onset of commercial tobacco use in the AI/AN callers. AI/AN callers are also more likely to live with another commercial tobacco user. Results demonstrate that AI/AN callers are disproportionately impacted by mental health challenges, including high levels of stress, anxiety, and depression. Similarly, AI/AN callers report more chronic medical issues including diseases of the lungs and cardiovascular system. CONCLUSIONS: These findings stress the critical need for tailored efforts to better reach AI/AN commercial tobacco users who are considering treatment, in order to make meaningful gains in commercial tobacco cessation for this vulnerable population. IMPLICATIONS: These findings demonstrate the disproportionate impact of commercial tobacco use on the AI/AN population who utilizes quitline services. These data stress the critical need for tailored efforts to better reach AI/AN commercial tobacco users who are considering treatment, in order to make meaningful gains in commercial tobacco cessation for this vulnerable population.

Quitline Outcomes for Smokers in 6 States: Rates of Successful Quitting Vary by Mental Health Status.

INTRODUCTION: Tobacco cessation quitlines are generally effective in assisting smokers who want to quit. However, up to half of quitline callers report a history of mental health conditions and/or recent emotional challenges (MH+), and there has been little study of cessation outcomes for this population. Moreover, evidence suggests that callers who expect their MH+ to interfere with quit attempts have less success with quitting. This study compares rates of quitting among MH+ callers and callers with no mental health conditions or recent emotional challenges (MH-). It also compares rates of quitting between those who felt that mental health issues would interfere with their quit attempt (MHIQ+) and those who did not (MHIQ-). METHODS: National Jewish Health collected telephone data from 6 state quitlines. Participants received up to 5 coaching sessions and up to 8 weeks of nicotine replacement therapy. Smoking status was assessed during 3-month and 6-month post-intervention calls in a subset of participants (n = 4,960) for whom follow-up interviews were completed. RESULTS: Participation in follow-up interviews was not significantly different between callers with MH+ and those without MH- (p = .13). However, at follow-up MH+ participants were less likely to report a successful quit compared with MH- (3-month: 31% vs. 43%; 6-month: 33% vs. 43%; both p < .001). Among MH+ participants, those reporting MHIQ+ were significantly less likely to quit compared with those who were MHIQ- (3-month: 24% vs. 34%; 6-month: 26% vs. 35%; both p ≤ .001). CONCLUSIONS: These findings highlight the importance of evaluating both the mental health status of individuals seeking support for smoking cessation as well as the individuals' expectations for success, because they may need more tailored intervention to ensure the potential for better compared with outcomes.

Internet and Telephone Treatment for smoking cessation: mediators and moderators of short-term abstinence.

INTRODUCTION: This study examined mediators and moderators of short-term treatment effectiveness from the iQUITT Study (Quit Using Internet and Telephone Treatment), a 3-arm randomized trial that compared an interactive smoking cessation Web site with an online social network (enhanced Internet) alone and in conjunction with proactive telephone counseling (enhanced Internet plus phone) to a static Internet comparison condition (basic Internet). METHODS: The analytic sample was N = 1,236 participants with complete 3-month data on all mediating variables. The primary outcome was 30-day point prevalence abstinence (ppa) at 3 months. Recognizing the importance of temporal precedence in mediation analyses, we also present findings for 6-month outcomes. Purported mediators were treatment utilization and changes in psychosocial constructs. Proposed moderators included baseline demographic, smoking, and psychosocial variables. Mediation analyses examined the extent to which between-arm differences in 30-day ppa could be attributed to differential Web site utilization, telephone counseling, and associated changes in smoking self-efficacy and social support for quitting. Effect modification analyses fitted interactions between treatment and prespecified moderators on abstinence. RESULTS: Significant mediators of 30-day ppa were changes in smoking temptations, quitting confidence, and positive and negative partner support, which were strongly associated with increased Web site utilization. The addition of telephone counseling to an enhanced Web site further improved abstinence rates, partly via an association with increased quitting confidence. Baseline smoking rate was the only significant moderator. CONCLUSIONS: Increased treatment utilization and associated changes in several psychosocial measures yielded higher abstinence rates. Findings validate the importance of treatment utilization, smoking self-efficacy, and social support to promote abstinence.

Effect of nicotine replacement therapy on quitting by young adults in a trial comparing cessation services.

CONTEXT: Young adult smokers have the highest smoking prevalence among all US age groups but are least likely to use evidence-based cessation counseling or medication to quit. OBJECTIVE: Use and effectiveness of nicotine patch were explored in a randomized trial evaluating smoking cessation interventions with this population. PARTICIPANTS: Smokers aged 18 to 30 (n = 3094) were recruited through online and off-line methods and from telephone quit lines and analyzed. DESIGN: Smokers were enrolled in a pretest-posttest trial, and randomized to 1 of 3 cessation services. SETTING: Trial delivering counseling services by self-help booklet, telephone quit lines, or online expert system in the 48 continental United States. INTERVENTION: Smokers could request a free 2-week course of nicotine replacement therapy (NRT) patches from the project. MAIN OUTCOME MEASURE: Follow-up surveys at 12 and 26 weeks assessed smoking abstinence, use of NRT, counseling, and other cessation medications, and smoking-related variables. RESULTS: Overall, 69.0% of smokers reported using NRT (M = 3.2 weeks) at 12 weeks and 74.8% (M = 3.3 weeks) at 26 weeks. More smokers who were sent the free nicotine patches (n = 1695; 54.8%) reported using NRT than those who did not receive them (12 weeks: 84.3% vs 41.9%, P < .001; 26 weeks: 87.6% vs 51.1%, P < .001). The use of NRT was associated with greater smoking abstinence at 12 weeks (P < .001) and 26 weeks (P < .05), especially if used for more than 2 weeks (P < .001). Smokers assigned to a self-help booklet or cessation Web site and heavier smokers were most likely to use NRT (P < .05), whereas those reporting marijuana use and binge drinking used NRT less (P < .05). CONCLUSIONS: Many young adults were willing to try NRT, and it appeared to help them quit in the context of community-based cessation services. Strategies should be developed to make NRT available to this age group and support them in using it to prevent lifelong smoking.

The emergency department action in smoking cessation (EDASC) trial: impact on cessation outcomes.

INTRODUCTION: The focus on acute care, time pressure, and lack of resources hamper the implementation of smoking cessation guidelines in the emergency department (ED). The purpose of this study was to determine whether an emergency nurse- initiated intervention based on the 5A's (Ask-Advise-Assess-Assist-Arrange) framework improves quit rates. METHODS: We conducted a pre-post implementation trial in 789 adult smokers who presented to two EDs in Iowa between August 13, 2008 and August 4, 2010. The intervention focused on improving delivery of the 5A's by ED nurses and physicians using academic detailing, charting/reminder tools, and group feedback. Performance of ED cessation counseling was measured using a 5A's composite score (ranging from 0 to 5). Smoking status was assessed by telephone interview at 3- and 6-month follow-up (with biochemical confirmation in those participants who reported abstinence at 6-month follow-up). RESULTS: Based on data from 650 smokers who completed the post-ED interview, there was a significant improvement in the mean 5A's composite score for emergency nurses during the intervention period at both hospitals combined (1.51 vs. 0.88, difference = 0.63, 95% confidence interval [CI] [0.41, 0.85]). At 6-month follow-up, 7-day point prevalence abstinence (PPA) was 6.8 and 5.1% in intervention and preintervention periods, respectively (adjusted odds ratio [OR] = 1.7, 95% CI [0.99, 2.9]). CONCLUSIONS: It is feasible to improve the delivery of brief smoking cessation counseling by ED staff. The observed improvements in performance of cessation counseling, however, did not translate into statistically significant improvements in cessation rates. Further improvements in the effectiveness of ED cessation interventions are needed.

Cost-effectiveness of internet and telephone treatment for smoking cessation: an economic evaluation of The iQUITT Study.

BACKGROUND: Internet and telephone treatments for smoking cessation can reach large numbers of smokers. There is little research on their costs and the impact of adherence on costs and effects. OBJECTIVE: To conduct an economic evaluation of The iQUITT Study, a randomised trial comparing Basic Internet, Enhanced Internet and Enhanced Internet plus telephone counselling ('Phone') at 3, 6, 12 and 18 months. METHODS: We used a payer perspective to evaluate the average and incremental cost per quitter of the three interventions using intention-to-treat analysis of 30-day single-point prevalence and multiple-point prevalence (MPP) abstinence rates. We also examined results based on adherence. Costs included commercial charges for each intervention. Discounting was not included given the short time horizon. RESULTS: Basic Internet had the lowest cost per quitter at all time points. In the analysis of incremental costs per additional quitter, Enhanced Internet+Phone was the most cost-effective using both single and MPP abstinence metrics. As adherence increased, the cost per quitter dropped across all arms. Costs per quitter were lowest among participants who used the 'optimal' level of each intervention, with an average cost per quitter at 3 months of US$7 for Basic Internet, US$164 for Enhanced Internet and US$346 for Enhanced Internet+Phone. CONCLUSIONS: 'Optimal' adherence to internet and combined internet and telephone interventions yields the highest number of quitters at the lowest cost. Cost-effective means of ensuring adherence to such evidence-based programmes could maximise their population-level impact on smoking prevalence.

Smoking reduction for persons with mental illnesses: 6-month results from community-based interventions.

Persons with mental illnesses use tobacco at significantly higher and heavier rates than the general population, and suffer greater tobacco- related morbidity and mortality. However, there are few existing tobacco cessation interventions for these individuals. This study examined two tobacco cessation interventions, a telephonic quitline intervention (counseling and nicotine replacement therapy) and a community-based group counseling intervention with adults currently receiving community mental health services. At 6-month follow-up, both groups demonstrated significantly reduced tobacco use, but participants who received both quitline services and the group counseling intervention were significantly more likely to have a 50% tobacco use reduction. Across groups, the overall intent-to-treat cessation rate was 7%. Tobacco dependence, depression symptoms, and psychotic symptoms decreased significantly for all treatment groups, while health and mental health functioning increased. Findings suggest that common community tobacco cessation services are effective for this population.

Uncontrolled asthma: assessing quality of life and productivity of children and their caregivers using a cross-sectional Internet-based survey.

BACKGROUND: Results of a national survey of asthmatic children that evaluated management goals established in 2004 by the National Asthma Education and Prevention Program (NAEPP) indicated that asthma symptom control fell short on nearly every goal. METHODS: An Internet-based survey was administered to adult caregivers of children aged 6-12 years with moderate to severe asthma. Asthma was categorized as uncontrolled when the caregiver reported pre-specified criteria for daytime symptoms, nighttime awakening, activity limitation, or rescue medication based on the NAEPP guidelines. Children's health-related quality of life (HRQOL) and caregivers' quality of life (QOL) were assessed using the Child Health Questionnaire Parent Form 28 (CHQ-PF28) and caregiver's work productivity using a modified Work Productivity and Activity Impairment Questionnaire. Children with uncontrolled vs. controlled asthma were compared. RESULTS: 360 caregivers of children with uncontrolled asthma and 113 of children with controlled asthma completed the survey. Children with uncontrolled asthma had significantly lower CHQ-PF28 physical (mean 38.1 vs 49.8, uncontrolled vs controlled, respectively) and psychosocial (48.2 vs 53.8) summary measure scores. They were more likely to miss school (5.5 vs 2.2 days), arrive late or leave early (26.7 vs 7.1%), miss school-related activities (40.6 vs 6.2%), use a rescue inhaler at school (64.2 vs 31.0%), and visit the health office or school nurse (22.5 vs 8.8%). Caregivers of children with uncontrolled asthma reported significantly greater work and activity impairment and lower QOL for emotional, time-related and family activities. CONCLUSIONS: Poorly controlled asthma symptoms impair HRQOL of children, QOL of their caregivers, and productivity of both. Proper treatment and management to improve symptom control may reduce humanistic and economic burdens on asthmatic children and their caregivers.

Uncontrolled asthma among children: impairment in social functioning and sleep.

OBJECTIVE: To evaluate asthma symptom frequency, severity, and control among children with asthma and to evaluate the impact on social functioning and sleep impairment. PATIENTS AND METHODS: Using a cross-sectional design, adult caregivers of children aged 6-12 years with moderate to severe asthma (severity based on National Asthma Education and Prevention Program guidelines) were surveyed about the child's symptoms, treatment, activity limitation, and sleep impairment. Asthma was categorized as uncontrolled if the caregiver reported any of the following of the child: experienced >2 days/week with symptoms, were awakened at night by symptoms during the preceding 4 weeks, had activity limited by a health problem, or used short-acting beta-agonist for rescue >5 times/week. Asthma not meeting any of these criteria was categorized as controlled. Social functioning and sleep impairment were assessed using questions adapted from the SleepLearnPlay instrument. Children with uncontrolled and controlled asthma were compared using t tests for continuous variables and Fisher's exact test for categorical variables. Multiple comparison adjustment using the Bonferroni procedure was made for social functioning and sleep impairment measures. RESULTS: A total of 473 caregivers completed the survey; 360 were caregivers of children with uncontrolled asthma and 113 of children with controlled asthma. Compared with controlled asthma, a greater proportion of children with uncontrolled asthma showed avoidance across all nine social activities assessed. Children with uncontrolled asthma were significantly more likely to wake up at night with symptoms (p <.0001) and use a rescue inhaler at night (p <.0001), experience difficulty waking up in the morning (p = .0001) and getting out of bed (p = .0039), and be overly tired all day (p <.0001). CONCLUSIONS: Uncontrolled asthma impacted functioning and sleep of children to a significantly greater degree than well-controlled asthma. Proper treatment and disease management to improve symptom control can reduce this impact on the lives of children.

Measuring asthma control is the first step to patient management: a literature review.

Asthma control is recognized as a critical aspect of the evaluation and management of the disease. Here we evaluate and compare existing instruments for measuring asthma control in an attempt to evaluate their clinical utility. Based on a literature review, we identified validated instruments used to assess asthma control in adults. We examined the specific measurement properties and the strengths and weaknesses of each instrument, and evaluated a single instrument, the Asthma Control Questionnaire (ACQ), more closely as an example, evaluating its applicability in the clinical setting. Our review identified five validated instruments designed to measure asthma control: the Asthma Control Questionnaire (ACQ), Asthma Control Scoring System (ACSS), Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), and the Lara Asthma Symptom Scale (LASS). None of the instruments covered all relevant control characteristics, but most were aligned with guideline definitions of control. All instruments demonstrated validity and responsiveness, with some measure of reliability. All instruments were short and easily administered, easy to interpret, and all had evidence to support their use in clinical decision making.

The impact of uncontrolled asthma on absenteeism and health-related quality of life.

OBJECTIVE: To evaluate the impact of uncontrolled asthma on the absenteeism and health-related quality of life (HRQOL) of adults and children with asthma and the caregivers of pediatric patients. PATIENTS AND METHODS: Patient information was obtained from datasets maintained by National Jewish Health for this cross-sectional study. Participants in the study were 12 years of age or older. Participants younger than 18 years had their information provided by caregivers. Caregivers also provided 6 months of absenteeism and QOL data. Participants were classified as having uncontrolled asthma based on a treatment and symptom guideline-based algorithm. Absenteeism was assessed from the self-reported number of work or school days missed due to asthma during the previous 6 months. HRQOL among adults was measured using the validated Marks Asthma Quality of Life Questionnaire (Marks-AQLQ) and among caregivers using the validated Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ). To account for the positive skew in absenteeism data, a zero-inflated Poisson regression model was used to compare group differences. HRQOL was analyzed for adults and caregivers using the Wilcoxon-Mann-Whitney test. RESULTS: A total of 15,149 patients met the inclusion criteria for the study and were included in the analysis. Adults with uncontrolled asthma and caregivers of children with uncontrolled asthma reported significantly higher absenteeism than their controlled counterparts: 43% vs 24% adults reported missing days of work, with a median 6 days vs 3 days missed; 31% vs 16% of caregivers reported missing days of work, with 4 days vs 2 days missed; and caregivers reported that more than 70% vs 45% pediatric patients missed school, with a median of 6 days vs 4 days missed (uncontrolled vs controlled asthma, respectively). Adult uncontrolled asthmatics and caregivers of uncontrolled pediatric patients had significantly lower HRQOL as indicated by the Marks-AQLQ (scores 1.5 points higher, p < 0.001) and PACQLQ (scores < 0.5 points lower, p < 0.001), respectively. CONCLUSIONS: Uncontrolled asthma has far-reaching impact on the productivity and quality of life of asthma patients and their caregivers. Proper assessment, treatment, and disease management to improve asthma control may reduce the impact of uncontrolled asthma on asthmatic adults, children, and the caretakers of pediatric asthmatic patients.

Regression to the mean: a limited issue in disease management programs for chronic obstructive pulmonary disease.

Our objective was to test for evidence of regression to the mean in chronic obstructive pulmonary disease (COPD)-related health care utilization in a Colorado Medicaid population that met the criteria for, but were not participating in, a COPD disease management (DM) program. National Jewish Medical and Research Center had enrolled individuals who (1) had a diagnosis of COPD for at least 1 year and (2) were active participants in Colorado Medicaid's 1-year DM program called breatheWise; the present study sought a comparator group for that population. In order to test for evidence of regression to the mean (ie, high utilization from the recruitment period reducing without active intervention) in this case management model, we conducted a case-controlled analysis of total spending for a comparator population that would have met the inclusion criteria for the DM program. The present study assessed health care utilization for fiscal years 2002 and 2003 in terms of total rates of emergency room (ER) visits and hospitalizations for all causes in the comparator group of COPD patients. In addition, total costs related to both ER visits and hospitalizations were compiled. In total, 354 individuals met the inclusion criteria and were identified as the comparator group. ER visits and hospitalizations were consistent for 2002 and 2003. ER visits totaled 314 and 315 in 2002 and 2003, respectively, indicating a 0.3% increase that was not significant. Hospitalizations decreased from 0.53 admissions per patient in 2002 to 0.48 in 2003-a 9.4% reduction that was not significant. With comparable rates of ER visits and hospitalizations, total costs for health care utilization remained virtually unchanged between 2002 and 2003. There is minimal evidence of regression to the mean over 2 consecutive years in the Colorado Medicaid patients with moderate to severe COPD.

Offering free NRT through a tobacco quitline: impact on utilisation and quit rates.

OBJECTIVE: To assess the impact on quitline utilisation and cessation outcomes of adding free nicotine patches to the existing programme offerings. METHODS: Tobacco use status data from the Ohio tobacco quitline were collected from a subset of quitline callers 6 months after the initial intake call. To evaluate the impact of the nicotine replacement therapy (NRT) initiative, quit rates for two groups were compared: those who entered and exited the quitline programme before the availability of free NRT (n = 4657) and those who entered and exited the quitline programme after the availability of free NRT (n = 5715). RESULTS: Call volume increased from 2351 intakes calls per month or 78 calls per day before the availability of free NRT to 3606 intake calls per month or 188 intakes per day following the availability of free NRT (p<0.0001). 7-day point prevalence abstinence at 6 months among all quitline callers increased from 10.3% (95% confidence interval (CI) 9.7 to 10.9) before the availability of NRT to 14.9% (95% CI 14.3 to 15.5) after the availability of NRT. CONCLUSION: Offering free NRT through a state quitline is an effective means of increasing quitline utilisation and improving quit rates.

Implementing smoking cessation guidelines for hospitalized Veterans: Cessation results from the VA-BEST trial.

PURPOSE: To examine the impact of a nurse-initiated tobacco cessation intervention focused on providing guideline-recommended care to hospitalized smokers. DESIGN: Pre-post quasi-experimental trial. SETTING: General medical units of four US Department of Veterans Affairs hospitals. SUBJECTS: 898 adult Veteran smokers (503 and 395 were enrolled in the baseline and intervention periods, respectively). INTERVENTION: The intervention included academic detailing, adaptation of the computerized medical record, patient self-management support, and organizational support and feedback. MEASURES: The primary outcome was self-reported 7-day point prevalence abstinence at six months. ANALYSIS: Tobacco use was compared for the pre-intervention and intervention periods with multivariable logistic regression using generalized estimating equations to account for clustering at the nurse level. Predictors of abstinence at six months were investigated with best subsets regression. RESULTS: Seven-day point prevalence abstinence during the intervention period did not differ significantly from the pre-intervention period at either three (adjusted odds ratio (AOR) and 95% confidence interval (CI95)=0.78 [0.51-1.18]) or six months (AOR=0.92; CI95=0.62-1.37). Predictors of abstinence included baseline self-efficacy for refraining from smoking when experiencing negative affect (p=0.0004) and perceived likelihood of staying off cigarettes following discharge (p<0.0001). CONCLUSIONS: Tobacco use interventions in the VA inpatient setting likely require more substantial changes in clinician behavior and enhanced post-discharge follow-up to improve cessation outcomes.

Scoring system and clinical application of COPD diagnostic questionnaires.

OBJECTIVES: In most primary care settings, spirometric screening of all patients at risk is not practical. In prior work, we developed questionnaires to help identify COPD in two risk groups: (1) persons with a positive smoking history but no history of obstructive lung disease (case finding), and (2) patients with prior evidence of obstructive lung disease (differential diagnosis). For these questionnaires, we now present a scoring system for use in primary care. METHODS: Scores for individual questions were based on the regression coefficients from logistic regression models using a spirometry-based diagnosis of obstruction as the reference outcome. Receiver operator characteristic analysis was used to determine performance characteristics for each questionnaire. Several simplified scoring systems were developed and tested. RESULTS: For both scenarios, we created a scoring system with two cut points intended to place subjects within one of three zones: persons with a high likelihood of having obstruction (high predictive value of a positive test result); persons with a low likelihood of obstruction (high predictive value of a negative test result); and an intermediate zone. Using these scoring systems, we achieved sensitivities of 54 to 82%, specificities of 58 to 88%, positive predictive values of 30 to 78%, and negative predictive values of 71 to 93%. CONCLUSIONS: These questionnaires can be used to help identify persons likely to have COPD among specific risk groups. The use of a simplified scoring system makes these tools beneficial in the primary care setting. Used in conjunction with spirometry, these tools can help improve the efficiency and accuracy of COPD diagnosis in primary care.

Chronic obstructive pulmonary disease in patients under age 65: utilization and costs from a managed care sample.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) affects all adult age groups, not just elderly males. We assessed the health care utilization and cost impact of COPD in different age groups. METHODS: We compared burden of illness, utilization, and charges for younger versus older COPD patients and versus age- and gender-matched controls. RESULTS: A total of 16.9% of patients with COPD were under age 65. Patients with COPD (n=19,338) had higher comorbidity than age-matched controls (n=94,384) across all age groups. Younger patients with COPD had lower comorbidity scores and fewer hospitalizations but more COPD-related emergency services than older patients with COPD. Average COPD-related charges were higher for younger patients. Facility-based care was the cost driver across all age groups. CONCLUSIONS: COPD is a burden to younger individuals in the workforce, who are likely to be enrolled in a commercial health plan.

The impact of chronic obstructive pulmonary disease on long-term disability costs.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) as a cause of disability with subsequent costs remains poorly recognized. The small, growing body of literature on COPD shows that it is one of the leading causes of missed work.greater than asthma or diabetes. However, much less is known about the impact of COPD on long-term disability (LTD). Because the health care burden for disabled, working-age patients will fall heavily on managed care organizations, better estimates of the economic and pharmacoeconomic costs of COPD are required. We seek to improve understanding of the burden of COPD on several national LTD programs. METHODS: We reviewed occupational health and disability literature and government statistics to determine how long-term, respiratory-related disability is addressed by disability pension programs in 8 developed countries (Canada, France, Germany, Italy, Japan, Spain, the United Kingdom, and the United States). We then applied respiratory-specific disability definitions to country-specific population and pension information to estimate the potential burden of COPD on LTD insurance programs in each country. RESULTS: Comprehensive, relevant data to evaluate respiratory-related disability are lacking. Of the study countries, only the United States has explicit respiratory specific criteria for disability eligibility, which are based solely on spirometry. We estimate that the total burden of COPD in the study countries may range from 5 billion dollars to as high as 25 billion dollars per year if all persons who met U.S. eligibility criteria for respiratory-related disability were granted compensation. CONCLUSION: The potential burden of COPD on LTD programs may be large. The lack of standard criteria for respiratory-related disability may lead to underrecognition of COPD's true potential impact. Further work is needed to develop consistent and cost-effective ways to measure the impact of COPD and to assist in disability determination for COPD patients.

Chronic obstructive pulmonary disease: the impact occurs earlier than we think.

OBJECTIVE: To determine the socioeconomic, demographic, and clinical utilization characteristics of the "typical" patient with chronic obstructive pulmonary disease (COPD). STUDY DESIGN: Retrospective analysis of a large dataset of patients enrolled in a disease management program for COPD. PATIENTS AND METHODS: Patients were 2129 individuals with a diagnosis of COPD. Information was collected at the time these individuals entered the National Jewish Medical and Research Center disease management program for COPD. RESULTS: The data show that the typical stereotype of a COPD patient (ie, elderly and unemployed) may not apply to a large proportion of patients already diagnosed with COPD. Almost half (49.7%) were less than 65 years old. In addition, 46.1% were employed and missed an average of 4.6 days of work in the previous 6 months. CONCLUSIONS: The cost of COPD to individuals and to society is increasing. Yet it is a potentially preventable and treatable disease. Early detection and intervention are essential.

Asthma disease management: regression to the mean or better?

OBJECTIVES: To assess the effectiveness of disease management as an adjunct to treatment for chronic illnesses, such as asthma, and to evaluate whether the statistical phenomenon of regression to the mean is responsible for many of the benefits commonly attributed to disease management. STUDY DESIGN: This study evaluated an asthma disease management intervention in a Colorado population covered by Medicaid. The outcomes are presented with the intervention group serving as its own control (baseline and postintervention measurements) and are compared with a matched control group during the same periods. METHODS: In the intervention group, 388 asthmatics entered and 258 completed the 6-month program; 446 subjects participated in the control group. Facilities charges were compared for both groups during the baseline and program periods. Both groups were well matched demographically and for costs at baseline. RESULTS: Using the intervention group as its own control revealed a 49.1% savings. The control group savings were 30.7%. Therefore, the net savings were 18.4% (P < .001) for the intervention group vs controls. Although the demonstrated savings were less using a control group to correct for regression to the mean, they were statistically significant and clinically relevant. CONCLUSION: When using a control group to control for the statistical effects of regression to the mean, a disease management intervention for asthma in a population covered by Medicaid is effective in reducing healthcare costs.