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While palliative care needs are assumed to improve during ICU care, few empiric data exist on need trajectories or their impact on long-term outcomes. We aimed to describe trajectories of palliative care needs during ICU care and to determine if changes in needs over 1 week was associated with similar changes in psychological distress symptoms at 3 months.Prospective cohort study.Six adult medical and surgical ICUs.Patients receiving mechanical ventilation for greater than or equal to 2 days and their family members.The primary outcome was the 13-item Needs at the End-of-Life Screening Tool (NEST; total score range 0-130) completed by family members at baseline, 3, and 7 days. The Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Post-Traumatic Stress Scale (PTSS) were completed at baseline and 3 months. General linear models were used to estimate differences in distress symptoms by change in need (NEST improvement ≥ 10 points or not). One-hundred fifty-nine family members participated (median age, 54.0 yr [interquartile range (IQR), 44.0-63.0 yr], 125 [78.6%] female, 54 [34.0%] African American). At 7 days, 53 (33%) a serious level of overall need and 35 (22%) ranked greater than or equal to 1 individual need at the highest severity level. NEST scores improved greater than or equal to 10 points in only 47 (30%). Median NEST scores were 22 (IQR, 12-40) at baseline and 19 (IQR, 9-37) at 7 days (change, -2.0; IQR, -11.0 to 5.0; p = 0.12). There were no differences in PHQ-9, GAD-7, or PTSS change scores by change in NEST score (all p0.15).Serious palliative care needs were common and persistent among families during ICU care. Improvement in needs was not associated with less psychological distress at 3 months. Serious needs may be commonly underrecognized in current practice.

Roy A Pleasants,1–3 Isaretta L Riley,1–3 David M Mannino4 1Duke Asthma, Allergy, and Airways Center, 2Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, 3Durham VA Medical Center, Durham, NC, 4Division of Pulmonary, Critical Care, and Sleep Medicine, Pulmonary Epidemiology Research Laboratory, University of Kentucky, Lexington, KY, USA Abstract: The global burden of chronic obstructive pulmonary disease (COPD) continues to grow in part due to better outcomes in other major diseases and in part because a substantial portion of the worldwide population continues to be exposed to inhalant toxins. However, adisproportionate burden of COPD occurs in people of low socioeconomic status (SES) due to differences in health behaviors, sociopolitical factors, and social and structural environmental exposures. Tobacco use, occupations with exposure to inhalant toxins, and indoor biomass fuel (BF) exposure are more common in low SES populations. Not only does SES affect the risk of developing COPD and etiologies, it is also associated with worsened COPD health outcomes. Effective interventions in these people are needed to decrease these disparities. Efforts that may help lessen these health inequities in low SES include 1) better surveillance targeting diagnosed and undiagnosed COPD in disadvantaged people, 2) educating the public and those involved in health care provision about the disease, 3) improving access to cost-effective and affordable health care, and 4) markedly increasing the efforts to prevent disease through smoking cessation, minimizing use and exposure to BF, and decreasing occupational exposures. COPD is considered to be one the most preventable major causes of death from a chronic disease in the world; therefore, effective interventions could have a major impact on reducing the global burden of the disease, especially in socioeconomically disadvantaged populations. Keywords: health disparities, COPD, interventions, prevention, management, international, socioeconomic status

Background: Adult African American (AA) asthmatics have high rates of nonadherence to pharmacotherapy; however little is known about interventions to improve adherence in this population. Purpose: To systematically review the literature on patient and family-level interventions aimed at improving pharmacotherapy adherence in adult AA asthmatics. Data Sources: MEDLINE®, EMBASE, Web of Science, and CINAHL from inception to February 2016; reference lists of key studies on this topic Study Selection: English-language studies enrolling adult AA asthmatics from the US comparing patient and/or family-level interventions to improve asthma pharmacotherapy with usual care, no intervention or another active intervention. Data Extraction: Two investigators independently selected, extracted data from and rated the risk of bias of relevant studies. Data Synthesis: 1,460 unique abstracts were identified from all sources, 3 randomized controlled trials (RCT) and 1 pre/post study met inclusion criteria. Studies ranged from 17-333 participants who were predominately middle-aged (33-47 years), AA (71%-93%), and women (69%-82%). The 3 RCTs enrolled patients with persistent asthma and evaluated three different types of interventions: problem solving, self-efficacy, and the use of patient advocates. All 3 compared the intervention with an active control featuring minimal asthma education, and we rated all three as having a medium risk of bias. None of the RCTs found a statistically significant improvement in adherence, FEV1, asthma control, asthma self-efficacy, or health care utilization outcomes. The RCT assessing self-efficacy (N=42) found a clinical and statistically significant improvement in asthma quality of life (adjusted difference between groups: 1.8, p=0.002). The pre/post study (N=17) evaluated a pharmacist-led educational intervention enrolling hospitalized asthmatics; we rated this study as having a high risk of bias primarily due to selection bias. Compared with baseline, participants had improved adherence at 6 months (absolute increase adherence rate 41%, p=0.0175) and reduced asthma-related ED and hospital visits (absolute reduction 1.23 visits per person, p=0.0016). Limitations: Small, diverse body of literature with some methodological limitations such as attrition, selection bias and measurement bias; possible publication bias Conclusion: Few studies assessing asthma adherence interventions focused on adult AA populations. Limited data from one RCT suggests that interventions focused on self-efficacy improve asthma related quality of life compared with controls. Although one pre/post study found improved adherence with a pharmacist-led intervention, none of the 3 included RCTs demonstrated improved adherence in participants randomized to an active intervention compared with controls.