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Although individuals with mild asthma account for 30% to 40% of acute asthma exacerbations (AAEs), relatively little attention has been paid to risk factors for AAEs in this population.

Social determinants of health have a significant impact on asthma outcomes, and factors such as income level and neighborhood environment have crucial roles.

IMPORTANCE: Approximately 24 million US individuals receive care at federally qualified health centers, which historically have low rates of colorectal cancer screening. The US Preventive Services Task Force recommends routine colorectal cancer screening for individuals aged 50 to 75 years. OBJECTIVE: To determine the effectiveness of an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program implemented in health centers as part of standard care. DESIGN, SETTING, AND PARTICIPANTS: This cluster randomized pragmatic clinical trial was conducted in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n = 13) or usual care (n = 13). All participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015). INTERVENTIONS: Electronic health record-embedded tools to identify eligible adults and to facilitate implementation of a stepwise mailed intervention involving (1) an introductory letter, (2) a mailed FIT, and (3) a reminder letter; training, collaborative learning, and facilitation through a practice improvement process. MAIN OUTCOMES AND MEASURES: Effectiveness was measured as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015. Implementation was measured as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT. RESULTS: Twenty-six clinics with 41 193 adults (mean [SD] age, 58.5 [6.3] years; 22 994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21 134 patients) or usual care (13 clinics; 20 059 patients). Compared with usual care clinics, intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%). We observed large variation across health centers in effectiveness (FIT completion differences range, −7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The number needed to mail to achieve a completed FIT was 4.8 overall, and 4.0 in clinics that mailed a FIT reminder. CONCLUSIONS AND RELEVANCE: An EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. Higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01742065

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The International Caries Consensus Collaboration (ICCC) has published recommendations on carious tissue removal to treat cavitated carious lesions in a manner that preserves hard tissue and retains teeth long term. This study quantifies The National Dental Practice-Based Research Network dentists’ use of selective caries removal.

IMPORTANCE: Most patients with asthma take fewer than half of prescribed doses of controller medication. Interventions to improve adherence have typically been costly, impractical, and at best only minimally successful. OBJECTIVE: To test a speech recognition (SR) intervention to improve adherence to pediatric asthma controller medication. DESIGN, SETTING, AND PARTICIPANTS: The Breathe Well study was a 24-month pragmatic randomized clinical trial. The study was conducted within Kaiser Permanente Colorado, a large, group-model health maintenance organization. A total of 1187 children aged 3 to 12 years with a persistent asthma diagnosis and prescription for an inhaled corticosteroid were randomized to the computerized SR intervention or usual care condition and followed up for 24 months between October 2009 and February 2013. INTERVENTIONS: Speech recognition telephone calls to parents in the intervention condition were triggered when an inhaled corticosteroid refill was due or overdue. Calls were automatically tailored with medical and demographic information from the electronic health record and from parent answers to questions in the call regarding recent refills or a desire to receive help refilling, learn more about asthma control, or speak with an asthma nurse or pharmacy staff member. MAIN OUTCOMES AND MEASURES: Adherence to pediatric asthma controller medication, measured as the medication possession ratio over 24 months. RESULTS: In the intention-to-treat analysis, inhaled corticosteroid adherence was 25.4% higher in the intervention group than in the usual care group (24-month mean [SE] adherence, 44.5% [1.2%] vs 35.5% [1.1%], respectively; P < .001). Asthma-related urgent care events did not differ between the 2 groups. The intervention effect was consistent in subgroups stratified by age, sex, race/ethnicity, body mass index, and disease-related characteristics. CONCLUSIONS AND RELEVANCE: The intervention’s significant impact on adherence demonstrates strong potential for low-cost SR adherence programs integrated with an electronic health record. The absence of change in urgent care visits may be attributable to the already low number of asthma urgent care visits within Kaiser Permanente Colorado. Application of electronic health record–leveraged SR interventions may reduce health care utilization when applied in a population with less-controlled asthma. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00958932

Based on results of clinical trials, inhaled corticosteroids (ICS) are the most-effective controller medications for preventing asthma-related exacerbations, yet few studies in real-life populations have evaluated the comparative effectiveness of ICS.

IMPORTANCE: The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts. OBJECTIVE: To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma. DESIGN, SETTING, AND PARTICIPANTS: A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (eg, ≥$75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (ie, Medicaid or Children’s Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (ie, income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics. MAIN OUTCOMES AND MEASURES: Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care. RESULTS: After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physician’s office visit (3.8% vs 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their children’s care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their children’s asthma care. CONCLUSIONS AND RELEVANCE: Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACA’s low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.

Excess adiposity and dietary factors may be important determinants of urinary albumin excretion (UAE).

AbstractBackground:The LIFE study was a randomized controlled trial assessing the impact of a self-acupressure intervention, Tapas Acupressure Technique® (TAT®), on weight-loss maintenance. The primary analysis showed no significant difference between TAT and social support (SS) for weight-loss maintenance, while exploratory post hoctests suggested that, among participants with highest initial weight-loss, those in the TAT condition regained less weight than those in the SS condition.Objective:The aim of the current study was to assess adherence to, and satisfaction with, the experimental self-acupressure intervention in the LIFE weight loss maintenance trial.Design:This was a secondary analysis of adherence and satisfaction patterns in a large randomized controlled trial.Setting:The study was conducted at a prominent health maintenance organization in the Pacific Northwest.Subjects:This study involved 142 obese participants who had lost >10 pounds in a conventional weight-loss program and who were randomized to the experimental acupressure intervention.Interventions:The experimental intervention (n=142) arm consisted of instruction and application of a self-acupressure intervention, the Tapas Acupressure Technique®(TAT®).Outcome Measures:The outcome sought was self-reported satisfaction and frequency of TAT practiceResults:Sixty-six percent of TAT participants attended at least 6 of 8 intervention sessions. More than 80% of participants reported practicing TAT at home, on average, at least 2 days per week. Sixty two percent reported practicing <10 minutes per session, while 27% reported practicing 10–20 minutes per session. Higher satisfaction scores were significantly correlated with less weight regain (p=0.001). Frequency of TAT practice was not significantly associated with changes in weight, stress, insomnia, depression, or quality of life.Conclusions:These data suggest moderate acceptance of, and adherence to, the TAT intervention. Further research is required to identify and achieve optimal home-practice levels of self-acupressure techniques.

Although caries is prevalent in adults, investigators have tested few preventive therapies in adult populations. In a randomized controlled trial, the authors evaluated the effectiveness of xylitol lozenges in preventing caries in adults at elevated risk of developing caries.

Although caries is prevalent in adults, investigators have tested few preventive therapies in adult populations. In a randomized controlled trial, the authors evaluated the effectiveness of xylitol lozenges in preventing caries in adults at elevated risk of developing caries.

Chronic obstructive pulmonary disease affects millions worldwide. It is America’s third leading cause of death, and results in significant morbidity and cost. Although many therapies exist and are being developed to alleviate symptoms and decrease morbidity and mortality in chronic obstructive pulmonary disease, most have only been studied in placebo-controlled efficacy studies in highly selected populations. Comparative effectiveness and translational research in chronic obstructive pulmonary disease will require the development of infrastructures to support collaboration between researchers and the stakeholders who generate, disseminate and use new knowledge. Methodologies need to evolve to both prioritize research questions and to conduct collaborative comparative effectiveness research studies. Given the impracticality of testing every clinical intervention in comparative pragmatic trials for comparative effectiveness research in chronic obstructive pulmonary disease, we advocate expanding methodology that includes the use of observational databases with serially performed effectiveness analyses and quasi-experimental designs that include following healthcare changes longitudinally over time to assess benefit, harm, subgroups and cost.

Never smokers comprise a substantial proportion of patients with COPD. Their characteristics and possible risk factors in this population are not yet well defined.

Inhaled corticosteroids (ICSs) are recommended as the first line of treatment in children with moderate-to-severe asthma. Exhaled nitric oxide (ENO) has been proposed as a clinically useful marker of control that might help identify patients in whom ICS dose may be safely reduced.

Chronic obstructive pulmonary disease (COPD) is a growing cause of morbidity and mortality worldwide, and accurate estimates of the prevalence of this disease are needed to anticipate the future burden of COPD, target key risk factors, and plan for providing COPD-related health services. We aimed to measure the prevalence of COPD and its risk factors and investigate variation across countries by age, sex, and smoking status.

Background:COPD is projected to be the third leading cause of death worldwide by 2020. The Burden of Obstructive Lung Disease initiative was started to measure the prevalence of COPD in a standardized way and to provide estimates of the social and economic burden of disease.

The ratio of controller medication to total asthma medications has been related to asthma utilization outcomes, but its relationship to patient-centered outcomes has not been explored.

Study question: What is the prevalence of respiratory symptoms and obstructive pulmonary disease by age, sex, and smoking history in a population aged 70 years and older? What is the association between selected comorbidities and obstructive pulmonary disease?

To provide a conceptual framework for defining severity and control in asthma, to describe recent advances in measuring asthma control, and to discuss the role of severity and control in asthma disease management.

We present reference values for arterial blood gas measurements for persons > 70 years old. At the same time, we wish to examine how different criteria for exclusion from the reference sample with regard to previous smoking and various comorbidities might influence reference values.

The preponderance of literature supports the efficacy of specialist care for asthma. Not every patient with asthma needs to be treated by a specialist, however. An optimal health care delivery model for asthma (i.e. one that provides high quality care that is cost effective) requires some mix of primary and specialty services. A tiered model of care in which the primary care physician acts as the first point of contact and decision-maker with regard to referral and that includes asthma specialists, including allergists, pulmonologists, and other health care professionals with expertise in asthma, appears to be a reasonable solution. The number of studies that compare various models for organizing asthma care is limited, however. Thus, further research is needed to determine how best to align the roles of primary care physicians, allied health professionals, and subspecialists in order to ensure seamless communication and cost-effective care that is targeted to individual patient needs.

To investigate the relationship between direct or environmental tobacco smoke (ETS) exposure and both hospital-based care (HBC) and quality of life (QOL) among subjects with asthma.

The natural history of lung growth and senescence in individuals with variable air flow obstruction or clinical asthma has been given less attention than the natural history of chronic airflow obstruction. This article reviews the information available on lung growth during childhood in persons with asthma and on the rate of decline of lung function during adult life in individuals with asthma or bronchial hyperresponsiveness. Lung growth appears to be relatively normal in most children with asthma but is reduced throughout childhood and adolescence in those with severe and persistent symptoms. It is not known if this reflects a failure to reach full growth or reversible bronchoconstriction. During adult life, clinical asthma is associated with a slight increase in the rate of decline in FEV1. In the middle-aged and elderly smoker it is virtually impossible to separate chronic bronchitis and asthma. Bronchial hyperresponsiveness appears to be associated with an increase in the rate of decline of lung function but it is not clear if this is a result of airway disease due to smoking or a true risk factor. Further research needs are identified.

Spirometry, respiratory symptom questionnaires, and chest radiographs were obtained from 688 loggers in Oregon and Washington. These were compared against previously published National Institute for Occupational Safety and Health studies of nonexposed blue-collar workers to determine if these predictions fit our population. The loggers forced expiratory volume in 1 second and forced vital capacity values were significantly greater than predicted, and their forced expiratory volume in 1 second/forced vital capacity values were less than predicted. The only consistent difference in symptoms between the sample and reference populations was for recent chest illnesses, which were more prevalent in the loggers than in the reference population. The chest radiographs showed a small excess of pleural thickening that we believe is most likely due to chest trauma. We conclude that the National Institute for Occupational Safety and Health studies spirometry prediction equations may not be generalized to other blue-collar populations.

Evidence is accumulating that elevated levels of serum IgE may play a role in the pathogenesis of chronic airflow obstruction. We examined this question using data on 863 subjects drawn from two cohort studies which we have followed over a period of nine to 11 years. One, the Portland cohort, represents a working population aged 25 to 55 years at baseline. The second, the Screening center cohort, spans a wider age range (18 to 87 years at baseline) and is biased towards respiratory disease. Spirometric tests and respiratory symptom questionnaires have been administered five times over a nine-year period for the Portland cohort, and over an 11-year period for the Screening center cohort. IgE was measured one time towards the end of the follow-up. Our data confirm the finding that smokers tend to have higher IgE levels than nonsmokers. For the combined sample, geometric mean levels of IgE were 31.0 IU/ml among smokers and 17.4 IU/ml among nonsmokers. Levels among ex-smokers were intermediate. Among smokers, IgE was not related to either amount smoked or pack-years. Cross-sectionally, FEV1was inversely related to IgE in the Screening center cohort, but not in the Portland cohort study. Among smokers, this association was only present for those subjects with symptoms of chronic bronchitis (chronic cough/sputum production). We found no association of IgE with longitudinal rate of decline of FEV, in either cohort. These findings are consistent with other studies and support the hypothesis that serum IgE is inversely related to function level cross-sectionally, but is not predictive of rate of decline of lung function.

The term “outcomes research” grew out of the research literature on the quality of medical care, which postulated that the quality of medical care can be assessed in terms of the structure, process, and outcome of care. Whereas early research on quality of care focused on structure and process measures, the assessment of patient-oriented health outcomes has recently emerged as a prominent area of research. Interest in this area reflects in part a growing acknowledgment that the mere provision of services does not ensure their appropriateness and that treatment efficacy may not predict treatment effectiveness. Understanding the results of outcomes research may be hampered by the fact that many of the measures involved could be used to assess both the process of care as well as its outcome. Health care utilization measures for chronic diseases, for instance, may be divided into process-oriented measures of ongoing “chronic” care and outcome-oriented measures of “acute” care. Generally speaking, what determines the difference between process research and outcomes research is determined by the purpose of the study. Outcomes research can also be viewed as an integral part of ongoing quality assurance, a cyclical process in which data are collected to test hypotheses about the effectiveness of the health care process and the results of such analyses are used to refine the process of care delivery.

This paper reports lifetime rates for posttraumatic stress disorder (PTSD) in two rural northwest communities. One community was affected by a major natural disaster, the eruption of Mt. St. Helens. Following an epidemiology study of this disaster, communitywide patterns of PTSD were identified. Disaster-related, combat, sexual assault, and all other types of PTSD are presented for men and women. Symptom patterns from these distinct PTSD stressors are compared along with concurrent psychiatric disorders. The findings are discussed with other studies that use a broader definition of disaster stress response syndromes. This comparison identifies a limitation of PTSD diagnostic criteria that may significantly underestimate community rates.

Although Occupational Safety and Health Administration (OSHA) issued antineoplastic drug handling guidelines in 1986, literature reports indicated that use of protection in the early 1980s did not meet OSHA standards. This study investigated the use of protection by pharmacy and nursing staff in a national sample of facilities participating in the National Surgical Adjuvant Breast and Bowel Project collaborative clinical trials network of the National Cancer Institute. Extent of handling, handling activity, and use of protection are compared by work setting and profession. Use of protection by the study sample in 1988 to 1989 is compared with their past use, with use of protection in previous studies, and with OSHA guidelines. In general, pharmacists are better protected than are nurses, and hospital staff are better protected than staff in outpatient settings who also tend to handle more drugs. Although improving over time, protective garment use does not meet OSHA guidelines, particularly among nurses when administering agents or handling patient excreta.

Since seasonal patterns in morbidity may identify triggers provoking hospital-based care for airflow obstruction, this study examined seasonal variation in patterns of hospitalizations for asthma, chronic bronchitis, and emphysema.

We studied 15 nonsmoking, clinically stable asthmatic subjects aged 27 to 39 years to evaluate the potential cardiotoxic effects of combined use of a β-adrenergic agonist drug and theophylline in the treatment of asthma. Subjects underwent a one-week washout period followed by two one-week periods of study receiving either oral terbutaline or sustained-release theophylline during week 1 and both drugs during week 2. Thirty-six-hour Holter monitoring was performed at the end of each period of study. No significant increase in the total number of ventricular premature beats was noted, although the average heart rate increased significantly between each period of study. Although not statistically significant, the number of individuals with multiform or complete and repetitive ventricular premature beats increased from one at baseline to three during each period of study, including one subject with ventricular tachycardia on combined therapy. These data suggest that combined therapy with theophylline and a ß-adrenergic agonist in young, otherwise healthy asthmatic subjects does not lead to an increase in the total number of ectopic beats but may increase the degree of complexity of ventricular premature beats.

We used a tracking index to measure the reproducibility of single breath nitrogen test variables (CV/VC, CC/TLC, ...N2/L) and spirometric variables (FEV1and FEV1/FVC) and to compare the characteristics of individuals whose pulmonary function tracks well with those whose pulmonary function tracks poorly. Data were derived from two cohorts followed longitudinally over a 9-11 year period. All variables were adjusted for age, sex and height by expressing them as Z-scores. In all smoking groups and in both cohorts, the tracking index was highest for FEV1, indicating that this variable was the most reproducible over the period of follow-up; ...N./L and FEV1/FVC had very similar but slightly lower tracking indices; CV/VC consistently had the lowest tracking indices. Tracking indices were generally higher in smokers than in nonsmokers. The reproducibility of CC/TLC increased over the period of follow-up whereas the FEV1reproducibility remained constant. We found no significant difference between those with high tracking indices and those with low indices in terms of sex, smoking status, prevalence of respiratory symptoms, history of respiratory disease, and rate of decline of FEV1. We conclude that FEV1is the most reproducible of the variables examined, both within and between individuals, and that poor tracking or reproducibility are not related to smoking or to the presence of respiratory symptoms or disease.

Objective: This project assessed the extent of agreement between drug‐taking data obtained from an in‐home assessment and that obtained from an automated outpatient pharmacy system and from a mail questionnaire.

Antineoplastic drug handling in the absence of adequate protective measures has been associated with biological uptake of the drugs among pharmacists and nurses. This study investigated the association between occupational exposure to antineoplastics and the presence of acute symptoms in a nationwide sample of 2,048 nurses and nurses' aides. Reported skin contact with the drugs was associated with a small but statistically significant increase in reported symptoms. Although number of doses handled and extent of protection used were significantly associated with number of symptoms, their effect was not independent of skin contact.

Intervention adherence and trial retention are challenging for clinical trials testing intensive behavioral interventions. Operational constraints or trial designs may preclude using effective retention strategies such as financial incentives. We examined whether implementing pre-enrollment orientation sessions was associated with higher intervention adherence and retention in a pragmatic clinical trial.

Background:Colorectal cancer screening (CRC) rates are low, particularly among individuals with low socioeconomic status. Organized CRC screening programs have demonstrated success in increasing screening rates. Little is known about provider attitudes, beliefs, and practices related to CRC screening or how they are influenced by an organized CRC screening program. Methods:In 2014 and 2016, providers from 26 safety net clinics in Oregon and Northern California were invited to complete baseline and follow-up online surveys for the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) study. The provider survey link was sent electronically to primary care providers serving adult patients. Providers were sent reminders every 2 weeks via email to complete the survey, up to 3 reminders total. In this article, we describe learnings about provider attitudes, beliefs, and practices related to CRC screening after implementation of the STOP CRC program. Results:A total of 166 unique providers completed baseline and/or follow-up surveys, representing 228 responses. Main themes included (1) favorable shifts in attitude toward fecal immunochemical test (FIT) and direct-mail cancer screening programs, (2) changes in provider perception of key barriers, and (3) growing interest in centralized automated systems for identifying patients due for CRC screening and eligible for population-based outreach. Discussion:Providers are interested in improved information systems for identifying patients due for CRC screening and delivering population-based outreach (ie, to distribute FIT kits outside of the clinic visit) to help reduce health system- and patient-level barriers to screening. Trial Registration:National Clinical Trial (NCT) Identifier NCT01742065.