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Determining worker exposure to hazardous volatile organic compounds (VOCs) in air at levels exceeding the Permissible Exposure Limits and Recommended Exposure Limits established by the U.S. federal agencies of Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH), respectively, will continue to be an important part of environmental and occupational health risk assessments. The purpose of this work was to develop a reliable analytical method for rapid and on-site assessments of occupational VOC exposures using field-capable thermal desorption-gas chromatography-mass spectrometry (TD-GC-MS) instrumentation (i.e. the HAPSITE® ER). The experiments involved in this study included determining TD-GC-MS parameters suitable for efficient analyte separation and quantitation on the HAPSITE® ER, determinations of analyte mass loadings that cause mass spectrometer detector saturations, generation of calibration curves, estimations of the limits of detection (LODs) and quantification (LOQs), as well as desorption efficiency and relative response factor repeatability. The LODs using Carbopack™ B and Tenax® TA sampling media were estimated and ranged from 0.2–1.9 ng and 0.045–0.3 ng, respectively. The LOQs using Carbopack™ B and Tenax TA sampling media were estimated and ranged from 1.0–6.3 ng and 0.2–1.1 ng, respectively. We have developed a reliable analytical method for chloroform, benzene, trichloroethylene, and heptane using field-portable HAPSITE® ER instrumentation and Tenax® TA sorbent media. Reliable and accurate methods were developed for chloroform and trichloroethylene using Carbopack™ B sorbent media, however, this particular sorbent hadlow desorption efficiency and insufficient repeatability in relative response factors for many analytes. Our current and ongoing work in determining the uptake rates for analytes on Tenax® TA sorbent media will make the methods described herein applicable for on-site occupational VOC exposure assessments of chloroform, benzene, trichloroethylene, and heptane using either passive or active air sampling techniques. [ABSTRACT FROM AUTHOR]

Background. A critical component of shared decision making (SDM) is the role played by health care providers in distributing decision aids (DAs) and initiating SDM conversations. Existing literature indicates that decisions about designing and implementing DAs must take provider perspectives into account. However, little is known about how differences in provider attitudes across specialties may impact DA implementation and how provider attitudes may shift after DA implementation. Group Health’s Decision Aid Implementation project was carried out in six specialties using 12 video-based DAs for preference-sensitive conditions; this study focused on two of the six specialties. Design. In-depth, qualitative interviews with specialty care providers in two specialties—orthopedics and cardiology—at two time points during DA implementation. Data were analyzed using a thematic analysis approach. Results. We interviewed 19 care providers in orthopedics and cardiology. All respondents believed that providing patients with accurate information on their health conditions and treatment options was important and that most patients wanted an active role in decision making. However, respondents diverged in decision-making styles and views on the practicality and appropriateness of using the DAs and SDM. For example, cardiology specialists were ambivalent about DAs for coronary artery disease because many viewed DAs and SDM as unnecessary or inappropriate for this clinical condition. Provider attitudes towards DAs and SDM were generally stable over two years. Limitations. Limitations include a lack of patient perspectives, social desirability bias, and possible selection bias. Conclusions. Successfully implementing DAs in clinical practice to promote SDM requires addressing individual provider attitudes, beliefs, and knowledge of SDM by specialty. During DA development and implementation, providers should be asked for input about the specific conditions and care processes that are most appropriate for SDM. [ABSTRACT FROM AUTHOR]

Overweight and obese patients commonly suffer from depression and choice of depression therapy may alter weight. We conducted a cohort study to investigate whether obesity is associated with treatment choices for depression; and whether obesity is associated with appropriate duration of depression treatment and receipt of follow-up visits. Adults with a diagnosis of depression between January 1, 2006 and March 31, 2010 who had 1+ new episodes of an antidepressant medication and/or psychotherapy were eligible. Medication use, encounters, diagnoses, height, and weight were collected from health plan databases. We modeled receipt of the different therapies (medication and psychotherapy) by BMI and BMI trajectory during the 9-months prior to initiation of therapy using logistic regression models that accommodated correlation within provider and adjusted for covariates. We modeled BMI via a restricted cubic spline. Fluoxetine was the reference treatment option in the medication models. Lower BMI was associated with greater use of mirtazapine, and a declining BMI prior to treatment was associated with greater odds of initiating mirtazapine and paroxetine. Higher BMI was associated with greater odds of initiating bupropion even after adjustment for smoking status. Obese patients were less likely to receive psychotherapy and less likely to receive appropriate duration (180-days) of depression treatment compared to normal weight subjects. Our study provides evidence that BMI is considered when choosing therapy but associations were weak. Our results should prompt discussion about recommending and choosing depression treatment plans that optimize depression care and weight management concurrently. Differences in care and follow-up by BMI warrant additional research.

AbstractA significant portion of the work of developing and validating methods for volatile organic compound (VOC) sampling in workplace atmospheres involves the use of laboratory-generated atmospheres. The sample variability was evaluated from the dynamic atmosphere generation system used for VOC atmosphere generation and sampling. Characterization of the bias and variability of samples was done for a variety of atmospheres containing neat n-heptane and mixtures of VOCs sampled on activated coconut shell charcoal. Estimates of sampling variability ranged from 2% for neat n-heptane to 12% for a component in the 10 VOC mix. Sample variability increased for lower concentration samples and for mixtures of VOCs compared to single component atmospheres. This study can serve as a baseline for future atmosphere sampling experiments evaluating performance at lower concentrations and mixed VOC environments. [ABSTRACT FROM AUTHOR]

Decision aids are evidence-based sources of health information that can help patients make informed treatment decisions. However, little is known about how decision aids affect health care use when they are implemented outside of randomized controlled clinical trials. We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State. Consistent with prior randomized trials, our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12-21 percent lower costs over six months. These findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients' and physicians' preferences, may reduce rates of elective surgery and lower costs. [ABSTRACT FROM AUTHOR]

Objectives: To examine the relationships among implementing decision aids (DAs) for benign prostatic hyperplasia (BPH) and prostate cancer (PRCA), and treatment rates and costs., Study Design: A pre-post observational evaluation of a quality improvement initiative in a healthcare system in Washington state., Methods: Men with BPH seen in urology clinics and all men diagnosed with localized PRCA were identified for an intervention period, in which urologists were instructed to order a DA for every patient with those conditions, and a historical control period. Outcomes were 6-month rates of surgery for BPH, any active treatment (hormone therapy, radiation, or surgery) for PRCA, and total healthcare costs. Results During the intervention, DAs were delivered to 22% of men with recent BPH drug treatment, 24% of men with untreated BPH, and 56% of men with PRCA. DA implementation was associated with a 32% lower rate of surgery among men with treated BPH (rate ratio [RR], 0.68; 95% CI, 0.49-0.94) and a nonsignificant 22% lower rate of surgery among men with previously untreated BPH (RR, 0.78; 95% CI, 0.50-1.22). For PRCA, DA implementation was associated with a 27% lower rate of active treatment (RR, 0.73; 95% CI, 0.57-0.93). We found no significant associations between DA implementation and costs of care for either condition., Conclusions: Implementing patient DAs was associated with lower rates of elective surgery for previously treated BPH and active treatment for localized PRCA; however, implementation of these DAs was not associated with lower costs of care.