Publications by authors named "Emily R Locke"

8 Publications

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Sociodemographic Characteristics and Physical Activity in Patients with COPD: A 3-Month Cohort Study.

COPD 2021 May 10:1-13. Epub 2021 May 10.

Department of Medicine, University of Washington, Seattle, WA, USA.

Decreased physical activity (PA) is associated with morbidity and mortality in COPD patients. In this secondary analysis of data from a 12-week longitudinal study, we describe factors associated with PA in COPD. Participants completed the Physical Activity Checklist (PAC) daily for a 7- to 8-day period. PA was measured monthly using the Physical Activity Scale for the Elderly (PASE). At three different time points, daily step count was measured for one week with an Omron HJ-720ITC pedometer. The 35 participants were primarily male (94%) and White (91%), with an average age of 66.5 years and FEV 44.9% predicted. Common activities reported on the PAC were walking (93%), preparing a meal (89%), and traveling by vehicle (96%). PA measured by both PASE score ( = 0.01) and average daily step count ( = 0.04) decreased during follow-up. In repeated measures multivariable modeling, participants living with others had a higher daily step count (ß = 942 steps, = 0.01) and better PASE scores (ß = 46.4, < 0.001). Older age was associated with decreased step count (ß = -77 steps, < 0.001) whereas White race was associated with lower PASE scores (ß = -55.4, < 0.001) compared to non-White race. Other demographic factors, quality of life, and medications were not associated with PA. A better understanding of the role of social networks and social support may help develop interventions to improve PA in COPD.
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May 2021

Frailty in Chronic Obstructive Pulmonary Disease and Risk of Exacerbations and Hospitalizations.

Int J Chron Obstruct Pulmon Dis 2020 11;15:1967-1976. Epub 2020 Aug 11.

Department of Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.

Background: Frailty is a complex clinical syndrome associated with vulnerability to adverse health outcomes. While frailty is thought to be common in chronic obstructive pulmonary disease (COPD), the relationship between frailty and COPD-related outcomes such as risk of acute exacerbations of COPD (AE-COPD) and hospitalizations is unclear.

Purpose: To examine the association between physical frailty and risk of acute exacerbations, hospitalizations, and mortality in patients with COPD.

Methods: A longitudinal analysis of data from a cohort of 280 participants was performed. Baseline frailty measures included exhaustion, weakness, low activity, slowness, and undernutrition. Outcome measures included AE-COPD, hospitalizations, and mortality over 2 years. Negative binomial regression and Cox proportional hazard modeling were used.

Results: Sixty-two percent of the study population met criteria for pre-frail and 23% were frail. In adjusted analyses, the frailty syndrome was not associated with COPD exacerbations. However, among the individual components of the frailty syndrome, weakness measured by handgrip strength was associated with increased risk of COPD exacerbations (IRR 1.46, 95% CI 1.09-1.97). The frailty phenotype was not associated with all-cause hospitalizations but was associated with increased risk of non-COPD-related hospitalizations.

Conclusion: This longitudinal cohort study shows that a high proportion of patients with COPD are pre-frail or frail. The frailty phenotype was associated with an increased risk of non-COPD hospitalizations but not with all-cause hospitalizations or COPD exacerbations. Among the individual frailty components, low handgrip strength was associated with increased risk of COPD exacerbations over a 2-year period. Measuring handgrip strength may identify COPD patients who could benefit from programs to reduce COPD exacerbations.
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August 2020

Using Video Telehealth to Facilitate Inhaler Training in Rural Patients with Obstructive Lung Disease.

Telemed J E Health 2019 03 17;25(3):230-236. Epub 2018 Jul 17.

1 Health Services Research and Development (HSR&D), Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.

Background: Proper inhaler technique is important for effective drug delivery and symptom control in chronic obstructive pulmonary disease (COPD) and asthma, yet not all patients receive inhaler instructions.

Introduction: Using a retrospective chart review of participants in a video telehealth inhaler training program, the study compared inhaler technique within and between monthly telehealth visits and reports associated with patient satisfaction.

Materials And Methods: Seventy-four (N = 74) rural patients prescribed ≥1 inhaler participated in three to four pharmacist telehealth inhaler training sessions using teach-to-goal (TTG) methodology. Within and between visit inhaler technique scores are compared, with descriptive statistics of pre- and postprogram survey results including program satisfaction and computer technical issues. Healthcare utilization is compared between pre- and post-training periods.

Results: Sixty-nine (93%) patients completed all three to four video telehealth inhaler training sessions. During the initial visit, patients demonstrated improvement in inhaler technique for metered dose inhalers (albuterol, budesonide/formoterol), dry powder inhalers (formoterol, mometasone, tiotropium), and soft mist inhalers (ipratropium/albuterol) (p < 0.01 for all). Improved inhaler technique was sustained at 2 months (p < 0.01). Ninety-four percent of participants were satisfied with the program. Although technical issues were common, occurring among 63% of attempted visits, most of these visits (87%) could be completed. There was no significant difference in emergency department visits and hospitalizations pre- and post-training.

Discussion: This study demonstrated high patient acceptance of video telehealth training and objective improvement in inhaler technique.

Conclusions: Video telehealth inhaler training using the TTG methodology is a promising program that improved inhaler technique and access to inhaler teaching for rural patients with COPD or asthma.
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March 2019

Association of ambient pollution with inhaler use among patients with COPD: a panel study.

Occup Environ Med 2018 05 13;75(5):382-388. Epub 2018 Mar 13.

Veterans Administration Puget Sound Health Care System, Seattle, Washington, USA.

Background: Studies have linked ambient air pollution to chronic obstructive pulmonary disease (COPD) healthcare encounters. However, the association between air quality and rescue medication use is unknown.

Objectives: We assessed the role of air pollution exposure for increased short-acting beta-2-agonist (SABA) use in patients with COPD through use of remote monitoring technology.

Methods: Participants received a portable electronic inhaler sensor to record the date, time and location for SABA use over a 3-month period. Ambient air pollution data and meteorological data were collected from a centrally located federal monitoring station. Mixed-effects Poisson regression was used to examine the association of daily inhaler use with pollutant levels. Four criteria pollutants (PM, PM, O and NO), two particulate matter species (elemental carbon (EC) and organic carbon), estimated coarse fraction of PM (PM) and four multipollutant air quality measures were each examined separately, adjusting for covariates that passed a false discovery rate (FDR) screening.

Results: We enrolled 35 patients with COPD (94.3% male and mean age: 66.5±8.5) with a mean forced expiratory volume in 1 s (FEV) % predicted of 44.9+17.2. Participants had a median of 92 observation days (range 52-109). Participants' average SABA inhaler use ranged from 0.4 to 13.1 puffs/day (median 2.8). Controlling for supplemental oxygen use, long-acting anticholinergic use, modified Medical Research Council Dyspnoea Scale and influenza season, an IQR increase in PM concentration (8.0 µg/m) was associated with a 6.6% increase in daily puffs (95% CI 3.5% to 9.9%; FDR <0.001). NO and EC concentration were also significantly associated with inhaler use (3.9% and 2.9% per IQR increase, respectively).

Conclusions: Exposure to increased ambient air pollution were associated with a significant increase in SABA use for patients with COPD residing in a low-pollution area.
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May 2018

Use of a Remote Inhaler Monitoring Device to Measure Change in Inhaler Use with Chronic Obstructive Pulmonary Disease Exacerbations.

J Aerosol Med Pulm Drug Deliv 2018 06 16;31(3):191-198. Epub 2017 Oct 16.

3 Department of Health Services Research and Development, VA Puget Sound Health Care System , Seattle, Washington.

Background: Remote inhaler monitoring is an emerging technology that enables the healthcare team to monitor the time and location of a patient's inhaler use. We assessed the feasibility of remote inhaler monitoring for chronic obstructive pulmonary disease (COPD) patients and the pattern of albuterol inhaler use associated with COPD exacerbations.

Methods: Thirty-five participants with COPD used an electronic inhaler sensor for 12 weeks which recorded the date and time of each albuterol actuation. Self-reported COPD exacerbations and healthcare utilization were assessed monthly. We used generalized estimating equations with a logit link to compare the odds of an exacerbation day to a nonexacerbation day by the frequency of daily albuterol use.

Results: Average daily albuterol use on nonexacerbation days varied greatly between patients, ranging from 1.5 to 17.5 puffs. There were 48 exacerbation events observed in 29 participants during the study period, of which 16 were moderate-to-severe exacerbations. During the moderate-to-severe exacerbation days, the median value in average daily albuterol use increased by 14.1% (interquartile range: 2.7%-56.9%) compared to average nonexacerbation days. A 100% increase in inhaler use was associated with increased odds of a moderate-to severe exacerbation (odds ratio 1.54; 95% CI: 1.21-1.97). Approximately 74% of participants reported satisfaction with the sensor.

Conclusions: The electronic inhaler sensor was well received in older patients with COPD over a 12-week period. Increased albuterol use captured by the device was associated with self-reported episodes of moderate-to-severe exacerbations.
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June 2018

Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life.

Respir Care 2017 Nov 18;62(11):1412-1422. Epub 2017 Jul 18.

Health Services Research and Development Service, Seattle Center of Innovation for Veteran-Centered and Value-Driven Care.

Background: COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence.

Methods: In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention.

Results: A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, = .01), fatigue (+0.6 points, < .001), emotional function (+0.5 points, = .001), and mastery (+0.7 points, < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points ( < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 ( = .045). The pharmacist reported technical issues in 64% of visits.

Conclusions: Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.
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November 2017

Disability and recovery of independent function in obstructive lung disease: the cardiovascular health study.

Respiration 2014 9;88(4):329-38. Epub 2014 Sep 9.

Health Services Research and Development, Department of Veterans Affairs, Seattle, Wash., USA.

Background: Chronic obstructive lung disease frequently leads to disability. Older patients may experience transitions between states of disability and independence over time.

Objective: To identify factors associated with transition between states of disability and independent function in obstructive lung disease.

Methods: We analyzed data on 4,394 participants in the Cardiovascular Health Study who completed prebronchodilator spirometry. We calculated the 1-year probability of developing and resolving impairment in ≥1 instrumental activity of daily living (IADL) or ≥1 activity of daily living (ADL) using transition probability analysis. We identified factors associated with resolving disability using relative risk (RR) regression.

Results: The prevalence of IADL impairment was higher with moderate (23.9%) and severe (36.9%) airflow obstruction compared to normal spirometry (22.5%; p < 0.001). Among participants with severe airflow obstruction, 23.5% recovered independence in IADLs and 40.5% recovered independence in ADLs. In the adjusted analyses, airflow obstruction predicted the development of IADL, but not ADL impairment. Participants with severe airflow obstruction were less likely to resolve IADL impairment [RR 0.67 and 95% confidence interval (CI) 0.49-0.94]. Compared to the most active individuals (i.e. who walked ≥28 blocks per week), walking less was associated with a decreased likelihood of resolving IADL impairment (7-27 blocks: RR 0.81 and 95% CI 0.69-0.86 and <7 blocks: RR 0.73 and 95% CI 0.61-0.86). Increased strength (RR 1.16 and 95% CI 1.05-1.29) was associated with resolving IADL impairment.

Conclusions: Disability is common in older people, especially in those with severe airflow obstruction. Increased physical activity and muscle strength are associated with recovery. Research is needed on interventions to improve these factors among patients with obstructive lung disease and disability.
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October 2015

Experience of a controlling or threatening partner among mothers with persistent symptoms of depression.

Am J Obstet Gynecol 2009 Aug 18;201(2):173.e1-9. Epub 2009 Jun 18.

Maternal and Child Health Epidemiology Unit, Section of Women's, Children's, and Family Health, Division of Public Health, Department of Health and Social Services, State of Alaska, Anchorage, Alaska, USA.

Objective: We evaluated the prevalence of symptoms of maternal depression (SMD) that continue beyond the postpartum period and the association between persistent SMD and reporting a controlling or threatening partner.

Study Design: We combined data from a survey of mothers 2-6 months after delivery and its 2-year follow-up survey and analyzed the responses of 444 women who responded to both surveys. We focused on exposure to a controlling partner because this was the sole factor that was associated with persistent SMD in preliminary analysis.

Results: Postpartum SMD was reported by 23% of the women. Among these women, 46% also reported SMD 2 years later. In bivariate analysis, a controlling partner was associated with persistent SMD (odds ratio, 6.9; 95% confidence interval, 1.5-31.8; P = .014).

Conclusion: Almost one-half of women with postpartum SMD continue to have symptoms 2 years later. Further research is needed to measure the strength of the association between controlling partners and persistent depression.
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August 2009