Publications by authors named "Vincent S Fan"

72 Publications

Trends over time in the risk of adverse outcomes among patients with SARS-CoV-2 infection.

Clin Infect Dis 2021 May 11. Epub 2021 May 11.

Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA, USA.

Background: We aimed to describe trends in adverse outcomes among patients who tested positive for SARS-CoV-2 between February and September 2020 within a national healthcare system.

Methods: We identified enrollees in the national U.S. Veterans Affairs healthcare system who tested positive for SARS-CoV-2 between 2/28/2020 and 9/30/2020 (n=55,952), with follow-up extending to 11/19/2020. We determined trends over time in incidence of the following outcomes that occurred within 30 days of testing positive: hospitalization, intensive care unit (ICU) admission, mechanical ventilation and death.

Results: Between February and July 2020, there were marked downward trends in the 30-day incidence of hospitalization (44.2% to 15.8%), ICU admission (20.3% to 5.3%), mechanical ventilation (12.7% to 2.2%), and death (12.5% to 4.4%), which subsequently plateaued between July and September 2020. These trends persisted after adjustment for sociodemographic characteristics, comorbid conditions, documented symptoms and laboratory tests, including among subgroups of patients hospitalized, admitted to the ICU or treated with mechanical ventilation. From February to September, there were decreases in the use of hydroxychloroquine (56.5% to 0%), azithromycin (48.3% to 16.6%) vasopressors (20.6% to 8.7%), and dialysis (11.6% to 3.8%) and increases in the use of dexamethasone (3.4% to 53.1%), other corticosteroids (4.9% to 29.0%) and remdesivir (1.7% to 45.4%) among hospitalized patients.

Conclusions: The risk of adverse outcomes in SARS-CoV-2-positive patients decreased markedly between February and July, with subsequent stabilization from July to September. These trends were not explained by changes in measured baseline patient characteristics and may reflect changing treatment practices or viral pathogenicity.
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http://dx.doi.org/10.1093/cid/ciab419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8136056PMC
May 2021

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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http://dx.doi.org/10.1080/15412555.2021.1920902DOI Listing
May 2021

Development of COVIDVax Model to Estimate the Risk of SARS-CoV-2-Related Death Among 7.6 Million US Veterans for Use in Vaccination Prioritization.

JAMA Netw Open 2021 04 1;4(4):e214347. Epub 2021 Apr 1.

Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington.

Importance: A strategy that prioritizes individuals for SARS-CoV-2 vaccination according to their risk of SARS-CoV-2-related mortality would help minimize deaths during vaccine rollout.

Objective: To develop a model that estimates the risk of SARS-CoV-2-related mortality among all enrollees of the US Department of Veterans Affairs (VA) health care system.

Design, Setting, And Participants: This prognostic study used data from 7 635 064 individuals enrolled in the VA health care system as of May 21, 2020, to develop and internally validate a logistic regression model (COVIDVax) that predicted SARS-CoV-2-related death (n = 2422) during the observation period (May 21 to November 2, 2020) using baseline characteristics known to be associated with SARS-CoV-2-related mortality, extracted from the VA electronic health records (EHRs). The cohort was split into a training period (May 21 to September 30) and testing period (October 1 to November 2).

Main Outcomes And Measures: SARS-CoV-2-related death, defined as death within 30 days of testing positive for SARS-CoV-2. VA EHR data streams were imported on a data integration platform to demonstrate that the model could be executed in real-time to produce dashboards with risk scores for all current VA enrollees.

Results: Of 7 635 064 individuals, the mean (SD) age was 66.2 (13.8) years, and most were men (7 051 912 [92.4%]) and White individuals (4 887 338 [64.0%]), with 1 116 435 (14.6%) Black individuals and 399 634 (5.2%) Hispanic individuals. From a starting pool of 16 potential predictors, 10 were included in the final COVIDVax model, as follows: sex, age, race, ethnicity, body mass index, Charlson Comorbidity Index, diabetes, chronic kidney disease, congestive heart failure, and Care Assessment Need score. The model exhibited excellent discrimination with area under the receiver operating characteristic curve (AUROC) of 85.3% (95% CI, 84.6%-86.1%), superior to the AUROC of using age alone to stratify risk (72.6%; 95% CI, 71.6%-73.6%). Assuming vaccination is 90% effective at preventing SARS-CoV-2-related death, using this model to prioritize vaccination was estimated to prevent 63.5% of deaths that would occur by the time 50% of VA enrollees are vaccinated, significantly higher than the estimate for prioritizing vaccination based on age (45.6%) or the US Centers for Disease Control and Prevention phases of vaccine allocation (41.1%).

Conclusions And Relevance: In this prognostic study of all VA enrollees, prioritizing vaccination based on the COVIDVax model was estimated to prevent a large proportion of deaths expected to occur during vaccine rollout before sufficient herd immunity is achieved.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.4347DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025111PMC
April 2021

BMI and Outcomes of SARS-CoV-2 Among US Veterans.

Obesity (Silver Spring) 2021 05 17;29(5):900-908. Epub 2021 Mar 17.

Division of Gastroenterology, Veterans Affairs Puget Sound Health Care System and University of Washington, Seattle, Washington, USA.

Objective: The purpose of this study is to examine the associations of BMI with testing positive for severe acute respiratory coronavirus 2 (SARS-CoV-2) and risk of adverse outcomes in a cohort of Veterans Affairs enrollees.

Method: Adjusted relative risks/hazard ratios (HRs) were calculated for the associations between BMI category (underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity) and testing positive for SARS-CoV-2 or experiencing hospitalization, intensive care unit admission, mechanical ventilation, and death among those testing positive.

Results: Higher BMI categories were associated with higher risk of a positive SARS-CoV-2 test compared with the normal weight category (class 3 obesity adjusted relative risk: 1.34, 95% CI: 1.28-1.42). Among 25,952 patients who tested positive for SARS-CoV-2, class 3 obesity was associated with higher risk of mechanical ventilation (adjusted HR [aHR]: 1.77, 95% CI: 1.35-2.32) and mortality (aHR: 1.42, 95% CI: 1.12-1.78) compared with normal weight individuals. These associations were present primarily in patients younger than 65 and were attenuated or absent in older age groups (interaction P < 0.05).

Conclusion: Veterans Affairs enrollees with higher BMI were more likely to test positive for SARS-CoV-2 and were more likely to be mechanically ventilated or die if infected with SARS-CoV-2. Higher BMI contributed relatively more to the risk of death in those younger than 65 years of age as compared with other age categories.
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http://dx.doi.org/10.1002/oby.23111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084878PMC
May 2021

Serotonin transporter gene polymorphisms and depressive symptoms in patients with chronic obstructive pulmonary disease.

Expert Rev Respir Med 2021 May 29;15(5):681-687. Epub 2020 Dec 29.

VA Puget Sound, University of Washington, Seattle, WA, USA.

: We examined the relationship between polymorphisms in the promoter region of the serotonin transport (SERT) gene (5-HTTLPR, short 'S' and long 'L' alleles) and in intron 2 variable number tandem repeat (STin2VNTR, 9, 10, or 12-repeat alleles) with depression or anxiety in patients with COPD.: 302 patients with moderate to severe COPD participated in SERT study. History and number of prior depressive episodes were measured using the Structured Clinical Interview for Depression; Hospital Anxiety Depression Scale (HAD) depression ≥8 or a Patient Health Questionnaire-9 (PHQ-9) >,10.: 240 (80%) male sample had a mean age of 68.0 years. Current depression was 22% (HAD) or 21% (PHQ-9), anxiety was 25% (HAD), and suicidal ideation (6%). 5-HTTLPR or STin2 VNTR genotypes were not associated with current depressive or anxiety symptoms. The mean number of prior depressive episodes was higher for patients with the 5-HTTLPR genotype S/S or S/L compared with L/L (4.4 ± 6.1; 5.3 ± 6.8; 4.0 ± 6.1, p < 0.001) and with STin2VNTR high-risk genotype (9/12 or 12/12), medium risk (9/10 or 10/12) compared to low risk (10/10) genotypes (5.1 ± 6.8; 4.9 ± 6.7; 2.7 ± 4.5, p < 0.001).: SERT 5-HTTLPR and STin2-VNTR polymorphisms were not associated with current depressive and anxiety symptoms, but the high-risk STin2-VNTR genotypes and S/L were associated with the number of prior depressive episodes.
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http://dx.doi.org/10.1080/17476348.2021.1865159DOI Listing
May 2021

Cirrhosis and Severe Acute Respiratory Syndrome Coronavirus 2 Infection in US Veterans: Risk of Infection, Hospitalization, Ventilation, and Mortality.

Hepatology 2020 Nov 21. Epub 2020 Nov 21.

Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, WA.

Background And Aims: Whether patients with cirrhosis have increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the extent to which infection and cirrhosis increase the risk of adverse patient outcomes remain unclear.

Approach And Results: We identified 88,747 patients tested for SARS-CoV-2 between March 1, 2020, and May 14, 2020, in the Veterans Affairs (VA) national health care system, including 75,315 with no cirrhosis-SARS-CoV-2-negative (C0-S0), 9,826 with no cirrhosis-SARS-CoV-2-positive (C0-S1), 3,301 with cirrhosis-SARS-CoV-2-negative (C1-S0), and 305 with cirrhosis-SARS-CoV-2-positive (C1-S1). Patients were followed through June 22, 2020. Hospitalization, mechanical ventilation, and death were modeled in time-to-event analyses using Cox proportional hazards regression. Patients with cirrhosis were less likely to test positive than patients without cirrhosis (8.5% vs. 11.5%; adjusted odds ratio, 0.83; 95% CI, 0.69-0.99). Thirty-day mortality and ventilation rates increased progressively from C0-S0 (2.3% and 1.6%) to C1-S0 (5.2% and 3.6%) to C0-S1 (10.6% and 6.5%) and to C1-S1 (17.1% and 13.0%). Among patients with cirrhosis, those who tested positive for SARS-CoV-2 were 4.1 times more likely to undergo mechanical ventilation (adjusted hazard ratio [aHR], 4.12; 95% CI, 2.79-6.10) and 3.5 times more likely to die (aHR, 3.54; 95% CI, 2.55-4.90) than those who tested negative. Among patients with SARS-CoV-2 infection, those with cirrhosis were more likely to be hospitalized (aHR, 1.37; 95% CI, 1.12-1.66), undergo ventilation (aHR, 1.61; 95% CI, 1.05-2.46) or die (aHR, 1.65; 95% CI, 1.18-2.30) than patients without cirrhosis. Among patients with cirrhosis and SARS-CoV-2 infection, the most important predictors of mortality were advanced age, cirrhosis decompensation, and high Model for End-Stage Liver Disease score.

Conclusions: SARS-CoV-2 infection was associated with a 3.5-fold increase in mortality in patients with cirrhosis. Cirrhosis was associated with a 1.7-fold increase in mortality in patients with SARS-CoV-2 infection.
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http://dx.doi.org/10.1002/hep.31649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753324PMC
November 2020

Risk Factors for testing positive for SARS-CoV-2 in a national US healthcare system.

Clin Infect Dis 2020 Oct 27. Epub 2020 Oct 27.

Division of Gastroenterology, University of Washington, Seattle, WA, USA.

Background: Identifying risk factors for SARS-CoV-2 infection could help health systems improve testing and screening strategies.

Objectives: Identify demographic factors, comorbid conditions, and symptoms independently associated with testing positive for SARS-CoV-2.

Design: Observational cross-sectional study.

Setting: Veterans Health Administration.

Patients: Persons tested for SARS-CoV-2 nucleic acid by polymerase chain reaction (PCR) between March 1 and May 14, 2020.

Measurements: Associations between demographic characteristics, diagnosed comorbid conditions, and documented symptoms with testing positive for SARS-CoV-2.

Results: Of 88,747 persons tested, 10,131 (11.4%) were SARS-CoV-2 PCR positive. Positivity was associated with older age (≥80 vs. <50 years: aOR 2.16, 95% CI 1.97-2.37), male sex (aOR 1.45, 95% CI 1.34-1.57), regional SARS-CoV-2 burden (≥2,000 vs. <400 cases/million: aOR 5.43, 95% CI 4.97-5.93), urban residence (aOR 1.78, 95% CI 1.70-1.87), Black (aOR 2.15, 95% CI 2.05-2.26) or American Indian/Alaska Native/Pacific Islander (aOR 1.26, 95% CI 1.05-1.52) vs. White race, and Hispanic ethnicity (aOR 1.52, 95% CI 1.40-1.65). Obesity and diabetes were the only two medical conditions associated with testing positive. Documented fevers, chills, cough, and diarrhea were also associated with testing positive. The population attributable fraction of positive tests was highest for regional SARS-CoV-2 burden (35.3%), followed by demographic variables (27.2%), symptoms (12.0%), obesity (10.5%), and diabetes (0.4%).

Limitations: Lack of information on SARS-CoV-2 exposures or the indications for testing which may affect the likelihood of testing positive.

Conclusion: The majority of positive SARS-CoV-2 tests were attributed to regional SARS-CoV-2 burden, demographic characteristics and obesity with a minor contribution of chronic comorbid conditions.
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http://dx.doi.org/10.1093/cid/ciaa1624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665412PMC
October 2020

Risk Factors for Hospitalization, Mechanical Ventilation, or Death Among 10 131 US Veterans With SARS-CoV-2 Infection.

JAMA Netw Open 2020 09 1;3(9):e2022310. Epub 2020 Sep 1.

Division of Pulmonary and Critical Care, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle.

Importance: Identifying independent risk factors for adverse outcomes in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can support prognostication, resource utilization, and treatment.

Objective: To identify excess risk and risk factors associated with hospitalization, mechanical ventilation, and mortality in patients with SARS-CoV-2 infection.

Design, Setting, And Participants: This longitudinal cohort study included 88 747 patients tested for SARS-CoV-2 nucleic acid by polymerase chain reaction between Feburary 28 and May 14, 2020, and followed up through June 22, 2020, in the Department of Veterans Affairs (VA) national health care system, including 10 131 patients (11.4%) who tested positive.

Exposures: Sociodemographic characteristics, comorbid conditions, symptoms, and laboratory test results.

Main Outcomes And Measures: Risk of hospitalization, mechanical ventilation, and death were estimated in time-to-event analyses using Cox proportional hazards models.

Results: The 10 131 veterans with SARS-CoV-2 were predominantly male (9221 [91.0%]), with diverse race/ethnicity (5022 [49.6%] White, 4215 [41.6%] Black, and 944 [9.3%] Hispanic) and a mean (SD) age of 63.6 (16.2) years. Compared with patients who tested negative for SARS-CoV-2, those who tested positive had higher rates of 30-day hospitalization (30.4% vs 29.3%; adjusted hazard ratio [aHR], 1.13; 95% CI, 1.08-1.13), mechanical ventilation (6.7% vs 1.7%; aHR, 4.15; 95% CI, 3.74-4.61), and death (10.8% vs 2.4%; aHR, 4.44; 95% CI, 4.07-4.83). Among patients who tested positive for SARS-CoV-2, characteristics significantly associated with mortality included older age (eg, ≥80 years vs <50 years: aHR, 60.80; 95% CI, 29.67-124.61), high regional COVID-19 disease burden (eg, ≥700 vs <130 deaths per 1 million residents: aHR, 1.21; 95% CI, 1.02-1.45), higher Charlson comorbidity index score (eg, ≥5 vs 0: aHR, 1.93; 95% CI, 1.54-2.42), fever (aHR, 1.51; 95% CI, 1.32-1.72), dyspnea (aHR, 1.78; 95% CI, 1.53-2.07), and abnormalities in the certain blood tests, which exhibited dose-response associations with mortality, including aspartate aminotransferase (>89 U/L vs ≤25 U/L: aHR, 1.86; 95% CI, 1.35-2.57), creatinine (>3.80 mg/dL vs 0.98 mg/dL: aHR, 3.79; 95% CI, 2.62-5.48), and neutrophil to lymphocyte ratio (>12.70 vs ≤2.71: aHR, 2.88; 95% CI, 2.12-3.91). With the exception of geographic region, the same covariates were independently associated with mechanical ventilation along with Black race (aHR, 1.52; 95% CI, 1.25-1.85), male sex (aHR, 2.07; 95% CI, 1.30-3.32), diabetes (aHR, 1.40; 95% CI, 1.18-1.67), and hypertension (aHR, 1.30; 95% CI, 1.03-1.64). Notable characteristics that were not significantly associated with mortality in adjusted analyses included obesity (body mass index ≥35 vs 18.5-24.9: aHR, 0.97; 95% CI, 0.77-1.21), Black race (aHR, 1.04; 95% CI, 0.88-1.21), Hispanic ethnicity (aHR, 1.03; 95% CI, 0.79-1.35), chronic obstructive pulmonary disease (aHR, 1.02; 95% CI, 0.88-1.19), hypertension (aHR, 0.95; 95% CI, 0.81-1.12), and smoking (eg, current vs never: aHR, 0.87; 95% CI, 0.67-1.13). Most deaths in this cohort occurred in patients with age of 50 years or older (63.4%), male sex (12.3%), and Charlson Comorbidity Index score of at least 1 (11.1%).

Conclusions And Relevance: In this national cohort of VA patients, most SARS-CoV-2 deaths were associated with older age, male sex, and comorbidity burden. Many factors previously reported to be associated with mortality in smaller studies were not confirmed, such as obesity, Black race, Hispanic ethnicity, chronic obstructive pulmonary disease, hypertension, and smoking.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.22310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7512055PMC
September 2020

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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http://dx.doi.org/10.2147/COPD.S245505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429100PMC
August 2020

Serum IgG Levels and Risk of COPD Hospitalization: A Pooled Meta-analysis.

Chest 2020 10 19;158(4):1420-1430. Epub 2020 May 19.

Department of Medicine, University of Maryland, Baltimore, MD.

Background: Hypogammaglobulinemia (serum IgG levels < 7.0 g/L) has been associated with increased risk of COPD exacerbations but has not yet been shown to predict hospitalizations.

Research Question: To determine the relationship between hypogammaglobulinemia and the risk of hospitalization in patients with COPD.

Study Design And Methods: Serum IgG levels were measured on baseline samples from four COPD cohorts (n = 2,259): Azithromycin for Prevention of AECOPD (MACRO, n = 976); Simvastatin in the Prevention of AECOPD (STATCOPE, n = 653), Long-Term Oxygen Treatment Trial (LOTT, n = 354), and COPD Activity: Serotonin Transporter, Cytokines and Depression (CASCADE, n = 276). IgG levels were determined by immunonephelometry (MACRO; STATCOPE) or mass spectrometry (LOTT; CASCADE). The effect of hypogammaglobulinemia on COPD hospitalization risk was evaluated using cumulative incidence functions for this outcome and deaths (competing risk). Fine-Gray models were performed to obtain adjusted subdistribution hazard ratios (SHR) related to IgG levels for each study and then combined using a meta-analysis. Rates of COPD hospitalizations per person-year were compared according to IgG status.

Results: The overall frequency of hypogammaglobulinemia was 28.4%. Higher incidence estimates of COPD hospitalizations were observed among participants with low IgG levels compared with those with normal levels (Gray's test, P < .001); pooled SHR (meta-analysis) was 1.29 (95% CI, 1.06-1.56, P = .01). Among patients with prior COPD admissions (n = 757), the pooled SHR increased to 1.58 (95% CI, 1.20-2.07, P < .01). The risk of COPD admissions, however, was similar between IgG groups in patients with no prior hospitalizations: pooled SHR = 1.15 (95% CI, 0.86-1.52, P =.34). The hypogammaglobulinemia group also showed significantly higher rates of COPD hospitalizations per person-year: 0.48 ± 2.01 vs 0.29 ± 0.83, P < .001.

Interpretation: Hypogammaglobulinemia is associated with a higher risk of COPD hospital admissions.
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http://dx.doi.org/10.1016/j.chest.2020.04.058DOI Listing
October 2020

Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2020 05;201(9):e56-e69

: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society.: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: ) a strong recommendation for the use of long-acting β-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; ) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; ) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; ) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; ) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and ) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy.: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.
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http://dx.doi.org/10.1164/rccm.202003-0625STDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7193862PMC
May 2020

Telomere length in COPD: Relationships with physical activity, exercise capacity, and acute exacerbations.

PLoS One 2019 17;14(10):e0223891. Epub 2019 Oct 17.

VA Boston Healthcare System, Boston, MA, United States of America.

Rationale: Shorter leukocyte telomere length (LTL) is associated with reduced health-related quality of life and increased risk for acute exacerbations (AEs) and mortality in chronic obstructive pulmonary disease (COPD). Increased physical activity and exercise capacity are associated with reduced risk for AEs and death. However, the relationships between LTL and physical activity, exercise capacity, and AEs in COPD are unknown.

Methods: Data from 3 COPD cohorts were examined: Cohort 1 (n = 112, physical activity intervention trial), Cohorts 2 and 3 (n = 182 and 294, respectively, separate observational studies). Subjects completed a 6-minute walk test (6MWT) and provided blood for LTL assessment using real-time PCR. Physical activity was measured as average daily step count using an accelerometer or pedometer. Number of self-reported AEs was available for 1) the year prior to enrollment (Cohorts 1 and 3) and 2) prospectively after enrollment (all cohorts). Multivariate models examined associations between LTL and average daily step count, 6MWT distance, and AEs.

Results: A significant association between longer LTL and increased 6MWT distance was observed in the three combined cohorts (β = 3x10-5, p = 0.045). No association between LTL and average daily step count was observed. Shorter LTL was associated with an increased number of AEs in the year prior to enrollment (Cohorts 1 and 3 combined, β = -1.93, p = 0.04) and with prospective AEs (Cohort 3, β = -1.3388, p = 0.0003).

Conclusions: Among COPD patients, increased LTL is associated with higher exercise capacity, but not physical activity. Shorter LTL was associated with AEs in a subgroup of cohorts.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223891PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797105PMC
March 2020

Effect of Physical Activity Coaching on Acute Care and Survival Among Patients With Chronic Obstructive Pulmonary Disease: A Pragmatic Randomized Clinical Trial.

JAMA Netw Open 2019 08 2;2(8):e199657. Epub 2019 Aug 2.

Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena.

Importance: While observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD), there are no population-based trials to date testing the effectiveness of physical activity (PA) interventions to reduce acute care use or improve survival.

Objective: To evaluate the long-term effectiveness of a community-based PA coaching intervention in patients with COPD.

Design, Setting, And Participants: Pragmatic randomized clinical trial with preconsent randomization to the 12-month Walk On! (WO) intervention or standard care (SC). Enrollment occurred from July 1, 2015, to July 31, 2017; follow-up ended in July 2018. The setting was Kaiser Permanente Southern California sites. Participants were patients 40 years or older who had any COPD-related acute care use in the previous 12 months; only patients assigned to WO were approached for consent to participate in intervention activities.

Interventions: The WO intervention included collaborative monitoring of PA step counts, semiautomated step goal recommendations, individualized reinforcement, and peer/family support. Standard COPD care could include referrals to pulmonary rehabilitation.

Main Outcomes And Measures: The primary outcome was a composite binary measure of all-cause hospitalizations, observation stays, emergency department visits, and death using adjusted logistic regression in the 12 months after randomization. Secondary outcomes included self-reported PA, COPD-related acute care use, symptoms, quality of life, and cardiometabolic markers.

Results: All 2707 eligible patients (baseline mean [SD] age, 72 [10] years; 53.7% female; 74.3% of white race/ethnicity; and baseline mean [SD] percent forced expiratory volume in the first second of expiration predicted, 61.0 [22.5]) were randomly assigned to WO (n = 1358) or SC (n = 1349). The intent-to-treat analysis showed no differences between WO and SC on the primary all-cause composite outcome (odds ratio [OR], 1.09; 95% CI, 0.92-1.28; P = .33) or in the individual outcomes. Prespecified, as-treated analyses compared outcomes between all SC and 321 WO patients who participated in any intervention activities (23.6% [321 of 1358] uptake). The as-treated, propensity score-weighted model showed nonsignificant positive estimates in favor of WO participants compared with SC on all-cause hospitalizations (OR, 0.84; 95% CI, 0.65-1.10; P = .21) and death (OR, 0.62; 95% CI, 0.35-1.11; P = .11). More WO participants reported engaging in PA compared with SC (47.4% [152 of 321] vs 30.7% [414 of 1349]; P < .001) and had improvements in the Patient-Reported Outcomes Measurement Information System 10 physical health domain at 6 months. There were no group differences in other secondary outcomes.

Conclusions And Relevance: Participation in a PA coaching program by patients with a history of COPD exacerbations was insufficient to effect improvements in acute care use or survival in the primary analysis.

Trial Registration: ClinicalTrials.gov identifier: NCT02478359.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.9657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704745PMC
August 2019

Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers.

J Cardiovasc Nurs 2019 Sep/Oct;34(5):399-409

Ranak B. Trivedi, PhD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto; and Assistant Professor, Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, California. Cindie Slightam, MPH Research Health Science Specialist, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California. Andrea Nevedal, PhD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California. Timothy C. Guetterman, PhD Assistant Professor, Department of Family Medicine, University of Michigan, Ann Arbor. Vincent S. Fan, MD, MPH Core Investigator, Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington; and Associate Professor, Department of Medicine, University of Washington, Seattle. Karin M. Nelson, MD, MSHS Core Investigator, Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington; and Professor, Department of Medicine, University of Washington, Seattle. Ann-Marie Rosland, MD Core Investigator, Center for Health Equity, VA Pittsburgh Health Care System; and Associate Professor, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania. Paul A. Heidenreich, MD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System; and Professor, Division of Cardiology, Stanford University School of Medicine, California. Christine Timko, PhD Research Career Scientist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Steven M. Asch, MD, MPH Director, Center for Innovation to Implementation, VA Palo Alto Health Care System; and Professor, Division of General Internal Medicine, Stanford University School of Medicine, California. John D. Piette, PhD Senior Research Career Scientist, Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Michigan; and Director, Center for Managing Chronic Disease, School of Public Health, University of Michigan, Ann Arbor.

Background: Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap.

Objective: The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers.

Methods: Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained.

Results: A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations.

Conclusions: Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care.
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http://dx.doi.org/10.1097/JCN.0000000000000591DOI Listing
July 2020

Comparing the Barriers and Facilitators of Heart Failure Management as Perceived by Patients, Caregivers, and Clinical Providers.

J Cardiovasc Nurs 2019 Sep/Oct;34(5):399-409

Ranak B. Trivedi, PhD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto; and Assistant Professor, Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, California. Cindie Slightam, MPH Research Health Science Specialist, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California. Andrea Nevedal, PhD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California. Timothy C. Guetterman, PhD Assistant Professor, Department of Family Medicine, University of Michigan, Ann Arbor. Vincent S. Fan, MD, MPH Core Investigator, Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington; and Associate Professor, Department of Medicine, University of Washington, Seattle. Karin M. Nelson, MD, MSHS Core Investigator, Seattle-Denver Center of Innovation, VA Puget Sound Health Care System, Seattle, Washington; and Professor, Department of Medicine, University of Washington, Seattle. Ann-Marie Rosland, MD Core Investigator, Center for Health Equity, VA Pittsburgh Health Care System; and Associate Professor, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania. Paul A. Heidenreich, MD Core Investigator, Center for Innovation to Implementation, VA Palo Alto Health Care System; and Professor, Division of Cardiology, Stanford University School of Medicine, California. Christine Timko, PhD Research Career Scientist, Center for Innovation to Implementation, VA Palo Alto Health Care System, California. Steven M. Asch, MD, MPH Director, Center for Innovation to Implementation, VA Palo Alto Health Care System; and Professor, Division of General Internal Medicine, Stanford University School of Medicine, California. John D. Piette, PhD Senior Research Career Scientist, Center for Practice Management and Outcomes Research, VA Ann Arbor Health Care System, Michigan; and Director, Center for Managing Chronic Disease, School of Public Health, University of Michigan, Ann Arbor.

Background: Heart failure (HF) management requires the participation of patients, their significant others, and clinical providers. Each group may face barriers to HF management that may be unique or may overlap.

Objective: The aim of this study was to compare the barriers and facilitators of HF management as perceived by patients, significant others, and clinical providers.

Methods: Participants were recruited from a Veterans Health Administration facility. Eligible patients had a diagnosis of HF (ICD9 code 428.XX), 1 or more HF-related visit in the previous year, and a significant other who was their primary caregiver. Significant others were adults with no history of cognitive impairments caring for patients with HF. Providers were eligible if they cared for patients with HF. All participants completed semistructured interviews designed to elicit barriers to managing HF and strategies that they used to overcome these barriers. Interviews were transcribed and analyzed using latent thematic analysis, and recruitment continued until thematic saturation was attained.

Results: A total of 17 couples and 12 providers were recruited. All 3 groups identified poor communication as a key barrier to HF management, including communication between patients and their significant other, between couples and providers, and providers with each other. Significant others noted that the lack of direct communication with clinical providers hindered their efforts to care for the patient. All 3 groups emphasized the importance of family members in optimizing adherence to HF self-management recommendations.

Conclusions: Providers, patients, and significant others all play important and distinct roles in the management of HF. Tools to enhance communication and collaboration for all 3 and supporting the needs of significant others are missing components of current HF care.
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http://dx.doi.org/10.1097/JCN.0000000000000591DOI Listing
July 2020

Traditional cooking practices and preferences for stove features among women in rural Senegal: Informing improved cookstove design and interventions.

PLoS One 2018 20;13(11):e0206822. Epub 2018 Nov 20.

Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.

Nearly half the world's population burns solid fuel for cooking, heating, and lighting. The incomplete combustion of these fuels is associated with detrimental health and environmental effects. The design and distribution of improved cookstoves that increase combustion efficiency and reduce indoor air pollution are a global priority. However, promoting exclusive and sustainable use of the improved stoves has proved challenging. In 2012, we conducted a survey in a community in rural Senegal to describe stove ownership and preferences for different stove technologies. This report aims to describe local stove and fuel use, to identify household preferences related to stove features and function, and to elicit the community perceptions of cleaner-burning stove alternatives with a focus on liquid propane gas. Similar to many resource-limited settings, biomass fuel use was ubiquitous and multiple stoves were used, even when cleaner burning alternatives were available; less than 1% of households that owned a liquid propane stove used it as the primary cooking device. Despite nearly universal use of the traditional open fire (92% of households), women did not prefer this stove when presented with other options. Propane gas, solar, and improved cookstoves were all viewed as more desirable when compared to the traditional open fire, however first-hand experience and knowledge of these stoves was limited. The stove features of greatest value were, in order: large cooking capacity, minimal smoke production, and rapid heating. Despite the low desirability and smoke emisions from the traditional open fire, its pervasive use, even in the presence of alternative stove options, may be related to its ability to satisfy the practical needs of the surveyed cooks, namely large cooking capacity and rapid, intense heat generation. Our data suggest women in this community want alternative stove options that reduce smoke exposure, however currently available stoves, including liquid propane gas, do not address all of the cooks' preferences.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0206822PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6245512PMC
April 2019

Applying the pragmatic-explanatory continuum indicator summary to the implementation of a physical activity coaching trial in chronic obstructive pulmonary disease.

Nurs Outlook 2018 09 12;66(5):455-463. Epub 2018 Jul 12.

Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.

Background: Observational studies show that physical inactivity is associated with worse outcomes in chronic obstructive pulmonary disease (COPD). Despite practice guidelines recommending regular physical activity (PA), there are no large-scale experimental studies to confirm that patients at high risk for COPD exacerbations can increase their PA and consequently, have improved outcomes.

Purpose: The purpose of this case study is to describe the use of a widely accepted pragmatic trials framework for the design and implementation of a pragmatic clinical trial (PCT) of PA coaching for COPD in a real-world setting.

Method: The aim of the trial was to determine the effectiveness of a 12-month PA coaching intervention (Walk On!) compared to standard care for 2,707 patients at high risk for COPD exacerbations from a large integrated health care system. The descriptions of our implementation experiences are anchored within the pragmatic-explanatory continuum indicator summary (PRECIS-2) framework.

Discussion: Facilitators of PCT implementation include early and ongoing engagement and support of multiple stakeholders including patients, health system leaders, administrators, physician champions, and frontline clinicians, an organizational/setting that prioritizes positive lifestyle behaviors, and a flexible intervention that allows for individualization. Pragmatic challenges include reliance on electronic data that are not complete or available in real-time for patient identification, timing of outreach may not synchronize with patients' readiness for change, and high turnover of clinical staff drawn from the existing workforce.

Discussion: PRECIS-2 is a useful guide for organizing decisions about study designs and implementation approaches to help diverse stakeholders recognize the compromises between internal and external validity with those decisions.
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http://dx.doi.org/10.1016/j.outlook.2018.05.005DOI Listing
September 2018

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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http://dx.doi.org/10.1089/tmj.2017.0330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916242PMC
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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http://dx.doi.org/10.1136/oemed-2017-104808DOI Listing
May 2018

Effect of symptoms on physical performance in COPD.

Heart Lung 2018 Mar - Apr;47(2):149-156. Epub 2018 Feb 1.

VA Puget Sound Health Care Center, Seattle, WA, USA.

Background: Chronic obstructive pulmonary disease (COPD) patients experience multiple symptoms including dyspnea, anxiety, depression, and fatigue, which are highly correlated with each other. Together, those symptoms may contribute to impaired physical performance.

Objectives: The purpose of this study was to examine interrelationships among dyspnea, anxiety, depressive symptoms, and fatigue as contributing factors to physical performance in COPD.

Methods: This study used baseline data of 282 COPD patients from a longitudinal observational study to explore the relationship between depression, inflammation, and functional status. Data analyses included confirmatory factor analyses and structural equation modeling.

Results: Dyspnea, anxiety and depression had direct effects on fatigue, and both dyspnea and anxiety had direct effects on physical performance. Higher levels of dyspnea were significantly associated with impaired physical performance whereas higher levels of anxiety were significantly associated with enhanced physical performance.

Conclusion: Dyspnea was the strongest predictor of impaired physical performance in patients with COPD.
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http://dx.doi.org/10.1016/j.hrtlng.2017.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857230PMC
December 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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http://dx.doi.org/10.1089/jamp.2017.1383DOI Listing
June 2018

Design of the Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) AIR Study.

BMJ Open Respir Res 2017 18;4(1):e000186. Epub 2017 May 18.

University of Washington, Seattle, Washington, USA.

Introduction: Population-based epidemiological evidence suggests that exposure to ambient air pollutants increases hospitalisations and mortality from chronic obstructive pulmonary disease (COPD), but less is known about the impact of exposure to air pollutants on patient-reported outcomes, morbidity and progression of COPD.

Methods And Analysis: The Subpopulations and Intermediate Outcome Measures in COPD (SPIROMICS) Air Pollution Study (SPIROMICS AIR) was initiated in 2013 to investigate the relation between individual-level estimates of short-term and long-term air pollution exposures, day-to-day symptom variability and disease progression in individuals with COPD. SPIROMICS AIR builds on a multicentre study of smokers with COPD, supplementing it with state-of-the-art air pollution exposure assessments of fine particulate matter, oxides of nitrogen, ozone, sulfur dioxide and black carbon. In the parent study, approximately 3000 smokers with and without airflow obstruction are being followed for up to 3 years for the identification of intermediate biomarkers which predict disease progression. Subcohorts undergo daily symptom monitoring using comprehensive daily diaries. The air monitoring and modelling methods employed in SPIROMICS AIR will provide estimates of individual exposure that incorporate residence-specific infiltration characteristics and participant-specific time-activity patterns. The overarching study aim is to understand the health effects of short-term and long-term exposures to air pollution on COPD morbidity, including exacerbation risk, patient-reported outcomes and disease progression.

Ethics And Dissemination: The institutional review boards of all the participating institutions approved the study protocols. The results of the trial will be presented at national and international meetings and published in peer-reviewed journals.
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http://dx.doi.org/10.1136/bmjresp-2017-000186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5595208PMC
May 2017

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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http://dx.doi.org/10.4187/respcare.05445DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6373850PMC
November 2017

Association between Social Support and Self-Care Behaviors in Adults with Chronic Obstructive Pulmonary Disease.

Ann Am Thorac Soc 2017 Sep;14(9):1419-1427

1 School of Nursing and.

Rationale: Higher social support is associated with a better quality of life and functioning in adults with chronic obstructive pulmonary disease (COPD).

Objectives: To determine the association between structural and functional social support and self-care behaviors in adults with COPD.

Methods: This was a longitudinal study using data from the CASCADE (COPD Activity: Serotonin Transporter, Cytokines, and Depression) study, which was focused on depression and functioning in COPD. Physical activity was measured with a validated accelerometer at baseline, year 1, and year 2. Additional self-care behaviors included pulmonary rehabilitation attendance, smoking status, receipt of influenza and/or pneumococcal vaccinations, and medication adherence. Structural social support indicators included living status, being partnered, number of close friends/relatives, and presence of a family caregiver. Functional social support was measured with the Medical Outcomes Social Support Survey (MOSSS). Mixed-effects and logistic regression models were used.

Results: A total of 282 participants with Global Initiative for Chronic Obstructive Lung Disease stage II to IV COPD were included (age, 68 ± 9 yr; 80% men; FEV% predicted, 45 ± 16). For physical activity, participants who lived with others accrued 903 more steps per day than those who lived alone (95% confidence interval [CI], 373-1,433; P = 0.001); increases in the MOSSS total score were associated with more steps per day (β = 10; 95% CI, 2-18; P = 0.02). The odds of pulmonary rehabilitation participation were more than 11 times higher if an individual had a spouse or partner caregiver compared with not having a caregiver (odds ratio [OR], 11.03; 95% CI, 1.93-62.97; P < 0.01). Higher functional social support (MOSSS total score) was associated with marginally lower odds of smoking (OR, 0.99; 95% CI, 0.98-1.00; P = 0.03) and higher odds of pneumococcal vaccination (OR, 1.02; 95% CI, 1.00-1.03; P = 0.02). Social support was not associated with influenza vaccination or medication adherence.

Conclusions: Structural social support, which was measured by reports of living with others and having a caregiver, was respectively associated with higher levels of physical activity and greater participation in pulmonary rehabilitation in adults with COPD. Our findings reinforce the critical importance of the social environment in shaping patients' success with self-care. Clinical Trial registered with clinicaltrials.gov (NCT01074515).
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http://dx.doi.org/10.1513/AnnalsATS.201701-026OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711401PMC
September 2017

Percent Emphysema and Daily Motor Activity Levels in the General Population: Multi-Ethnic Study of Atherosclerosis.

Chest 2017 05 6;151(5):1039-1050. Epub 2016 Dec 6.

Department of Medicine, Columbia University, New York, NY. Electronic address:

Background: COPD is associated with reduced physical capacity. However, it is unclear whether pulmonary emphysema, which can occur without COPD, is associated with reduced physical activity in daily life, particularly among people without COPD and never smokers. We hypothesized that greater percentage of emphysema-like lung on CT scan is associated with reduced physical activity assessed by actigraphy and self-report.

Methods: The Multi-Ethnic Study of Atherosclerosis (MESA) enrolled participants free of clinical cardiovascular disease from the general population. Percent emphysema was defined as percentage of voxels < -950 Hounsfield units on full-lung CT scans. Physical activity was measured by wrist actigraphy over 7 days and a questionnaire. Multivariable linear regression was used to adjust for age, sex, race/ethnicity, height, weight, education, smoking, pack-years, and lung function.

Results: Among 1,435 participants with actigraphy and lung measures, 47% had never smoked, and 8% had COPD. Percent emphysema was associated with lower activity levels on actigraphy (P = .001), corresponding to 1.5 hour less per week of moderately paced walking for the average participant in quintile 2 vs 4 of percent emphysema. This association was significant among participants without COPD (P = .004) and among ever (P = .01) and never smokers (P = .03). It was also independent of coronary artery calcium and left ventricular ejection fraction. There was no evidence that percent emphysema was associated with self-reported activity levels.

Conclusions: Percent emphysema was associated with decreased physical activity in daily life objectively assessed by actigraphy in the general population, among participants without COPD, and nonsmokers.
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http://dx.doi.org/10.1016/j.chest.2016.11.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472515PMC
May 2017

Symptom profiles and inflammatory markers in moderate to severe COPD.

BMC Pulm Med 2016 12 3;16(1):173. Epub 2016 Dec 3.

University of Washington & Puget Sound Veterans Administration, Seattle, USA.

Background: Physical and psychological symptoms are the hallmark of patients' subjective perception of their illness. The purpose of this analysis was to determine if patients with COPD have distinctive symptom profiles and to examine the association of symptom profiles with systemic biomarkers of inflammation.

Methods: We conducted latent class analyses of three physical (dyspnea, fatigue, and pain) and two psychological symptoms (depression and anxiety) in 302 patients with moderate to severe COPD using baseline data from a longitudinal observational study of depression in COPD. Systemic inflammatory markers included IL1, IL8, IL10, IL12, IL13, INF, GM-CSF, TNF-α (levels >75centile was considered high); and CRP (levels >3 mg/L was considered high). Multinominal logistic regression models were used to examine the association between symptom classes and inflammation while adjusting for key socio-demographic and disease characteristics.

Results: We found that a 4-class model best fit the data: 1) low physical and psychological symptoms (26%, Low-Phys/Low-Psych), 2) low physical but moderate psychological symptoms (18%, Low-Phys/Mod Psych), 3) high physical but moderate psychological symptoms (25%, High-Phys/Mod Psych), and 4) high physical and psychological symptoms (30%, High-Phys/High Psych). Unadjusted analyses showed associations between symptom class with high levels of IL7, IL-8 (p ≤ .10) and CRP (p < .01). In the adjusted model, those with a high CRP level were less likely to be in the High-Phys/Mod-Psych class compared to the Low-Phys/Low-Psych (OR: 0.41, 95%CI 0.19, 0.90) and Low-Phys/Mod-Psych classes (OR: 0.35, 95%CI 0.16, 0.78); elevated CRP was associated with in increased odds of being in the High-Phys/High-Psych compared to the High-Phys/Mod-Psych class (OR: 2.22, 95%CI 1.08, 4.58). Younger age, having at least a college education, oxygen use and depression history were more prominent predictors of membership in the higher symptom classes.

Conclusions: Patients with COPD can be classified into four distinct symptom classes based on five commonly co-occurring physical and psychological symptoms. Systemic biomarkers of inflammation were not associated with symptom class. Additional work to test the reliability of these symptom classes, their biological drivers and their validity for prognostication and tailoring therapy in larger and more diverse samples is needed.

Trial Registration: Clinicaltrials.gov, NCT01074515 .
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http://dx.doi.org/10.1186/s12890-016-0330-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5135800PMC
December 2016

Association Between Mental Health Staffing Level and Primary Care-Mental Health Integration Level on Provision of Depression Care in Veteran's Affairs Medical Facilities.

Adm Policy Ment Health 2018 01;45(1):131-141

Health Services Research & Development (HSR&D), Veteran Affairs (VA) Puget Sound Health Care System, 1660 Columbian Way, Seattle, WA, 98108, USA.

We examined the association of mental health staffing and the utilization of primary care/mental health integration (PCMHI) with facility-level variations in adequacy of psychotherapy and antidepressants received by Veterans with new, recurrent, and chronic depression. Greater likelihood of adequate psychotherapy was associated with increased (1) PCMHI utilization by recurrent depression patients (AOR 1.02; 95% CI 1.00, 1.03); and (2) staffing for recurrent (AOR 1.03; 95% CI 1.01, 1.06) and chronic (AOR 1.02; 95% CI 1.00, 1.03) depression patients (p < 0.05). No effects were found for antidepressants. Mental health staffing and PCMHI utilization explained only a small amount of the variance in the adequacy of depression care.
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http://dx.doi.org/10.1007/s10488-016-0775-9DOI Listing
January 2018

A Couples' Based Self-Management Program for Heart Failure: Results of a Feasibility Study.

Front Public Health 2016 29;4:171. Epub 2016 Aug 29.

University of Michigan, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA.

Background: Heart failure (HF) is associated with frequent exacerbations and shortened lifespan. Informal caregivers such as significant others often support self-management in patients with HF. However, existing programs that aim to enhance self-management seldom engage informal caregivers or provide tools that can help alleviate caregiver burden or improve collaboration between patients and their informal caregivers.

Objective: To develop and pilot test a program targeting the needs of self-management support among HF patients as well as their significant others.

Methods: We developed the Dyadic Health Behavior Change model and conducted semi-structured interviews to determine barriers to self-management from various perspectives. Participants' feedback was used to develop a family-centered self-management program called "SUCCEED: Self-management Using Couples' Coping EnhancEment in Diseases." The goals of this program are to improve HF self-management, quality of life, communication within couples, relationship quality, and stress and caregiver burden. We conducted a pilot study with 17 Veterans with HF and their significant others to determine acceptability of the program. We piloted psychosocial surveys at baseline and after participants' program completion to evaluate change in depressive symptoms, caregiver burden, self-management of HF, communication, quality of relationship, relationship mutuality, and quality of life.

Results: Of the 17 couples, 14 completed at least 1 SUCCEED session. Results showed high acceptability for each of SUCCEED's sessions. At baseline, patients reported poor quality of life, clinically significant depressive symptoms, and inadequate self-management of HF. After participating in SUCCEED, patients showed improvements in self-management of HF, communication, and relationship quality, while caregivers reported improvements in depressive symptoms and caregiver burden. Quality of life of both patients and significant others declined over time.

Conclusion: In this small pilot study, we showed positive trends with involving significant others in self-management. SUCCEED has the potential of addressing the growing public health problem of HF among patients who receive care from their significant other.
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http://dx.doi.org/10.3389/fpubh.2016.00171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5004799PMC
September 2016

Estimating pediatric asthma prevalence in rural senegal: A cross-sectional survey.

Pediatr Pulmonol 2017 03 23;52(3):303-309. Epub 2016 Aug 23.

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

Rationale: In Senegal, the prevalence of childhood asthma and utilization of appropriate asthma therapies is unknown.

Methodology: We used the International Study of Asthma and Allergies in Childhood (ISAAC) survey instrument to assess childhood respiratory health in rural Senegal. We interviewed the caregivers of children aged 5 through 8 years of age in the four largest Niakhar villages in August 2012.

Results: We interviewed 1,103 primary caregivers for 1,513 children, representing 91% of all age-eligible children in the study area. Overall, 206 (14%) children had wheeze at any time in the past, 130 (9%) had wheeze within the past year, and only 41 (3%) reported a clinical diagnosis of asthma. Among children with wheeze within the past year, 81 (62%) had symptoms of severe asthma. Nocturnal cough was reported in 186 (14%) children who denied any history of wheezing illness. Only four (3%) children with wheeze in the past year had ever received bronchodilator therapy. Children with wheeze in the past year were significantly more likely to seek medical care for respiratory symptoms and to be perceived as less healthy than their peers. Children of lower socioeconomic status were significantly more likely to have wheeze.

Conclusions: Nearly one in ten children in Niakhar, Senegal had symptoms suggestive of asthma; however, few children have a diagnosis of asthma or use appropriate therapies. This study highlights an opportunity to raise community awareness of asthma in rural Senegal and to increase access to appropriate medical therapies. Pediatr Pulmonol. 2017;52:303-309. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/ppul.23545DOI Listing
March 2017

Overuse of short-acting beta-agonist bronchodilators in COPD during periods of clinical stability.

Respir Med 2016 07 12;116:100-6. Epub 2016 May 12.

Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, CO, USA.

Background: Overuse of short-acting beta-agonists (SABA) is described in asthma, but little is known about overuse of SABA in chronic obstructive pulmonary disease (COPD).

Methods: Prospective 3-month cohort study of patients with moderate-to-severe COPD who were provided a portable electronic inhaler sensor to monitor daily SABA use. Subjects wore a pedometer for 3 seven-day periods and were asked to complete a daily diary of symptoms and inhaler use. Overuse was defined as >8 actuations of their SABA per day while clinically stable.

Results: Among 32 participants, 15 overused their SABA inhaler at least once (mean 8.6 ± 5.0 puffs/day), and 6 overused their inhaler more than 50% of monitored days. Compared to those with no overuse, overusers had greater dyspnea (modified Medical Research Council Dyspnea Scale: 2.7 vs. 1.9, p = 0.02), were more likely to use home oxygen (67% vs. 29%, p = 0.04), and were more likely to be on maximal inhaled therapy (long-acting beta-agonist, long-acting antimuscarinic agent, and an inhaled steroid: 40% vs. 6%, p = 0.03), and most had completed pulmonary rehabilitation (67% vs. 0%, p < 0.001). However, 27% of overusers of SABA were not on guideline-concordant COPD therapy.

Conclusions: Overuse of SABA was common and associated with increased disease severity and symptoms, even though overusers were on more COPD-related inhalers and more had completed pulmonary rehabilitation. More research is needed to understand factors associated with inhaler overuse and how to improve correct inhaler use.
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http://dx.doi.org/10.1016/j.rmed.2016.05.011DOI Listing
July 2016