Using an asthma control questionnaire and administrative data to predict health-care utilization

OBJECTIVE: To examine the merits of the Asthma Therapy Assessment Questionnaire (ATAQ) control index together with prior asthma health-care utilization from administrative data in predicting future acute asthma health-care utilization. DESIGN: Prospective cohort study. POPULATION: A total of 4,788 adult asthma patients aged 17 to 93 years who completed a baseline evaluation and had at least 6 months of follow-up data. STATISTICAL METHODS: Classification and regression tree methodology to predict future risk of acute health-care utilization events. RESULTS: These results show that the ATAQ control index and administrative data are jointly useful for predicting future health-care utilization. The utility of the ATAQ control index in the presence of information about prior health-care utilization is to further stratify risk among the subset of younger individuals who did not have any prior acute health-care utilization. While administrative health-care utilization data served as the strongest predictor of future health-care utilization, the ATAQ control index helped to identify 1% of individuals without recent acute care that had approximately a sixfold elevated risk (95% confidence interval, 4.2 to 8.4) of future acute health-care utilization. This is an important result since only a small fraction of individuals with acute events in a given year will have had acute events in the previous year. CONCLUSION: These findings should assist the practicing clinician and organizations interested in population-based asthma disease management.     

Estimating asthma control questionnaire (ACQ) scores from claims data

Background: Asthma control is the main focus of treatment guidelines. Valid instruments such as the Asthma Control Questionnaire (ACQ) require prospective survey. These surveys may be challenging for large population health applications. Objective: To develop an algorithm for estimating ACQ-5 scores from commonly available claims data. Methods: Data was derived from four prospective surveys including the ACQ-5 combined with retrospective claims of Kaiser Permanente of Colorado (KPCO) patients. The statistical approach consisted of derivation and validation of a prediction algorithm including medical and pharmacy claims data using stepwise regression elimination. Validation was conducted by estimating mean squared error (MSE) and mean absolute error (MAE) in one hundred split-sample iterations. Ordinary least squares (OLS), Tobit and Median regression were used. Results: There were 2,657 individuals with valid ACQ-5 scores, claims and eligibility at baseline. The following had statistically significant associations with ACQ-5 scores: gender, use of oral corticosteroids and short-acting beta agonists, the number of asthma drug classes, and emergency and outpatient visits. Average MSE and MAE were similar for the estimation and validation samples. Conclusion: This research provides preliminary results of the feasibility of predicting ACQ-5 scores using commonly available medical and pharmacy claims data. The resulting algorithm may facilitate public health and population level analyses of asthma control. Future studies in different populations will be important to validate the algorithm.     

Double-blind comparison of tiapamil and atenolol in patients with mild to moderate hypertension: A multicenter trial

Summary The efficacy and safety of tiapamil, a new calcium-channel blocker, was compared with the cardio-selective beta-blocker atenolol in a 16-week double-blind, multicenter trial with an initial 4-week placebo run-in period. Eighty-one outpatients with WHO stage I or II hypertension, 55 men and 26 women, entered the study. There was a total of nine drop-outs, six in the tiapamil group and three in the atenolol group. Five were due to side effects (four in the tiapamil group and one in the atenolol group). Sixty-one patients performed a graded exercise test sitting on a ergometer bicycle before and after completion of the therapy.Patients eligible for the study after the placebo period received either tiapamil 450 mg b.i.d. or atenolol 100 mg daily. Both drugs lowered systolic and diastolic blood pressure significantly. After 12 weeks of therapy, supine blood pressure in the tiapamil group fell from 167/104 mmHg to 154/91 mmHg (p<0.005), and in the atenolol group from 166/102 mmHg to 151/89 mmHg (p<0.005). A satisfactory reduction in diastolic blood pressure, defined as a reduction of more than 10 mmHg and/or values below or equal to 90 mmHg at the end of the study, was achieved in 29 of 35 patients in the tiapamil group and in 27 of 37 in the atenolol group. No changes in heart rate were observed in the tiapamil group, whereas there was a significant fall in heart rate in the atenolol group. The maximal exercise workload tolerated increased equally in both groups, from 135 to 147 watts. No changes in laboratory parameters were observed.Tiapamil seems to be an effective and safe drug in the treatment of mild to moderate hypertension and in this respect is comparable to atenolol.     

Effects of bisoprolol on left ventricular hypertrophy in essential hypertension

Summary Previous studies have shown that beta-adrenergic blocking drugs can reverse ventricular hypertrophy in patients with systemic hypertension. Thirty patients with essential hypertension and left ventricular hypertrophy were studied at baseline after withdrawing all previous treatments and after 6 months of treatment with 5–20 mg of bisoprolol, a new beta-selective agent, to assess its possible action on left ventricular mass. Three patients did not finish the study. Blood pressure was reduced to below 160/90 mmHg in 22 of the remaining 27 patients. At the end of follow-up, the left ventricular mass (echocardiography) was reduced from 308.1±89 g to 262.3±51 g (p<0.001) and left ventricular mass index from 165±47.4 g/m² to 141.03±26.7 g/m² (p<0.001). The ratio of E wave/A wave velocity of transmitral blood flow measured by Doppler increased from 0.86±0.44 to 1.07±0.45 (p=0.005). Peak filling rate, derived from nuclear ventriculography, changed from 2.05±0.4 EDV/sec before the treatment to 2.23±0.47 EDV/sec after it (p=0.0046). Serum lipids as well as other biochemical tests were unchanged. Left ventricular volumes and ejection fraction did not change, and treadmill exercise time increased from 343±125 seconds to 420±135 seconds (p=0.002). Maximal systolic blood pressure during exercise decreased from 197.2±19.7 mmHg to 182.9±25.8 mmHg (p=0.011). There were few side effects. We conclude that bisoprolol reduces left ventricular mass, preserves systolic function, and improves diastolic function of the left ventricle in hypertensive subjects with left ventricular hypertrophy.     

Association of birth weight with asthma-related outcomes at age 2 years

BACKGROUND: Although lower birth weight associated with prematurity raises the risk of asthma in childhood, few prospective studies have examined higher birth weight, and few have separated the two components of birth weight, fetal growth and length of gestation. OBJECTIVE: To examine the associations of fetal growth and length of gestation with asthma-related outcomes by age 2 years. METHODS: We studied 1,372 infants and toddlers born after 34 weeks' gestation in Project Viva, a prospective cohort study of pregnant mothers and their children. The main outcome measures were parent report of (1) any wheezing (or whistling in the chest) from birth to age 2 years, (2) recurrent wheezing during the first 2 years of life, and (3) doctor's diagnosis of asthma, wheeze or reactive airway disease ("asthma") by age 2. We calculated gestational age from the last menstrual period or ultrasound examination, and determined birth weight for gestational age z-value ("fetal growth") using US national reference data. RESULTS: Infants' mean birth weight was 3,527 (SD, 517; range, 1,559-5,528) grams. By age 2 years, 34% of children had any wheezing, 14% had recurrent wheezing, and 16% had doctor-diagnosed asthma. After adjusting for several parent, child, and household characteristics in logistic regression models, we found that infants with birth weight > or = 4,000 g were not more likely to have any wheezing (odds ratio (OR), 0.91; 95% confidence interval (CI): 0.62, 1.34) or doctor-diagnosed asthma (OR, 0.80; 95% CI: 0.49, 1.31) than infants with birth weight 3,500-3,999 g. In models examining length of gestation and fetal growth separately, neither the highest nor the lowest groups of either predictor were associated with the three outcomes. Boys had a higher incidence of asthma-related outcomes than girls, and exposure to passive smoking, parental history of asthma, and exposure to older siblings were all associated with greater risk of recurrent wheeze or asthma-related outcomes at age 2 years. CONCLUSION: Although male sex, exposure to smoking, parental history of asthma, and exposure to older siblings were associated with increased risk of wheezing and asthma-related outcomes in this prospective study of children born after 34 weeks gestation, fetal growth and length of gestation were not.     

HVPG measurement: is it mandatory for the management of portal hypertension?—Con

Abstract   Complications of portal hypertension are common in the cirrhotic, and bleeding varices are a significant cause of morbidity and mortality in this population. We currently can identify the patients at greatest risk for bleeding by the endoscopic appearance of the varices and we know that once a patient bleeds, rebleeding is almost inevitable. Thus, both groups of patients are targets for preventative therapy. Currently, non-selective beta-blockers are used to reduce the risk of bleeding in both types of patients but many patients fail this form of therapy and bleed or rebleed. Recent studies have shown that patients who fail to have a hemodynamic response to beta blocker therapy are most likely to fail therapy and it has been suggested that measurement of the hepatic vein pressure gradient (HVPG) be used in the routine management of this group of patients. Unfortunately, there are many unresolved issues as to the utility of the hemodynamic response in the management of cirrhotics. Outside of academic medical centers, the ability to measure pressures accurately is limited and thus significant training would be required before the test can have widespread acceptance. More importantly, it has not been shown in prospective randomized trials that using the hemodynamic response to define the therapeutic approach is any better than the current approach of giving everyone beta-blockers and using variceal band ligation in those who bleed or rebleed. Pending the completion and publishing of these types of controlled trials, measurement of the HVPG will remain of academic interest only.     

Transition to Managed Care Impacts Health Care Service Utilization by Children Insured by Medicaid

Purpose. To evaluate the impact of transition to managed care from fee for service on asthma service utilization among Maryland Medicaid insured children. Methods. Healthcare claims from 1997–2000 for children with asthma insured by Maryland Medicaid were extracted and analyzed. Results. Between 1997–2000, inhaled corticosteroid use increased as a proportion of all asthma medications. Outpatient asthma visits increased from 4.2% to 5.9% of all outpatient claims as both asthma-related hospitalizations and emergency department visits decreased. Conclusions. Restructuring of Maryland Medicaid for children from fee for service to managed care was associated with improvement in asthma-related healthcare utilization claims.     

Use of beta-blockers in obesity hypertension: potential role of weight gain

Beta‐blockers are the most frequently used drugs for the treatment of hypertension. Apart from concerns regarding potential adverse metabolic effects on lipids or insulin sensitivity, beta‐blockers can also cause weight gain in some patients. This fact appears little known to clinical practitioners and trialists. Thus, only a minority of clinical trials with beta‐blockers report weight changes during treatment. In trials that do report weight changes, beta‐blockers are associated with a weight gain of 1.2 (range ?0.4–3.5) kg. This may be attributable to the fact that beta blockade can decrease metabolic rate by 10%. Beta‐blockers may also have other negative effects on energy metabolism. Obesity management in overweight hypertensive patients may therefore be more difficult in the presence of beta‐blocker treatment. We therefore question the use of beta‐blockers as first‐line therapy for overweight or obese patients with uncomplicated hypertension.     

非选择性beta受体阻滞剂治疗肝硬化门脉高压症患者研究进展*

目的 肝硬化是各种慢性肝病进展后的病理学阶段,失代偿期常以肝功能减退和门脉高压症为主要临床表现。非选择性β受体阻滞剂(NSBB)可有效降低门脉压力,是近30年来治疗肝硬化门脉高压症的主要方法之一。然而,NSBB改变血流动力学的作用常对患者的循环功能造成影响,是否应用NSBB及其用法用量需因人而异。本文综述了肝硬化患者合理应用NSBB及其争议问题的讨论。     

Transition to Managed Care Impacts Health Care Service Utilization by Children Insured by Medicaid

Purpose. To evaluate the impact of transition to managed care from fee for service on asthma service utilization among Maryland Medicaid insured children. Methods. Healthcare claims from 1997-2000 for children with asthma insured by Maryland Medicaid were extracted and analyzed. Results. Between 1997-2000, inhaled corticosteroid use increased as a proportion of all asthma medications. Outpatient asthma visits increased from 4.2% to 5.9% of all outpatient claims as both asthma-related hospitalizations and emergency department visits decreased. Conclusions. Restructuring of Maryland Medicaid for children from fee for service to managed care was associated with improvement in asthma-related healthcare utilization claims.     

The association of comorbid anxiety and depression with asthma-related quality of life and symptom perception in adults

Background and objective:   There are limited data on the association and interaction between anxiety and depression comorbidity and asthma-related quality of life (AQOL) and symptom perception. This study evaluated these associations in patients subsequent to an emergency department (ED) visit for asthma.
Methods:   This was a cross-sectional study of 110 (38 male) adult asthma patients (mean age 42 years), who had visited an ED in the previous 18 months. Participants completed the hospital anxiety and depression scale, measures of AQOL and the asthma symptom checklist.
Results:   Depression symptoms independently showed a significant negative association with AQOL after controlling for depression/anxiety, age, gender, smoking status and ED visits in the previous 12 months (ED-12). Overall, anxiety and depression symptoms accounted for 28.3% of the variance in AQOL. Greater anxiety was associated with increased perception of asthma-specific panic-fear and hyperventilation symptoms during an asthma attack, irrespective of depression status. Categorical analyses of groups of patients, differentiated by psychometric properties on the hospital anxiety and depression scale (anxiety vs normal, anxiety and depression vs normal depression) confirmed most results. However, for the anxiety group there was a significant association with the AQOL domains of emotional functioning and response to environmental stimuli, after controlling for depression symptoms.
Conclusions:   The negative association of depression symptom scores with AQOL and of anxiety with increased panic-fear and hyperventilation symptoms suggests a potential role for interventions addressing this psychological comorbidity, in order to improve AQOL.     

The Veterans Short Form 36 questionnaire is predictive of mortality and health-care utilization in a population of veterans with a self-reported diagnosis of asthma or COPD

STUDY OBJECTIVE: Measures of health-related quality of life (HRQL) correlate with disease stage in persons with COPD. However, as their predictive capacity for mortality or medical utilization is less well defined, we sought to examine the relationship of a general measure of HRQL and outcomes in persons with obstructive lung disease. DESIGN: Prospective cohort study. SETTING: Upper Midwest Veterans Integrated Service Network (VISN)-13. PARTICIPANTS: All veterans in VISN-13 (n = 70,017) were surveyed with the Veterans Short Form 36 (SF-36V). Persons with reported asthma or COPD who completed the SF-36V formed the study cohort (n = 8,354). MEASUREMENTS AND RESULTS: For purposes of analysis, individuals were divided into quartiles of HRQL according to their physical component summary (PCS) and mental component summary (MCS), values derived from the SF-36V. Outcomes of mortality, hospitalization, and outpatient visits were recorded for 12 months after the survey. Outpatient utilization was dichotomized into high vs low use, with high use being defined as the upper quartile of visits in the 12 months prior to survey mailing. The study cohort had a mean age of 65 years and was largely male (95%), both consistent with a veteran population. After correcting for potential confounding factors through multivariable regression, the PCS was independently predictive of death, hospitalization, and high outpatient utilization. When using the first quartile of PCS as the reference population, those in the fourth quartile of PCS had a hazard ratio for death of 5.47 (95% confidence interval [CI], 3.63 to 8.26). Similarly, the odds ratios for hospitalization, high primary care visits, and high specialty medicine visits in the fourth quartile of PCS were 1.82 (95% CI, 1.51 to 2.19), 1.54 (95% CI, 1.26 to 1.87), and 1.46 (95% CI, 1.21 to 1.78), respectively. The MCS, through multivariable regression, was predictive of death but unassociated with subsequent hospitalization or high outpatient utilization. CONCLUSION: HRQL, as assessed by the SF-36V, is an independent predictor of mortality, hospitalization, and outpatient utilization in persons with self-reported obstructive lung disease.     

New Information on the Role of Beta-Blockers in Cardiac Therapy

Summary. Hypertension and ischemic heart disease are important precursors of heart failure. The prevention of progression to heart failure is a prime objective when treating patients with hypertension or ischemic heart disease. In patients with hypertension, treatment with either diuretics or beta-blockers reduces the risk of chronic heart failure. In patients with ischemic heart disease, beta-blocker therapy reduces the risk of recurrent myocardial infarction and ensuing cardiac dysfunction. The beneficial effects of beta-blocker therapy may be greater in post-infarction patients who have impaired left ventricular function than in those patients without such impairment.When considering heart failure itself, the efficacy of angiotensin-converting enzyme (ACE) inhibitors has been demonstrated in patients with mild-to-severe left ventricular dysfunction and their use is indicated for all stages of heart failure to reduce symptoms and retard further impairment of left ventricular function. Diuretics and digitalis offer relief from the symptoms of the disease, while positive inotropes are reserved for parenteral administration in end-stage heart failure, as a bridge to transplantation, or in acute exacerbations of the disease. Added to standard therapy, beta-blockade is of value in the treatment of heart failure, preventing further deterioration and improving hemodynamics, exercise tolerance, quality of life, and long-term prognosis.     

Prevalence and Clinical Profile of Resistant Hypertension among Treated Hypertensive Subjects

We assessed prevalence and clinical characteristics of resistant hypertension (RH) and prevalence of false RH (white-coat effect [WCE] by home blood pressure [BP] monitoring), among a population of 302 treated hypertensive patients, mean age 66.6 (±13.8), 67.5% women. Resistant hypertension was defined according to the American Heart Association criteria. Prevalence of RH was 10%, and the following five variables were independently associated with it: body mass index, diabetes, isolated systolic hypertension, orthostatic hypotension, and use of beta-blockers. Prevalence of WCE among subjects with office-RH was 27.6%. Our study identified easily measurable parameters related to RH. Standing BP should be systematically measured in individuals with RH.     

Improving Pediatric Asthma Control Among Minority Children Participating in Medicaid: Providing Practice Redesign Support to Deliver a Chronic Care Model

Background. Asthma, a leading chronic disease of children, currently affects about 6.2 million (8.5%) children in the United States. Despite advances in asthma research and availability of increasingly effective therapy, many children do not receive appropriate medications to control the disease, have overreliance on reliever medication, and lack systematic follow-up care. The situation is even worse for poor inner-city and minority children who have significantly worse asthma rates, severity, and outcomes. National Asthma Education and Prevention Program Guidelines recommend a multimodal, chronic care approach. Objective. The authors assessed the effectiveness of practice redesign and computerized provider feedback in improving both practitioner adherence to National Asthma Education and Prevention Program Guidelines (NAEPP), and patient outcomes in 295 poor minority children across four Federally Qualified Health Centers (FQHC). Methods. In a nonrandomized, two-group (intervention versus comparison), two-phase trial, all sites were provided redesign support to provide quarterly well-asthma visits using structured visit forms, community health workers for outreach and follow-up, a Web-based disease registry for tracking and scheduling, and a provider education package. Intervention sites were given an additional Web-based, computerized patient-specific provider feedback system that produced a guideline-driven medication assessment prompt. Results. Logistic regression results showed that providers at intervention sites were more than twice as likely on average to prescribe guideline-appropriate medications after exposure to our feedback system during the Phase I enrollment period than providers at comparison sites (exp(B) = 2.351, confidence interval [CI] = 1.315–4.204). In Phase II (the postenrollment visit period), hierarchical linear models (HLMs) and latent growth curves were used to show that asthma control improved significantly by .19 (SE = .05) on average for each of the remaining four visits (about 11% of a standard deviation), and improved even more for patients at intervention sites. These results show that implementation of practice redesign support guided by a pediatric chronic care model can improve provider adherence to treatment guidelines as well as patients’ asthma control. Conclusions. The addition of patient-specific feedback for providers results in quicker adoption of guideline recommendations and potentially greater improvements in asthma control compared to the basic practice redesign support alone.