المؤلفون: Spece, Laura J, Epler, Eric M, Duan, Kevin, Donovan, Lucas M, Griffith, Matthew F, LaBedz, Stephanie, Thakur, Neeta, Wiener, Renda Soylemez, Krishnan, Jerry A, Au, David H, Feemster, Laura C

المصدر: Annals of the American Thoracic Society. 18(3)

مصطلحات موضوعية: Humans, Pulmonary Disease, Chronic Obstructive, Oxygen, Hospitalization, Cohort Studies, Aged, Medicare, United States, Prescriptions, COPD, care quality, oxygen, Lung, Clinical Trials and Supportive Activities, Chronic Obstructive Pulmonary Disease, Clinical Research, Respiratory

الوصف: Rationale: Hypoxemia associated with acute exacerbations of chronic obstructive pulmonary disease (COPD) often resolves with time. Current guidelines recommend that patients recently discharged with supplemental home oxygen after hospitalization should not have renewal of the prescription without assessment for hypoxemia. Understanding patterns of home oxygen reassessment is an opportunity to improve quality and value in home oxygen prescribing and may provide future targets for deimplementation.Objectives: We sought to measure the frequency of home oxygen reassessment within 90 days of hospitalization for COPD and determine the potential population eligible for deimplementation.Methods: We performed a cohort study of patients ≥40 years hospitalized for COPD at five Veterans Affairs facilities who were prescribed home oxygen at discharge. Our primary outcome was the frequency of reassessment within 90 days by oxygen saturation (SpO2) measurement. Secondary outcomes included the proportion of patients potentially eligible for discontinuation (SpO2 > 88%) and patients in whom oxygen was discontinued. Our primary exposures were treatment with long-acting bronchodilators, prior history of COPD exacerbation, smoking status, and pulmonary hypertension. We used a mixed-effects Poisson model to measure the association between patient-level variables and our outcome, clustered by site. We also performed a positive deviant analysis using chart review to uncover system processes associated with high-quality oxygen prescribing.Results: A total of 287 of 659 (43.6%; range 24.8-78.5% by site) patients had complete reassessment within 90 days. None of our patient-level exposures were associated with oxygen reassessment. Nearly half of those with complete reassessment were eligible for discontinuation on the basis of Medicare guidelines (43.2%; n = 124/287). When using the newest evidence available by the Long-Term Oxygen Treatment Trial, most of the cohort did not have resting hypoxemia (84.3%; 393/466) and would be eligible for discontinuation. The highest-performing Veterans Affairs facility had four care processes to support oxygen reassessment and discontinuation, versus zero to one at all other sites.Conclusions: Fewer than half of patients prescribed home oxygen after a COPD exacerbation are reassessed within 90 days. New system processes supporting timely reassessment and discontinuation of unnecessary home oxygen therapy could improve the quality and value of care.

وصف الملف: application/pdf

الوصول الحر: https://escholarship.org/uc/item/9bh887wwTest

المؤلفون: Keller, Thomas, Spece, Laura J, Donovan, Lucas M, Udris, Edmunds, Coggeshall, Scott S, Griffith, Matthew, Bryant, Alexander D, Casaburi, Richard, Cooper, J Allen, Criner, Gerard J, Diaz, Philip T, Fuhlbrigge, Anne L, Gay, Steven E, Kanner, Richard E, Martinez, Fernando J, Panos, Ralph J, Shade, David, Sternberg, Alice, Stibolt, Thomas, Stoller, James K, Tonascia, James, Wise, Robert, Yusen, Roger D, Au, David H, Feemster, Laura C

المصدر: CHEST Journal. 158(2)

مصطلحات موضوعية: Biomedical and Clinical Sciences, Clinical Sciences, Patient Safety, Comparative Effectiveness Research, Lung, Chronic Obstructive Pulmonary Disease, Clinical Trials and Supportive Activities, Clinical Research, Respiratory, Good Health and Well Being, Administration, Inhalation, Adrenal Cortex Hormones, Adrenergic beta-2 Receptor Agonists, Aged, Drug Therapy, Combination, Female, Humans, Male, Middle Aged, Muscarinic Antagonists, Nebulizers and Vaporizers, Oxygen Inhalation Therapy, Practice Guidelines as Topic, Pulmonary Disease, Chronic Obstructive, Quality of Life, COPD, guidelines, inhaled corticosteroids, pharmacotherapy, Respiratory System, Cardiovascular medicine and haematology, Clinical sciences

الوصف: BackgroundAlthough inhaled therapy reduces exacerbations among patients with COPD, the effectiveness of providing inhaled treatment per risk stratification models remains unclear.Research questionAre inhaled regimens that align with the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy associated with clinically important outcomes?Study design and methodsWe conducted secondary analyses of Long-term Oxygen Treatment Trial (LOTT) data. The trial enrolled patients with COPD with moderate resting or exertional hypoxemia between 2009 and 2015. Our exposure was the patient-reported inhaled regimen at enrollment, categorized as either aligning with, undertreating, or potentially overtreating per the 2017 GOLD strategy. Our primary composite outcome was time to death or first hospitalization for COPD. Additional outcomes included individual components of the composite outcome and time to first exacerbation. We generated multivariable Cox proportional hazard models across strata of GOLD-predicted exacerbation risk (high vs low) to estimate between-group hazard ratios for time to event outcomes. We adjusted models a priori for potential confounders, clustered by site.ResultsThe trial enrolled 738 patients (73.4% men; mean age, 68.8 years). Of the patients, 571 (77.4%) were low risk for future exacerbations. Of the patients, 233 (31.6%) reported regimens aligning with GOLD recommendations; most regimens (54.1%) potentially overtreated. During a 2.3-year median follow-up, 332 patients (44.9%) experienced the composite outcome. We found no difference in time to composite outcome or death among patients reporting regimens aligning with recommendations compared with undertreated patients. Among patients at low risk, potential overtreatment was associated with higher exacerbation risk (hazard ratio, 1.42; 95% CI, 1.09-1.87), whereas inhaled corticosteroid treatment was associated with 64% higher risk of pneumonia (incidence rate ratio, 1.64; 95% CI, 1.01-2.66).InterpretationAmong patients with COPD with moderate hypoxemia, we found no difference in clinical outcomes between inhaled regimens aligning with the 2017 GOLD strategy compared with those that were undertreated. These findings suggest the need to reevaluate the effectiveness of risk stratification model-based inhaled treatment strategies.

وصف الملف: application/pdf

الوصول الحر: https://escholarship.org/uc/item/6mk655vpTest

المؤلفون: Hayes, Sophia, Duan, Kevin I., Wai, Travis Hee, Picazo, Fernando, Donovan, Lucas M., Spece, Laura J., Plumley, Robert, Slatore, Christopher G., Thakur, Neeta, Crothers, Kristina, Au, David H., Feemster, Laura C.

المصدر: Annals of the American Thoracic Society; Apr2024, Vol. 21 Issue 4, p669-672, 4p

مصطلحات موضوعية: CHRONIC obstructive pulmonary disease, DISEASE prevalence, ETHNICITY, NEIGHBORHOODS

المؤلفون: Castaneda, Jason M., Wai, Travis Hee, Spece, Laura J., Duan, Kevin I., Leonhard, Aristotle, Griffith, Matthew F., Plumley, Robert, Palen, Brian N., Feemster, Laura C., Au, David H., Donovan, Lucas M.

المصدر: Annals of the American Thoracic Society; Jan2024, Vol. 21 Issue 1, pE1-E8, 8p

مصطلحات موضوعية: CHRONIC obstructive pulmonary disease, FLUTICASONE, ADRENERGIC beta agonists, ZOLPIDEM, INTERNATIONAL Statistical Classification of Diseases & Related Health Problems

المؤلفون: Donovan, Lucas M., Wai, Travis, Spece, Laura J., Duan, Kevin I., Griffith, Matthew F., Leonhard, Aristotle, Plumley, Robert, Hayes, Sophia A., Picazo, Fernando, Crothers, Kristina, Kapur, Vishesh K., Palen, Brian N., Au, David H., Feemster, Laura C.

المصدر: Annals of the American Thoracic Society; Nov2023, Vol. 20 Issue 11, p1642-1653, 12p

مصطلحات موضوعية: CHRONIC obstructive pulmonary disease, DROWSINESS, SLEEP apnea syndromes, SLEEP, PULMONARY function tests, INFLUENZA vaccines

مستخلص: Rationale: Many advocate the application of propensity- matching methods to real-world data to answer key questions around obstructive sleep apnea (OSA) management. One such question is whether identifying undiagnosed OSA impacts mortality in high-risk populations, such as those with chronic obstructive pulmonary disease (COPD). Objectives: Assess the association of sleep testing with mortality among patients with COPD and a high likelihood of undiagnosed OSA. Methods: We identified patients with COPD and a high likelihood of undiagnosed OSA. We then distinguished those receiving sleep testing within 90 days of index COPD encounters. We calculated propensity scores for testing based on 37 variables and compared long-term mortality in matched groups. In sensitivity analyses, we compared mortality using inverse propensity weighting and instrumental variable methods. We also compared the incidence of nonfatal events including adverse outcomes (hospitalizations and COPD exacerbations) and routine services that are regularly indicated in COPD (influenza vaccination and pulmonary function testing). We compared the incidence of each nonfatal event as a composite outcome with death and separately compared the marginal probability of each nonfatal event independently, with death as a competing risk. Results: Among 135,958 patients, 1,957 (1.4%) received sleep testing. We propensity matched all patients with sleep testing to an equal number without testing, achieving excellent balance on observed confounders, with standardized differences < 0.10. We observed lower mortality risk among patients with sleep testing (incidence rate ratio, 0.88; 95% confidence interval [CI], 0.79-0.99) and similar results using inverse propensity weighting and instrumental variable methods. Contrary to mortality, we found that sleep testing was associated with a similar or greater risk for nonfatal adverse events, including inpatient COPD exacerbations (subhazard ratio, 1.29; 95% CI, 1.02-1.62) and routine services like influenza vaccination (subhazard ratio, 1.26; 95% CI, 1.17-1.36). Conclusions: Our disparate findings can be interpreted in multiple ways. Sleep testing may indeed cause both reduced mortality and greater incidence of nonfatal adverse outcomes and routine services. However, it is also possible that our findings stem from residual confounding by patients' likelihood of accessing care. Given the limitations of propensity-based analyses, we cannot confidently distinguish these two possibilities. This uncertainty highlights the limitations of using propensity-based analyses to guide patient care and policy decisions. [ABSTRACT FROM AUTHOR]

: Copyright of Annals of the American Thoracic Society is the property of American Thoracic Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

المؤلفون: Griffith, Matthew F., Feemster, Laura C., Zeliadt, Steven B., Donovan, Lucas M., Spece, Laura J., Udris, Edmunds M., Au, David H.

المصدر: Journal of General Internal Medicine ; volume 35, issue 3, page 679-686 ; ISSN 0884-8734 1525-1497

مصطلحات موضوعية: Internal Medicine

الإتاحة: https://doi.org/10.1007/s11606-019-05461-1Test

المؤلفون: Donovan, Lucas M, Fernandes, Laurie A, Williams, Katherine M, Parsons, Elizabeth C, O'Hearn, Daniel J, He, Ken, McCall, Catherine A, Spece, Laura J, Feemster, Laura C, Kirsh, Susan, Au, David H, Palen, Brian N

المصدر: Sleep ; volume 42, issue Supplement_1, page A398-A398 ; ISSN 0161-8105 1550-9109

مصطلحات موضوعية: Physiology (medical), Neurology (clinical)

الإتاحة: https://doi.org/10.1093/sleep/zsz067.986Test
http://academic.oup.com/sleep/article-pdf/42/Supplement_1/A398/28384880/zsz067.986.pdfTest

المؤلفون: Duan, Kevin I., Donovan, Lucas M., Spece, Laura J., Feemster, Laura C., Bryant, Alexander D., Plumley, Robert, Collins, Margaret P., Au, David H.

المصدر: Annals of the American Thoracic Society; May2023, Vol. 20 Issue 5, p668-676, 15p

مستخلص: Rationale: Guidelines recommend inhaled corticosteroids (ICS) for patients with chronic obstructive pulmonary disease (COPD) and select indications, including asthma history, high exacerbation risk, or high serum eosinophils. ICS are commonly prescribed outside of these indications, despite evidence of harm. We defined a "low-value" ICS prescription as the receipt of an ICS without evidence of a guideline-recommended indication. ICS prescription patterns are not well characterized and could inform health system interventions to reduce low-value practices. Objectives: To evaluate the national trends in initial low-value ICS prescriptions in the U.S. Department of Veterans Affairs and to determine whether rural-urban differences in low-value ICS prescribing exist. Methods: We performed a cross-sectional study between January 4, 2010, and December 31, 2018, identifying veterans with COPD who were new users of inhaler therapy. We defined low-value ICS as prescriptions in patients with 1) no asthma, 2) low risk of future exacerbation (Global Initiative for Chronic Obstructive Lung Disease group A or B), and 3) serum eosinophils ,300 cells/µl. We performed multivariable logistic regression to evaluate trends in low-value ICS prescription over time, adjusting for potential confounders. We performed fixed effects logistic regression to assess rural-urban prescribing patterns. Results: We identified a total of 131,009 veterans with COPD starting inhaler therapy, 57,472 (44%) of whom were prescribed low-value ICS as initial therapy. From 2010 to 2018, the probability of receiving low-value ICS as initial therapy increased by 0.42 percentage points per year (95% confidence interval, 0.31-0.53). Compared with urban residence, rural residence was associated with a 2.5-percentage-point (95% confidence interval, 1.9-3.1) higher probability of receiving low-value ICS as initial therapy. Conclusions: The prescription of low-value ICS as initial therapy is common and increasing slightly over time for both rural and urban veterans. Given the widespread and persistent nature of low-value ICS prescribing, health system leaders should consider system-wide approaches to address this low-value prescribing practice. [ABSTRACT FROM AUTHOR]

: Copyright of Annals of the American Thoracic Society is the property of American Thoracic Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

المؤلفون: Spece, Laura J., Mitchell, Kristina H., Caldwell, Ellen S., Gundel, Stephanie J., Jolley, Sarah E., Hough, Catherine L.

المصدر: Journal of Critical Care ; volume 44, page 72-76 ; ISSN 0883-9441

مصطلحات موضوعية: Critical Care and Intensive Care Medicine

الإتاحة: https://doi.org/10.1016Test/j.jcrc.2017.10.021
https://api.elsevier.com/content/article/PII:S0883944117303623?httpAccept=text/xmlTest
https://api.elsevier.com/content/article/PII:S0883944117303623?httpAccept=text/plainTest

المؤلفون: Donovan, Lucas M., Parsons, Elizabeth C., McCall, Catherine A., He, Ken, Sharma, Rahul, Gamache, Justina, Pannick, Anna P., McDowell, Jennifer A., Pai, James, Epler, Eric, Duan, Kevin I., Spece, Laura J., Feemster, Laura C., Kapur, Vishesh K., Au, David H., Palen, Brian N.

المصدر: Sleep & Breathing; Mar2023, Vol. 27 Issue 1, p303-308, 6p

مستخلص: Purpose: In-person visits with a trained therapist have been standard care for patients initiating continuous positive airway pressure (CPAP). These visits provide an opportunity for hands-on training and an in-person assessment of mask fit. However, to improve access, many health systems are shifting to remote CPAP initiation with equipment mailed to patients. While there are potential benefits of a mailed approach, relative patient outcomes are unclear. Specifically, many have concerns that a lack of in-person training may contribute to reduced CPAP adherence. To inform this knowledge gap, we aimed to compare treatment usage after in-person or mailed CPAP initiation. Methods: Our medical center shifted from in-person to mailed CPAP dispensation in March 2020 during the COVID-19 pandemic. We assembled a cohort of patients with newly diagnosed obstructive sleep apnea (OSA) who initiated CPAP in the months before (n = 433) and after (n = 186) this shift. We compared 90-day adherence between groups. Results: Mean nightly PAP usage was modest in both groups (in-person 145.2, mailed 140.6 min/night). We did not detect between-group differences in either unadjusted or adjusted analyses (adjusted difference − 0.2 min/night, 95% − 27.0 to + 26.5). Conclusions: Mail-based systems of CPAP initiation may be able to improve access without reducing CPAP usage. Future work should consider the impact of mailed CPAP on patient-reported outcomes and the impact of different remote setup strategies. [ABSTRACT FROM AUTHOR]

: Copyright of Sleep & Breathing is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)