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Among Medicare patients with chronic obstructive pulmonary disease (COPD), those who had at least one exacerbation and had a COPD-related hospitalization were most likely to receive nebulized arformoterol, according to study to identify predictors of its use. In addition to being sicker, being treated by a pulmonologist rather than a primary care physician and being white were factors that increased a patient’s likelihood of receiving nebulized arformoterol.

designer491/Thinkstock

Patients less likely to receive the nebulized version of this long-acting beta2 adrenoreceptor agonist (LABA) were African Americans, patients with psychiatric comorbidities, and patients eligible for both Medicare and Medicaid.

“Studies have shown that 40% to 71% of Medicare beneficiaries receive no maintenance treatment for COPD. Although a recent longitudinal study on Medicare populations reported that use of maintenance medications has been improving, in general, it is recognized that Medicare beneficiaries with COPD remain undertreated,” Todd P. Gilmer, PhD, from the department of family medicine and public health at the University of California, San Diego, and colleagues wrote.

The investigators identified patients with COPD using Medicare administrative data; of these patients, 11,887 were arformoterol users, and 450,178 were control patients who did not use arformoterol. Patients were included in the study if they had at least one claim for COPD medication and were continuously enrolled in Medicare Parts A, B, and D. The cohort consisted of mostly white women aged 70 years or older, and 47% were dual-eligible to receive both Medicare and Medicaid benefits. A subgroup of 1,778 arformoterol users were also identified for analysis who were hospitalized and discharged within 30 days of using arformoterol, as well as a subgroup of 21,910 control patients with hospitalizations.

The researchers found COPD-related hospitalization (odds ratio, 1.31; 95% confidence interval, 1.24-1.39; P less than .001), exacerbation (OR, 1.33; 95% CI, 1.26-1.41; P less than .001), use of a systemic corticosteroid (OR, 1.50; 95% CI, 1.43-1.57; P less than .001) or methylxanthine (OR, 1.37; 95% CI, 1.28-1.47; P less than .001), use of oxygen therapy (OR, 2.01; 95% CI, 1.93-2.09; P less than .001), pulmonologist care (OR, 1.40; 95% CI, 1.34-1.46; P less than .001), and respiratory therapist care (OR, 1.23; 95% CI, 1.11-1.36; P less than .001) strongly predicted arformoterol use, while racial/ethnic minority status, psychiatric comorbidity (OR, 0.65; 95% CI, 0.56-0.76; P less than .001), acquired immune deficiency syndrome (OR, 0.69; 95% CI, 0.52-0.94; P less than .01), and dual-eligibility for Medicare and Medicaid (OR, 0.73; 95% CI, 0.70-0.77; P less than .001) lowered the odds of arformoterol use (P less than .001). In the subgroup of patients with hospitalizations, COPD-related admission (OR, 1.83; 95% CI, 1.55-2.14; P less than .001), exacerbation (OR, 2.62; 95% CI, 1.88-3.63; P less than .001)m and inpatient care from a pulmonologist (OR, 1.78; 95% CI, 1.58-2.01; P less than .001) predicted arformoterol use.

“Given the results of this study, increasing access to nebulized maintenance therapy is warranted for select populations with COPD including racial/ethnic minorities, the dual-eligible, and those with certain comorbidities, such as psychiatric disorders,” Dr. Gilmer and colleagues wrote in their study. “Future studies are needed to explore the optimal time to initiate nebulized maintenance therapy, and the potential differential impact of early versus late initiation on patient outcomes.”

Researchers noted that, although their results may seem initially counterintuitive given that COPD has a higher prevalence in men, 56% of the beneficiaries in their Medicare data were women who were 65 years or older, and the results are consistent with other studies that show similar gender distribution findings for maintenance treatment patterns among COPD patients receiving Medicare.

“Since most Medicare beneficiaries with COPD are older than 70 years of age, the higher percentage of women than men in our two cohorts can be explained by the age distributions that ensued as a result of applying our various inclusion and exclusion criteria,” they said.

This study was funded by Sunovian. Dr. Gilmer and one coauthor are paid employees of University of California San Diego, which receives research funding from Advance Health Solutions. Another coauthor is an advisory board member for Advance Health Solutions and a consultant for GlaxoSmithKline, Boehringer-Ingelheim, Astra Zeneca, Novartis, and Pulmonix. Two other coauthors are paid employees of Advance Health Solutions, and another is a paid employee of Sunovion.

SOURCE: Gilmer TP et al. COPD. 2019 Jun 19. doi: 10.1080/15412555.2019.1618256.

Among Medicare patients with chronic obstructive pulmonary disease (COPD), those who had at least one exacerbation and had a COPD-related hospitalization were most likely to receive nebulized arformoterol, according to study to identify predictors of its use. In addition to being sicker, being treated by a pulmonologist rather than a primary care physician and being white were factors that increased a patient’s likelihood of receiving nebulized arformoterol.

designer491/Thinkstock

Patients less likely to receive the nebulized version of this long-acting beta2 adrenoreceptor agonist (LABA) were African Americans, patients with psychiatric comorbidities, and patients eligible for both Medicare and Medicaid.

“Studies have shown that 40% to 71% of Medicare beneficiaries receive no maintenance treatment for COPD. Although a recent longitudinal study on Medicare populations reported that use of maintenance medications has been improving, in general, it is recognized that Medicare beneficiaries with COPD remain undertreated,” Todd P. Gilmer, PhD, from the department of family medicine and public health at the University of California, San Diego, and colleagues wrote.

The investigators identified patients with COPD using Medicare administrative data; of these patients, 11,887 were arformoterol users, and 450,178 were control patients who did not use arformoterol. Patients were included in the study if they had at least one claim for COPD medication and were continuously enrolled in Medicare Parts A, B, and D. The cohort consisted of mostly white women aged 70 years or older, and 47% were dual-eligible to receive both Medicare and Medicaid benefits. A subgroup of 1,778 arformoterol users were also identified for analysis who were hospitalized and discharged within 30 days of using arformoterol, as well as a subgroup of 21,910 control patients with hospitalizations.

The researchers found COPD-related hospitalization (odds ratio, 1.31; 95% confidence interval, 1.24-1.39; P less than .001), exacerbation (OR, 1.33; 95% CI, 1.26-1.41; P less than .001), use of a systemic corticosteroid (OR, 1.50; 95% CI, 1.43-1.57; P less than .001) or methylxanthine (OR, 1.37; 95% CI, 1.28-1.47; P less than .001), use of oxygen therapy (OR, 2.01; 95% CI, 1.93-2.09; P less than .001), pulmonologist care (OR, 1.40; 95% CI, 1.34-1.46; P less than .001), and respiratory therapist care (OR, 1.23; 95% CI, 1.11-1.36; P less than .001) strongly predicted arformoterol use, while racial/ethnic minority status, psychiatric comorbidity (OR, 0.65; 95% CI, 0.56-0.76; P less than .001), acquired immune deficiency syndrome (OR, 0.69; 95% CI, 0.52-0.94; P less than .01), and dual-eligibility for Medicare and Medicaid (OR, 0.73; 95% CI, 0.70-0.77; P less than .001) lowered the odds of arformoterol use (P less than .001). In the subgroup of patients with hospitalizations, COPD-related admission (OR, 1.83; 95% CI, 1.55-2.14; P less than .001), exacerbation (OR, 2.62; 95% CI, 1.88-3.63; P less than .001)m and inpatient care from a pulmonologist (OR, 1.78; 95% CI, 1.58-2.01; P less than .001) predicted arformoterol use.

“Given the results of this study, increasing access to nebulized maintenance therapy is warranted for select populations with COPD including racial/ethnic minorities, the dual-eligible, and those with certain comorbidities, such as psychiatric disorders,” Dr. Gilmer and colleagues wrote in their study. “Future studies are needed to explore the optimal time to initiate nebulized maintenance therapy, and the potential differential impact of early versus late initiation on patient outcomes.”

Researchers noted that, although their results may seem initially counterintuitive given that COPD has a higher prevalence in men, 56% of the beneficiaries in their Medicare data were women who were 65 years or older, and the results are consistent with other studies that show similar gender distribution findings for maintenance treatment patterns among COPD patients receiving Medicare.

“Since most Medicare beneficiaries with COPD are older than 70 years of age, the higher percentage of women than men in our two cohorts can be explained by the age distributions that ensued as a result of applying our various inclusion and exclusion criteria,” they said.

This study was funded by Sunovian. Dr. Gilmer and one coauthor are paid employees of University of California San Diego, which receives research funding from Advance Health Solutions. Another coauthor is an advisory board member for Advance Health Solutions and a consultant for GlaxoSmithKline, Boehringer-Ingelheim, Astra Zeneca, Novartis, and Pulmonix. Two other coauthors are paid employees of Advance Health Solutions, and another is a paid employee of Sunovion.

SOURCE: Gilmer TP et al. COPD. 2019 Jun 19. doi: 10.1080/15412555.2019.1618256.

Among Medicare patients with chronic obstructive pulmonary disease (COPD), those who had at least one exacerbation and had a COPD-related hospitalization were most likely to receive nebulized arformoterol, according to study to identify predictors of its use. In addition to being sicker, being treated by a pulmonologist rather than a primary care physician and being white were factors that increased a patient’s likelihood of receiving nebulized arformoterol.

designer491/Thinkstock

Patients less likely to receive the nebulized version of this long-acting beta2 adrenoreceptor agonist (LABA) were African Americans, patients with psychiatric comorbidities, and patients eligible for both Medicare and Medicaid.

“Studies have shown that 40% to 71% of Medicare beneficiaries receive no maintenance treatment for COPD. Although a recent longitudinal study on Medicare populations reported that use of maintenance medications has been improving, in general, it is recognized that Medicare beneficiaries with COPD remain undertreated,” Todd P. Gilmer, PhD, from the department of family medicine and public health at the University of California, San Diego, and colleagues wrote.

The investigators identified patients with COPD using Medicare administrative data; of these patients, 11,887 were arformoterol users, and 450,178 were control patients who did not use arformoterol. Patients were included in the study if they had at least one claim for COPD medication and were continuously enrolled in Medicare Parts A, B, and D. The cohort consisted of mostly white women aged 70 years or older, and 47% were dual-eligible to receive both Medicare and Medicaid benefits. A subgroup of 1,778 arformoterol users were also identified for analysis who were hospitalized and discharged within 30 days of using arformoterol, as well as a subgroup of 21,910 control patients with hospitalizations.

The researchers found COPD-related hospitalization (odds ratio, 1.31; 95% confidence interval, 1.24-1.39; P less than .001), exacerbation (OR, 1.33; 95% CI, 1.26-1.41; P less than .001), use of a systemic corticosteroid (OR, 1.50; 95% CI, 1.43-1.57; P less than .001) or methylxanthine (OR, 1.37; 95% CI, 1.28-1.47; P less than .001), use of oxygen therapy (OR, 2.01; 95% CI, 1.93-2.09; P less than .001), pulmonologist care (OR, 1.40; 95% CI, 1.34-1.46; P less than .001), and respiratory therapist care (OR, 1.23; 95% CI, 1.11-1.36; P less than .001) strongly predicted arformoterol use, while racial/ethnic minority status, psychiatric comorbidity (OR, 0.65; 95% CI, 0.56-0.76; P less than .001), acquired immune deficiency syndrome (OR, 0.69; 95% CI, 0.52-0.94; P less than .01), and dual-eligibility for Medicare and Medicaid (OR, 0.73; 95% CI, 0.70-0.77; P less than .001) lowered the odds of arformoterol use (P less than .001). In the subgroup of patients with hospitalizations, COPD-related admission (OR, 1.83; 95% CI, 1.55-2.14; P less than .001), exacerbation (OR, 2.62; 95% CI, 1.88-3.63; P less than .001)m and inpatient care from a pulmonologist (OR, 1.78; 95% CI, 1.58-2.01; P less than .001) predicted arformoterol use.

“Given the results of this study, increasing access to nebulized maintenance therapy is warranted for select populations with COPD including racial/ethnic minorities, the dual-eligible, and those with certain comorbidities, such as psychiatric disorders,” Dr. Gilmer and colleagues wrote in their study. “Future studies are needed to explore the optimal time to initiate nebulized maintenance therapy, and the potential differential impact of early versus late initiation on patient outcomes.”

Researchers noted that, although their results may seem initially counterintuitive given that COPD has a higher prevalence in men, 56% of the beneficiaries in their Medicare data were women who were 65 years or older, and the results are consistent with other studies that show similar gender distribution findings for maintenance treatment patterns among COPD patients receiving Medicare.

“Since most Medicare beneficiaries with COPD are older than 70 years of age, the higher percentage of women than men in our two cohorts can be explained by the age distributions that ensued as a result of applying our various inclusion and exclusion criteria,” they said.

This study was funded by Sunovian. Dr. Gilmer and one coauthor are paid employees of University of California San Diego, which receives research funding from Advance Health Solutions. Another coauthor is an advisory board member for Advance Health Solutions and a consultant for GlaxoSmithKline, Boehringer-Ingelheim, Astra Zeneca, Novartis, and Pulmonix. Two other coauthors are paid employees of Advance Health Solutions, and another is a paid employee of Sunovion.

SOURCE: Gilmer TP et al. COPD. 2019 Jun 19. doi: 10.1080/15412555.2019.1618256.

The Indian Health Service (IHS) and the Cherokee Nation Health Service are launching a new pilot project to help “accelerate progress” toward ending the HIV epidemic in native communities.

The project, which will investigate the most effective prevention strategies and share the findings locally, is part of the initiative Ending the HIV Epidemic: A Plan for America. That plan focuses prevention and treatment efforts on 48 counties and 7 southern states with a higher proportion of HIV diagnosis in rural areas. The Cherokee Nation is in Oklahoma, which has the highest American Indian population among the 7 southern states.

Recent data show new HIV infections at the lowest level yet, but progress in prevention has slowed, in part due to new threats such as the opioid crisis: 10% of new HIV infections are among injectable-drug users.

The Cherokee Nation’s proven track record in hepatitis C prevention and treatment makes it a valuable partner in the project. Half of its health services patients have been screened, and among the 3.2% testing positive, 90% have been cured. The pilot project will use a similar model, IHS says. Current statistics show that 35% of Cherokee National patients using the tribe’s health centers have been screened for HIV, with < 1% testing positive. Of the patients diagnosed with HIV, 90% are receiving care and 90% of those are virally suppressed. The pilot project is aimed at boosting the screening numbers.

The pilot is one of several HHS efforts to jumpstart key activities in select communities using resources from the Minority HIV/AIDS fund. The CDC also is launching projects in select communities.

“Improved health care over multiple generations is our top priority,” said Cherokee Nation Principal Chief Bill John Baker. “If we can collaborate with our federal partners at IHS to raise awareness, increase education, and actively work to prevent new cases of HIV, then we will be creating a healthier future for northeast Oklahoma.”

The Indian Health Service (IHS) and the Cherokee Nation Health Service are launching a new pilot project to help “accelerate progress” toward ending the HIV epidemic in native communities.

The project, which will investigate the most effective prevention strategies and share the findings locally, is part of the initiative Ending the HIV Epidemic: A Plan for America. That plan focuses prevention and treatment efforts on 48 counties and 7 southern states with a higher proportion of HIV diagnosis in rural areas. The Cherokee Nation is in Oklahoma, which has the highest American Indian population among the 7 southern states.

Recent data show new HIV infections at the lowest level yet, but progress in prevention has slowed, in part due to new threats such as the opioid crisis: 10% of new HIV infections are among injectable-drug users.

The Cherokee Nation’s proven track record in hepatitis C prevention and treatment makes it a valuable partner in the project. Half of its health services patients have been screened, and among the 3.2% testing positive, 90% have been cured. The pilot project will use a similar model, IHS says. Current statistics show that 35% of Cherokee National patients using the tribe’s health centers have been screened for HIV, with < 1% testing positive. Of the patients diagnosed with HIV, 90% are receiving care and 90% of those are virally suppressed. The pilot project is aimed at boosting the screening numbers.

The pilot is one of several HHS efforts to jumpstart key activities in select communities using resources from the Minority HIV/AIDS fund. The CDC also is launching projects in select communities.

“Improved health care over multiple generations is our top priority,” said Cherokee Nation Principal Chief Bill John Baker. “If we can collaborate with our federal partners at IHS to raise awareness, increase education, and actively work to prevent new cases of HIV, then we will be creating a healthier future for northeast Oklahoma.”

The Indian Health Service (IHS) and the Cherokee Nation Health Service are launching a new pilot project to help “accelerate progress” toward ending the HIV epidemic in native communities.

The project, which will investigate the most effective prevention strategies and share the findings locally, is part of the initiative Ending the HIV Epidemic: A Plan for America. That plan focuses prevention and treatment efforts on 48 counties and 7 southern states with a higher proportion of HIV diagnosis in rural areas. The Cherokee Nation is in Oklahoma, which has the highest American Indian population among the 7 southern states.

Recent data show new HIV infections at the lowest level yet, but progress in prevention has slowed, in part due to new threats such as the opioid crisis: 10% of new HIV infections are among injectable-drug users.

The Cherokee Nation’s proven track record in hepatitis C prevention and treatment makes it a valuable partner in the project. Half of its health services patients have been screened, and among the 3.2% testing positive, 90% have been cured. The pilot project will use a similar model, IHS says. Current statistics show that 35% of Cherokee National patients using the tribe’s health centers have been screened for HIV, with < 1% testing positive. Of the patients diagnosed with HIV, 90% are receiving care and 90% of those are virally suppressed. The pilot project is aimed at boosting the screening numbers.

The pilot is one of several HHS efforts to jumpstart key activities in select communities using resources from the Minority HIV/AIDS fund. The CDC also is launching projects in select communities.

“Improved health care over multiple generations is our top priority,” said Cherokee Nation Principal Chief Bill John Baker. “If we can collaborate with our federal partners at IHS to raise awareness, increase education, and actively work to prevent new cases of HIV, then we will be creating a healthier future for northeast Oklahoma.”

Two-thirds of patients hospitalized with pneumonia received an excess duration of antibiotics, according to a recent study of more than 6,000 patients.

Longer antibiotic courses did not increase the survival rate or prevent any subsequent health care utilization, authors said; instead, they increased the risk of patient-reported adverse events.

The findings bolster a growing body of evidence showing that short-course therapy for pneumonia is safe and that longer durations are not only unnecessary, but “potentially harmful,” said Valerie M. Vaughn, MD, assistant professor of medicine at the University of Michigan, Ann Arbor, and coinvestigators.

“Reducing excess treatment durations should be a top priority for antibiotic stewardship nationally,” the investigators wrote in their report, which appears in the Annals of Internal Medicine.

The primary analysis of their retrospective cohort study included 6,481 individuals with pneumonia treated at 43 hospitals participating in a statewide quality initiative designed to improve care for hospitalized medical patients at risk of adverse events. About half of the patients were women, and the median age was 70 years. Nearly 60% had severe pneumonia.

The primary outcome of the study was the rate of excess antibiotic therapy duration beyond the shortest expected treatment duration consistent with guidelines. Patients with community-acquired pneumonia (CAP), representing about three-quarters of the study cohort, were expected to have a treatment duration of at least 5 days, while patients with health care–acquired pneumonia (HCAP) were expected to have at least 7 days of treatment.

Overall, 4,391 patients (67.8%) had antibiotic courses longer than the shortest effective duration, with a median duration of 8 days, and a median excess duration of 2 days, the researchers noted.

The great majority of excess days (93.2%) were due to antibiotic prescribed at discharge, according to Dr. Vaughn and colleagues.

Excess treatment duration was not linked to any improvement in 30-day mortality, readmission rates, or subsequent emergency department visits, they found.

In a telephone call at 30 days, 38% of patients treated to excess said they had gone to the doctor for an antibiotic-associated adverse event, compared with 31% who received appropriate-length courses (P = .003).

Odds of a patient-reported adverse event were increased by 5% for every excess treatment day, the investigators wrote.

Taken together, these findings have implications for patient care, research efforts, and future guidelines, according to Dr. Vaughn and coinvestigators.

“The next iteration of CAP and HCAP guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration,” they said in a discussion of their study results.

Dr. Vaughn reported no disclosures related to the study. Coauthors reported grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, personal fees from Wiley Publishing, and royalties from Wolters Kluwer Publishing and Oxford University Press, among other disclosures.

SOURCE: Vaughn VM et al. Ann Intern Med. 2019;171:153-63. doi: 10.7326/M18-3640.

Two-thirds of patients hospitalized with pneumonia received an excess duration of antibiotics, according to a recent study of more than 6,000 patients.

Longer antibiotic courses did not increase the survival rate or prevent any subsequent health care utilization, authors said; instead, they increased the risk of patient-reported adverse events.

The findings bolster a growing body of evidence showing that short-course therapy for pneumonia is safe and that longer durations are not only unnecessary, but “potentially harmful,” said Valerie M. Vaughn, MD, assistant professor of medicine at the University of Michigan, Ann Arbor, and coinvestigators.

“Reducing excess treatment durations should be a top priority for antibiotic stewardship nationally,” the investigators wrote in their report, which appears in the Annals of Internal Medicine.

The primary analysis of their retrospective cohort study included 6,481 individuals with pneumonia treated at 43 hospitals participating in a statewide quality initiative designed to improve care for hospitalized medical patients at risk of adverse events. About half of the patients were women, and the median age was 70 years. Nearly 60% had severe pneumonia.

The primary outcome of the study was the rate of excess antibiotic therapy duration beyond the shortest expected treatment duration consistent with guidelines. Patients with community-acquired pneumonia (CAP), representing about three-quarters of the study cohort, were expected to have a treatment duration of at least 5 days, while patients with health care–acquired pneumonia (HCAP) were expected to have at least 7 days of treatment.

Overall, 4,391 patients (67.8%) had antibiotic courses longer than the shortest effective duration, with a median duration of 8 days, and a median excess duration of 2 days, the researchers noted.

The great majority of excess days (93.2%) were due to antibiotic prescribed at discharge, according to Dr. Vaughn and colleagues.

Excess treatment duration was not linked to any improvement in 30-day mortality, readmission rates, or subsequent emergency department visits, they found.

In a telephone call at 30 days, 38% of patients treated to excess said they had gone to the doctor for an antibiotic-associated adverse event, compared with 31% who received appropriate-length courses (P = .003).

Odds of a patient-reported adverse event were increased by 5% for every excess treatment day, the investigators wrote.

Taken together, these findings have implications for patient care, research efforts, and future guidelines, according to Dr. Vaughn and coinvestigators.

“The next iteration of CAP and HCAP guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration,” they said in a discussion of their study results.

Dr. Vaughn reported no disclosures related to the study. Coauthors reported grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, personal fees from Wiley Publishing, and royalties from Wolters Kluwer Publishing and Oxford University Press, among other disclosures.

SOURCE: Vaughn VM et al. Ann Intern Med. 2019;171:153-63. doi: 10.7326/M18-3640.

Two-thirds of patients hospitalized with pneumonia received an excess duration of antibiotics, according to a recent study of more than 6,000 patients.

Longer antibiotic courses did not increase the survival rate or prevent any subsequent health care utilization, authors said; instead, they increased the risk of patient-reported adverse events.

The findings bolster a growing body of evidence showing that short-course therapy for pneumonia is safe and that longer durations are not only unnecessary, but “potentially harmful,” said Valerie M. Vaughn, MD, assistant professor of medicine at the University of Michigan, Ann Arbor, and coinvestigators.

“Reducing excess treatment durations should be a top priority for antibiotic stewardship nationally,” the investigators wrote in their report, which appears in the Annals of Internal Medicine.

The primary analysis of their retrospective cohort study included 6,481 individuals with pneumonia treated at 43 hospitals participating in a statewide quality initiative designed to improve care for hospitalized medical patients at risk of adverse events. About half of the patients were women, and the median age was 70 years. Nearly 60% had severe pneumonia.

The primary outcome of the study was the rate of excess antibiotic therapy duration beyond the shortest expected treatment duration consistent with guidelines. Patients with community-acquired pneumonia (CAP), representing about three-quarters of the study cohort, were expected to have a treatment duration of at least 5 days, while patients with health care–acquired pneumonia (HCAP) were expected to have at least 7 days of treatment.

Overall, 4,391 patients (67.8%) had antibiotic courses longer than the shortest effective duration, with a median duration of 8 days, and a median excess duration of 2 days, the researchers noted.

The great majority of excess days (93.2%) were due to antibiotic prescribed at discharge, according to Dr. Vaughn and colleagues.

Excess treatment duration was not linked to any improvement in 30-day mortality, readmission rates, or subsequent emergency department visits, they found.

In a telephone call at 30 days, 38% of patients treated to excess said they had gone to the doctor for an antibiotic-associated adverse event, compared with 31% who received appropriate-length courses (P = .003).

Odds of a patient-reported adverse event were increased by 5% for every excess treatment day, the investigators wrote.

Taken together, these findings have implications for patient care, research efforts, and future guidelines, according to Dr. Vaughn and coinvestigators.

“The next iteration of CAP and HCAP guidelines should explicitly recommend (rather than imply) that providers prescribe the shortest effective duration,” they said in a discussion of their study results.

Dr. Vaughn reported no disclosures related to the study. Coauthors reported grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, personal fees from Wiley Publishing, and royalties from Wolters Kluwer Publishing and Oxford University Press, among other disclosures.

SOURCE: Vaughn VM et al. Ann Intern Med. 2019;171:153-63. doi: 10.7326/M18-3640.

SAN DIEGO – The prevalence of obstructive sleep apnea (OSA) is substantially lower using the Centers for Medicare & Medicaid Services apnea-hypopnea index definition of OSA than using the one recommended by the American Academy of Sleep Medicine.

Doug Brunk/MDedge News

In addition, among individuals who did not have OSA using the CMS definition but met criteria using the AASM definition of OSA, an apnea-hypopnea index (AHI) of five events or greater per hour was associated with a greater likelihood of having hypertension.

The findings come from an analysis which set out to assess the relationship between OSA and hypertension using the AASM-recommended definition and the 2018 American Heart Association/American College of Cardiology blood pressure guidelines, and to determine if there is an association between hypertension and OSA among individuals who did not meet the CMS definition of OSA.

“Given the substantial morbidity associated with hypertension, these results suggest that universal adoption of the AASM AHI definition would be a reasonable step in ensuring appropriate diagnosis and treatment of OSA,” lead study author Stuart F. Quan, MD, said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Quan, of the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston, noted that a number of studies have demonstrated that OSA is a risk factor for hypertension and a variety of other medical conditions. “Rightly or wrongly, the most important metric for determining whether OSA is present and determining its severity, is the apnea-hypopnea index,” he said. “It’s the most common metric used for determining OSA severity, and mostly importantly, Medicare and some other insurers use this metric to determine whether a person is eligible for treatment. If a person falls above the line, they can get continuous positive airway pressure, for example. If they’re below the line, that’s too bad; they don’t have OSA insofar as the insurance company is concerned.”

There is no controversy as to what constitutes apnea, he continued, but some disagreement exists on the definition of hypopnea. The AASM recommends using a 3% oxygen desaturation or an arousal, while Medicare uses a definition of hypopnea requiring only a 4% oxygen desaturation. Hypertension definitions have changed recently as well. Before 2018, the definition of hypertension was greater than 140/90 mm Hg for people younger than age 65 years and 150/80 mm Hg for people age 65 years and older. In 2018, the AHA and ACC changed the hypertension guidelines, defining normal as less than 120/80 mm Hg.

“Previous studies linking OSA and hypertension used older definitions, but to my knowledge there are no current studies examining the association between OSA and hypertension using new definitions,” Dr. Quan said.

He reported on results from an analysis of 6,307 participants in the Sleep Heart Health Study who underwent home polysomnography. Their AHI defined by a 3% oxygen desaturation or an arousal was classified into four categories of OSA severity: fewer than 5 events per hour (normal sleep), 5-14 events per hour (mild sleep apnea), 15-29 events per hour (moderate sleep apnea), and 30 or more events per hour (severe sleep apnea).

The researchers used three definitions of dichotomous BP elevation: elevated (greater than 120/80 mm Hg or use of hypertension medications [meds]), stage 1 (greater than 130/80 mm Hg or meds), or stage 2 (greater than 140/90 mm Hg or meds). They used logistic regression to assess the association between elevated BP and/or hypertension and OSA severity, controlling for demographics and body mass index. Additional analyses utilized multiple linear regression to determine the relationship between natural log AHI and systolic and diastolic BP, controlling for the same covariates.

For all definitions of elevated BP, increasing OSA severity was associated with greater likelihood of an elevated or hypertensive status in fully adjusted models. Specifically, the odds ratios among those with elevated BP was 1.30 (95% confidence interval, 1.10-1.54), 1.41 (95% CI, 1.15-1.72), and 1.69 (95% CI, 1.32-2.17) for mild, moderate, and severe sleep apnea, respectively. The ORs among those with stage 1 BP was 1.27 (95% CI, 1.09-1.49), 1.36 (95% CI, 1.13-1.63), 1.58 (95% CI, 1.27-1.97) for mild, moderate, and severe sleep apnea, while the OR among those with stage 2 BP was 1.07 (95% CI, 0.92-1.26), 1.22 (95% CI, 1.02-1.45), 1.38 (95% CI, 1.12-1.69) for mild, moderate, and severe sleep apnea. Linear regression found that AHI was associated with both systolic and diastolic BP in fully adjusted models.

“Using the AASM and CMS AHI definitions, increasing severity of AHI is associated with greater likelihood of having an elevated blood pressure or hypertension,” Dr. Quan concluded. “However, the prevalence of OSA was substantially lower using the CMS definition of OSA. In fact, 218 of these individuals had moderate to severe OSA when the AASM definition was applied.”

He characterized the study as “a practical analysis, a way to help identify patients who might benefit from treatment. This is not the issue of whether the science of 3% AHI is better than 4%.”

The Sleep Heart Health Study was supported by the National Heart, Lung, and Blood Institute. Dr. Quan reported that he helped draft the AASM AHI recommendations but had no other relevant disclosures.

dbrunk@mdedge.com

SOURCE: Quan SF et al. SLEEP 2019, Abstract 0501.

SAN DIEGO – The prevalence of obstructive sleep apnea (OSA) is substantially lower using the Centers for Medicare & Medicaid Services apnea-hypopnea index definition of OSA than using the one recommended by the American Academy of Sleep Medicine.

Doug Brunk/MDedge News

In addition, among individuals who did not have OSA using the CMS definition but met criteria using the AASM definition of OSA, an apnea-hypopnea index (AHI) of five events or greater per hour was associated with a greater likelihood of having hypertension.

The findings come from an analysis which set out to assess the relationship between OSA and hypertension using the AASM-recommended definition and the 2018 American Heart Association/American College of Cardiology blood pressure guidelines, and to determine if there is an association between hypertension and OSA among individuals who did not meet the CMS definition of OSA.

“Given the substantial morbidity associated with hypertension, these results suggest that universal adoption of the AASM AHI definition would be a reasonable step in ensuring appropriate diagnosis and treatment of OSA,” lead study author Stuart F. Quan, MD, said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Quan, of the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston, noted that a number of studies have demonstrated that OSA is a risk factor for hypertension and a variety of other medical conditions. “Rightly or wrongly, the most important metric for determining whether OSA is present and determining its severity, is the apnea-hypopnea index,” he said. “It’s the most common metric used for determining OSA severity, and mostly importantly, Medicare and some other insurers use this metric to determine whether a person is eligible for treatment. If a person falls above the line, they can get continuous positive airway pressure, for example. If they’re below the line, that’s too bad; they don’t have OSA insofar as the insurance company is concerned.”

There is no controversy as to what constitutes apnea, he continued, but some disagreement exists on the definition of hypopnea. The AASM recommends using a 3% oxygen desaturation or an arousal, while Medicare uses a definition of hypopnea requiring only a 4% oxygen desaturation. Hypertension definitions have changed recently as well. Before 2018, the definition of hypertension was greater than 140/90 mm Hg for people younger than age 65 years and 150/80 mm Hg for people age 65 years and older. In 2018, the AHA and ACC changed the hypertension guidelines, defining normal as less than 120/80 mm Hg.

“Previous studies linking OSA and hypertension used older definitions, but to my knowledge there are no current studies examining the association between OSA and hypertension using new definitions,” Dr. Quan said.

He reported on results from an analysis of 6,307 participants in the Sleep Heart Health Study who underwent home polysomnography. Their AHI defined by a 3% oxygen desaturation or an arousal was classified into four categories of OSA severity: fewer than 5 events per hour (normal sleep), 5-14 events per hour (mild sleep apnea), 15-29 events per hour (moderate sleep apnea), and 30 or more events per hour (severe sleep apnea).

The researchers used three definitions of dichotomous BP elevation: elevated (greater than 120/80 mm Hg or use of hypertension medications [meds]), stage 1 (greater than 130/80 mm Hg or meds), or stage 2 (greater than 140/90 mm Hg or meds). They used logistic regression to assess the association between elevated BP and/or hypertension and OSA severity, controlling for demographics and body mass index. Additional analyses utilized multiple linear regression to determine the relationship between natural log AHI and systolic and diastolic BP, controlling for the same covariates.

For all definitions of elevated BP, increasing OSA severity was associated with greater likelihood of an elevated or hypertensive status in fully adjusted models. Specifically, the odds ratios among those with elevated BP was 1.30 (95% confidence interval, 1.10-1.54), 1.41 (95% CI, 1.15-1.72), and 1.69 (95% CI, 1.32-2.17) for mild, moderate, and severe sleep apnea, respectively. The ORs among those with stage 1 BP was 1.27 (95% CI, 1.09-1.49), 1.36 (95% CI, 1.13-1.63), 1.58 (95% CI, 1.27-1.97) for mild, moderate, and severe sleep apnea, while the OR among those with stage 2 BP was 1.07 (95% CI, 0.92-1.26), 1.22 (95% CI, 1.02-1.45), 1.38 (95% CI, 1.12-1.69) for mild, moderate, and severe sleep apnea. Linear regression found that AHI was associated with both systolic and diastolic BP in fully adjusted models.

“Using the AASM and CMS AHI definitions, increasing severity of AHI is associated with greater likelihood of having an elevated blood pressure or hypertension,” Dr. Quan concluded. “However, the prevalence of OSA was substantially lower using the CMS definition of OSA. In fact, 218 of these individuals had moderate to severe OSA when the AASM definition was applied.”

He characterized the study as “a practical analysis, a way to help identify patients who might benefit from treatment. This is not the issue of whether the science of 3% AHI is better than 4%.”

The Sleep Heart Health Study was supported by the National Heart, Lung, and Blood Institute. Dr. Quan reported that he helped draft the AASM AHI recommendations but had no other relevant disclosures.

dbrunk@mdedge.com

SOURCE: Quan SF et al. SLEEP 2019, Abstract 0501.

SAN DIEGO – The prevalence of obstructive sleep apnea (OSA) is substantially lower using the Centers for Medicare & Medicaid Services apnea-hypopnea index definition of OSA than using the one recommended by the American Academy of Sleep Medicine.

Doug Brunk/MDedge News

In addition, among individuals who did not have OSA using the CMS definition but met criteria using the AASM definition of OSA, an apnea-hypopnea index (AHI) of five events or greater per hour was associated with a greater likelihood of having hypertension.

The findings come from an analysis which set out to assess the relationship between OSA and hypertension using the AASM-recommended definition and the 2018 American Heart Association/American College of Cardiology blood pressure guidelines, and to determine if there is an association between hypertension and OSA among individuals who did not meet the CMS definition of OSA.

“Given the substantial morbidity associated with hypertension, these results suggest that universal adoption of the AASM AHI definition would be a reasonable step in ensuring appropriate diagnosis and treatment of OSA,” lead study author Stuart F. Quan, MD, said at the annual meeting of the Associated Professional Sleep Societies.

Dr. Quan, of the division of sleep and circadian disorders at Brigham and Women’s Hospital in Boston, noted that a number of studies have demonstrated that OSA is a risk factor for hypertension and a variety of other medical conditions. “Rightly or wrongly, the most important metric for determining whether OSA is present and determining its severity, is the apnea-hypopnea index,” he said. “It’s the most common metric used for determining OSA severity, and mostly importantly, Medicare and some other insurers use this metric to determine whether a person is eligible for treatment. If a person falls above the line, they can get continuous positive airway pressure, for example. If they’re below the line, that’s too bad; they don’t have OSA insofar as the insurance company is concerned.”

There is no controversy as to what constitutes apnea, he continued, but some disagreement exists on the definition of hypopnea. The AASM recommends using a 3% oxygen desaturation or an arousal, while Medicare uses a definition of hypopnea requiring only a 4% oxygen desaturation. Hypertension definitions have changed recently as well. Before 2018, the definition of hypertension was greater than 140/90 mm Hg for people younger than age 65 years and 150/80 mm Hg for people age 65 years and older. In 2018, the AHA and ACC changed the hypertension guidelines, defining normal as less than 120/80 mm Hg.

“Previous studies linking OSA and hypertension used older definitions, but to my knowledge there are no current studies examining the association between OSA and hypertension using new definitions,” Dr. Quan said.

He reported on results from an analysis of 6,307 participants in the Sleep Heart Health Study who underwent home polysomnography. Their AHI defined by a 3% oxygen desaturation or an arousal was classified into four categories of OSA severity: fewer than 5 events per hour (normal sleep), 5-14 events per hour (mild sleep apnea), 15-29 events per hour (moderate sleep apnea), and 30 or more events per hour (severe sleep apnea).

The researchers used three definitions of dichotomous BP elevation: elevated (greater than 120/80 mm Hg or use of hypertension medications [meds]), stage 1 (greater than 130/80 mm Hg or meds), or stage 2 (greater than 140/90 mm Hg or meds). They used logistic regression to assess the association between elevated BP and/or hypertension and OSA severity, controlling for demographics and body mass index. Additional analyses utilized multiple linear regression to determine the relationship between natural log AHI and systolic and diastolic BP, controlling for the same covariates.

For all definitions of elevated BP, increasing OSA severity was associated with greater likelihood of an elevated or hypertensive status in fully adjusted models. Specifically, the odds ratios among those with elevated BP was 1.30 (95% confidence interval, 1.10-1.54), 1.41 (95% CI, 1.15-1.72), and 1.69 (95% CI, 1.32-2.17) for mild, moderate, and severe sleep apnea, respectively. The ORs among those with stage 1 BP was 1.27 (95% CI, 1.09-1.49), 1.36 (95% CI, 1.13-1.63), 1.58 (95% CI, 1.27-1.97) for mild, moderate, and severe sleep apnea, while the OR among those with stage 2 BP was 1.07 (95% CI, 0.92-1.26), 1.22 (95% CI, 1.02-1.45), 1.38 (95% CI, 1.12-1.69) for mild, moderate, and severe sleep apnea. Linear regression found that AHI was associated with both systolic and diastolic BP in fully adjusted models.

“Using the AASM and CMS AHI definitions, increasing severity of AHI is associated with greater likelihood of having an elevated blood pressure or hypertension,” Dr. Quan concluded. “However, the prevalence of OSA was substantially lower using the CMS definition of OSA. In fact, 218 of these individuals had moderate to severe OSA when the AASM definition was applied.”

He characterized the study as “a practical analysis, a way to help identify patients who might benefit from treatment. This is not the issue of whether the science of 3% AHI is better than 4%.”

The Sleep Heart Health Study was supported by the National Heart, Lung, and Blood Institute. Dr. Quan reported that he helped draft the AASM AHI recommendations but had no other relevant disclosures.

dbrunk@mdedge.com

SOURCE: Quan SF et al. SLEEP 2019, Abstract 0501.

If it’s swimming season, it’s also Cryptosporidium season. The parasite, spread through feces of infected humans or animals, is the culprit in most disease outbreaks linked to water.

Between 2009 and 2017, Crypto-related outbreaks increased an average 13% per year, according to the CDC. In the 444 outbreaks reported, 7,465 people became sick, 287 people were hospitalized, and 1 person died. The CDC says these numbers are likely to be underestimates.

One-third of the outbreaks were in treated swimming water, including pools and water playgrounds. Smaller percentages were linked to contact with cattle, infected people in childcare settings, and raw milk or apple cider.

Crypto’s tough protective shell is the secret to its long life. It can survive for days even in chlorinated pools or on surfaces disinfected with chlorine bleach. Moreover, Cryptosporidium oocysts are immediately infectious upon excretion and are excreted in numbers multiple orders of magnitude higher than the human infectious dose (≤ 10 oocysts). Just a few germs can make someone sick—and there can be millions in a pool. Infection with Cryptosporidium can cause profuse, watery diarrhea that lasts for up to 3 weeks. It’s particularly dangerous for immunocompromised patients, leading to malnutrition and wasting.

The CDC has some advice for staying Crypto free:

• Don’t swim or let kids swim if anyone has diarrhea, and keep them home from daycare;
• Don’t swallow the water you swim in;
• Wash hands with soap and water after any contact with animals, especially animal feces (note: alcohol-based hand sanitizers are not effective against Crypto; hydrogen peroxide should be used in childcare settings to disinfect); 
• Remove shoes worn in animal environments before going inside your home; and
• Drink only pasteurized milk or apple cider.

Although the numbers are still high, the CDC says testing has improved and might be helping with increased detection, especially since CryptoNet, the first US molecularly based surveillance system for a parasitic disease, was instituted. Based on DNA fingerprinting, it has already demonstrated that it can elucidate Cryptosporidium transmission chains in treated recreational water outbreaks, the CDC says, and has the potential to do the same for investigations in other Crypto outbreaks.

If it’s swimming season, it’s also Cryptosporidium season. The parasite, spread through feces of infected humans or animals, is the culprit in most disease outbreaks linked to water.

Between 2009 and 2017, Crypto-related outbreaks increased an average 13% per year, according to the CDC. In the 444 outbreaks reported, 7,465 people became sick, 287 people were hospitalized, and 1 person died. The CDC says these numbers are likely to be underestimates.

One-third of the outbreaks were in treated swimming water, including pools and water playgrounds. Smaller percentages were linked to contact with cattle, infected people in childcare settings, and raw milk or apple cider.

Crypto’s tough protective shell is the secret to its long life. It can survive for days even in chlorinated pools or on surfaces disinfected with chlorine bleach. Moreover, Cryptosporidium oocysts are immediately infectious upon excretion and are excreted in numbers multiple orders of magnitude higher than the human infectious dose (≤ 10 oocysts). Just a few germs can make someone sick—and there can be millions in a pool. Infection with Cryptosporidium can cause profuse, watery diarrhea that lasts for up to 3 weeks. It’s particularly dangerous for immunocompromised patients, leading to malnutrition and wasting.

The CDC has some advice for staying Crypto free:

• Don’t swim or let kids swim if anyone has diarrhea, and keep them home from daycare;
• Don’t swallow the water you swim in;
• Wash hands with soap and water after any contact with animals, especially animal feces (note: alcohol-based hand sanitizers are not effective against Crypto; hydrogen peroxide should be used in childcare settings to disinfect); 
• Remove shoes worn in animal environments before going inside your home; and
• Drink only pasteurized milk or apple cider.

Although the numbers are still high, the CDC says testing has improved and might be helping with increased detection, especially since CryptoNet, the first US molecularly based surveillance system for a parasitic disease, was instituted. Based on DNA fingerprinting, it has already demonstrated that it can elucidate Cryptosporidium transmission chains in treated recreational water outbreaks, the CDC says, and has the potential to do the same for investigations in other Crypto outbreaks.

If it’s swimming season, it’s also Cryptosporidium season. The parasite, spread through feces of infected humans or animals, is the culprit in most disease outbreaks linked to water.

Between 2009 and 2017, Crypto-related outbreaks increased an average 13% per year, according to the CDC. In the 444 outbreaks reported, 7,465 people became sick, 287 people were hospitalized, and 1 person died. The CDC says these numbers are likely to be underestimates.

One-third of the outbreaks were in treated swimming water, including pools and water playgrounds. Smaller percentages were linked to contact with cattle, infected people in childcare settings, and raw milk or apple cider.

Crypto’s tough protective shell is the secret to its long life. It can survive for days even in chlorinated pools or on surfaces disinfected with chlorine bleach. Moreover, Cryptosporidium oocysts are immediately infectious upon excretion and are excreted in numbers multiple orders of magnitude higher than the human infectious dose (≤ 10 oocysts). Just a few germs can make someone sick—and there can be millions in a pool. Infection with Cryptosporidium can cause profuse, watery diarrhea that lasts for up to 3 weeks. It’s particularly dangerous for immunocompromised patients, leading to malnutrition and wasting.

The CDC has some advice for staying Crypto free:

• Don’t swim or let kids swim if anyone has diarrhea, and keep them home from daycare;
• Don’t swallow the water you swim in;
• Wash hands with soap and water after any contact with animals, especially animal feces (note: alcohol-based hand sanitizers are not effective against Crypto; hydrogen peroxide should be used in childcare settings to disinfect); 
• Remove shoes worn in animal environments before going inside your home; and
• Drink only pasteurized milk or apple cider.

Although the numbers are still high, the CDC says testing has improved and might be helping with increased detection, especially since CryptoNet, the first US molecularly based surveillance system for a parasitic disease, was instituted. Based on DNA fingerprinting, it has already demonstrated that it can elucidate Cryptosporidium transmission chains in treated recreational water outbreaks, the CDC says, and has the potential to do the same for investigations in other Crypto outbreaks.

The “digital divide”: That is how the VA describes the situation of the 42% of veterans without reliable—or any—Internet access. The lack of access means they are effectively barred from participating in telehealth and other online services.

 With the goal of “digital inclusion,” the Veterans Health Administration (VHA) is partnering with a variety of nongovernmental businesses. VHA and T-Mobile, for instance, host the VA Video Connect application, which connects veterans to health care providers on a secure line on all devices with T-Mobile for free.

Walmart, Philips, and Veteran Service Organizations have set up remote clinics for veterans to access telehealth services closer to their home; with those partners, the VHA also lends Internet-connected iPads to veterans who do not have home computers.

Now, the VHA is working with Microsoft and Internet service providers to bring broadband access to rural areas with large populations of veterans.

The initiatives will not only improve access to health care, but also open other avenues. Dr. Kevin Galpin, executive director of VHA Telehealth Services, says, “We really want veterans to have the opportunities that come with being connected. There is lots of value in being able to maintain social relationships, conduct job searches online, and connect with VA. We know limited access is a problem and we’re exploring a multitude of options.”

The “digital divide”: That is how the VA describes the situation of the 42% of veterans without reliable—or any—Internet access. The lack of access means they are effectively barred from participating in telehealth and other online services.

 With the goal of “digital inclusion,” the Veterans Health Administration (VHA) is partnering with a variety of nongovernmental businesses. VHA and T-Mobile, for instance, host the VA Video Connect application, which connects veterans to health care providers on a secure line on all devices with T-Mobile for free.

Walmart, Philips, and Veteran Service Organizations have set up remote clinics for veterans to access telehealth services closer to their home; with those partners, the VHA also lends Internet-connected iPads to veterans who do not have home computers.

Now, the VHA is working with Microsoft and Internet service providers to bring broadband access to rural areas with large populations of veterans.

The initiatives will not only improve access to health care, but also open other avenues. Dr. Kevin Galpin, executive director of VHA Telehealth Services, says, “We really want veterans to have the opportunities that come with being connected. There is lots of value in being able to maintain social relationships, conduct job searches online, and connect with VA. We know limited access is a problem and we’re exploring a multitude of options.”

The “digital divide”: That is how the VA describes the situation of the 42% of veterans without reliable—or any—Internet access. The lack of access means they are effectively barred from participating in telehealth and other online services.

 With the goal of “digital inclusion,” the Veterans Health Administration (VHA) is partnering with a variety of nongovernmental businesses. VHA and T-Mobile, for instance, host the VA Video Connect application, which connects veterans to health care providers on a secure line on all devices with T-Mobile for free.

Walmart, Philips, and Veteran Service Organizations have set up remote clinics for veterans to access telehealth services closer to their home; with those partners, the VHA also lends Internet-connected iPads to veterans who do not have home computers.

Now, the VHA is working with Microsoft and Internet service providers to bring broadband access to rural areas with large populations of veterans.

The initiatives will not only improve access to health care, but also open other avenues. Dr. Kevin Galpin, executive director of VHA Telehealth Services, says, “We really want veterans to have the opportunities that come with being connected. There is lots of value in being able to maintain social relationships, conduct job searches online, and connect with VA. We know limited access is a problem and we’re exploring a multitude of options.”

SAN ANTONIO – Patients with obstructive sleep apnea who complain of feeling tired when they wake up, being sleepy during the day, and have a high score on the Epworth Sleepiness Scale face an increased risk for cardiovascular disease, results from a population-based analysis suggest.

Doug Brunk/MDedge News

“OSA is a highly heterogeneous disease, with multiple clinical presentations and consequences,” the study’s first author, Diego R. Mazzotti, PhD, said at the annual meeting of the Associated Professional Sleep Societies. “These patients also have diverse comorbidities, and there are arbitrary severity definitions and variable therapeutic responses. It’s difficult to lump these patients together.”

Symptom subtypes of OSA were originally described in the Icelandic Sleep Apnea Cohort, and defined as excessively sleepy, minimally symptomatic, and disturbed sleep (Eur Respir J. 2014; 44[6]:1600-7). These distinct clusters were identified based on symptom experiences and the existence of major comorbidities. “This concept is more popular today, trying to identify symptom clusters, or groups of individuals, that share similar polysomnographic data, and then compare differences in prevalence or incidence of cardiovascular disease,” said Dr. Mazzotti, a research associate at the University of Pennsylvania, Philadelphia. “That’s a concept that needs to be moving forward.”

Dr. Mazzotti and colleagues set out to determine if OSA symptom subtypes are present in the Sleep Heart Health Study, a multicenter, prospective, community-based cohort of individuals aged 40 years and older designed to assess the cardiovascular (CV) consequences of OSA. They also wanted to know if there is additional evidence of the relevance of OSA symptom subtypes, particularly with respect to cardiovascular disease .

Participant-reported symptoms, such as difficulty falling and staying asleep, snoring, fatigue, drowsy driving and daytime sleepiness, and responses to the Epworth Sleepiness Scale were used to determine the patient’s subtype. Assessments including questionnaires and in-home polysomnography were conducted at baseline (between 1995 and 1998) and follow-up (between 2001 and 2003), while CV outcomes were assessed until the end of follow-up (between 2008 and 2011).

In all, 1,207 patients from the Sleep Heart Health Study met criteria for moderate to severe OSA (apnea-hypopnea index, or AHI, of 15 or greater) and were included in the final analysis. They were followed for a mean of 12 years. Based on the clustering of symptoms, the researchers identified four OSA symptom subtypes: disturbed sleep (12%), minimally symptomatic (33%), excessively sleepy (17%), and moderately sleepy (38%) – proportions that were similar to those observed in prior studies.

The disturbed sleep subtype presented with increased prevalence of “insomnialike” symptoms, such as difficulty initiating or maintaining sleep, according to Dr. Mazzotti. “On the other hand, the excessively sleepy subtype presented with a very high prevalence of several symptoms related to excessive daytime sleepiness, while the moderately sleepy showed a moderately high prevalence of such symptoms, but not as much when compared to the excessively sleepy subtype,” he explained. “Finally, the minimally symptomatic subtype was found to have the lowest prevalence of all investigated symptoms, suggesting that these patients have low symptom burden. They do not complain as much, even though they have moderate-to-severe OSA.”

Next, Dr. Mazzotti and colleagues used Kaplan-Meier survival analysis and Cox proportional hazards models to evaluate whether subtypes were associated with incident coronary heart disease (CHD), heart failure, and CV disease, including CV mortality. Similar analyses were performed comparing each symptom subtype with 2,830 individuals without OSA (AHI less than 5).

Compared with other subtypes, the excessively sleepy group had a more than threefold increased odds of prevalent heart failure, after adjustment for other CV risk factors. They also had a 1.7- to 2.3-fold increased risk for incident CV disease (P less than .001), CHD (P = .015) and heart failure (P = 0.018), after adjustment for other CV risk factors.

“Compared to individuals without OSA, the excessively sleepy subtype is the only subtype with increased risk of incident CV disease and CHD,” Dr. Mazzotti said. “It is possible that excessively sleepy OSA patients are more likely to benefit from CPAP therapy in preventing CV disease.” These results were published online earlier this year (Am J Respir Crit Care Med. 2019 Feb 15. doi: 10.1164/rccm.201808-1509OC).

Dr. Mazzotti reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Mazzotti D et al. SLEEP 2019, Abstract 0586.

SAN ANTONIO – Patients with obstructive sleep apnea who complain of feeling tired when they wake up, being sleepy during the day, and have a high score on the Epworth Sleepiness Scale face an increased risk for cardiovascular disease, results from a population-based analysis suggest.

Doug Brunk/MDedge News

“OSA is a highly heterogeneous disease, with multiple clinical presentations and consequences,” the study’s first author, Diego R. Mazzotti, PhD, said at the annual meeting of the Associated Professional Sleep Societies. “These patients also have diverse comorbidities, and there are arbitrary severity definitions and variable therapeutic responses. It’s difficult to lump these patients together.”

Symptom subtypes of OSA were originally described in the Icelandic Sleep Apnea Cohort, and defined as excessively sleepy, minimally symptomatic, and disturbed sleep (Eur Respir J. 2014; 44[6]:1600-7). These distinct clusters were identified based on symptom experiences and the existence of major comorbidities. “This concept is more popular today, trying to identify symptom clusters, or groups of individuals, that share similar polysomnographic data, and then compare differences in prevalence or incidence of cardiovascular disease,” said Dr. Mazzotti, a research associate at the University of Pennsylvania, Philadelphia. “That’s a concept that needs to be moving forward.”

Dr. Mazzotti and colleagues set out to determine if OSA symptom subtypes are present in the Sleep Heart Health Study, a multicenter, prospective, community-based cohort of individuals aged 40 years and older designed to assess the cardiovascular (CV) consequences of OSA. They also wanted to know if there is additional evidence of the relevance of OSA symptom subtypes, particularly with respect to cardiovascular disease .

Participant-reported symptoms, such as difficulty falling and staying asleep, snoring, fatigue, drowsy driving and daytime sleepiness, and responses to the Epworth Sleepiness Scale were used to determine the patient’s subtype. Assessments including questionnaires and in-home polysomnography were conducted at baseline (between 1995 and 1998) and follow-up (between 2001 and 2003), while CV outcomes were assessed until the end of follow-up (between 2008 and 2011).

In all, 1,207 patients from the Sleep Heart Health Study met criteria for moderate to severe OSA (apnea-hypopnea index, or AHI, of 15 or greater) and were included in the final analysis. They were followed for a mean of 12 years. Based on the clustering of symptoms, the researchers identified four OSA symptom subtypes: disturbed sleep (12%), minimally symptomatic (33%), excessively sleepy (17%), and moderately sleepy (38%) – proportions that were similar to those observed in prior studies.

The disturbed sleep subtype presented with increased prevalence of “insomnialike” symptoms, such as difficulty initiating or maintaining sleep, according to Dr. Mazzotti. “On the other hand, the excessively sleepy subtype presented with a very high prevalence of several symptoms related to excessive daytime sleepiness, while the moderately sleepy showed a moderately high prevalence of such symptoms, but not as much when compared to the excessively sleepy subtype,” he explained. “Finally, the minimally symptomatic subtype was found to have the lowest prevalence of all investigated symptoms, suggesting that these patients have low symptom burden. They do not complain as much, even though they have moderate-to-severe OSA.”

Next, Dr. Mazzotti and colleagues used Kaplan-Meier survival analysis and Cox proportional hazards models to evaluate whether subtypes were associated with incident coronary heart disease (CHD), heart failure, and CV disease, including CV mortality. Similar analyses were performed comparing each symptom subtype with 2,830 individuals without OSA (AHI less than 5).

Compared with other subtypes, the excessively sleepy group had a more than threefold increased odds of prevalent heart failure, after adjustment for other CV risk factors. They also had a 1.7- to 2.3-fold increased risk for incident CV disease (P less than .001), CHD (P = .015) and heart failure (P = 0.018), after adjustment for other CV risk factors.

“Compared to individuals without OSA, the excessively sleepy subtype is the only subtype with increased risk of incident CV disease and CHD,” Dr. Mazzotti said. “It is possible that excessively sleepy OSA patients are more likely to benefit from CPAP therapy in preventing CV disease.” These results were published online earlier this year (Am J Respir Crit Care Med. 2019 Feb 15. doi: 10.1164/rccm.201808-1509OC).

Dr. Mazzotti reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Mazzotti D et al. SLEEP 2019, Abstract 0586.

SAN ANTONIO – Patients with obstructive sleep apnea who complain of feeling tired when they wake up, being sleepy during the day, and have a high score on the Epworth Sleepiness Scale face an increased risk for cardiovascular disease, results from a population-based analysis suggest.

Doug Brunk/MDedge News

“OSA is a highly heterogeneous disease, with multiple clinical presentations and consequences,” the study’s first author, Diego R. Mazzotti, PhD, said at the annual meeting of the Associated Professional Sleep Societies. “These patients also have diverse comorbidities, and there are arbitrary severity definitions and variable therapeutic responses. It’s difficult to lump these patients together.”

Symptom subtypes of OSA were originally described in the Icelandic Sleep Apnea Cohort, and defined as excessively sleepy, minimally symptomatic, and disturbed sleep (Eur Respir J. 2014; 44[6]:1600-7). These distinct clusters were identified based on symptom experiences and the existence of major comorbidities. “This concept is more popular today, trying to identify symptom clusters, or groups of individuals, that share similar polysomnographic data, and then compare differences in prevalence or incidence of cardiovascular disease,” said Dr. Mazzotti, a research associate at the University of Pennsylvania, Philadelphia. “That’s a concept that needs to be moving forward.”

Dr. Mazzotti and colleagues set out to determine if OSA symptom subtypes are present in the Sleep Heart Health Study, a multicenter, prospective, community-based cohort of individuals aged 40 years and older designed to assess the cardiovascular (CV) consequences of OSA. They also wanted to know if there is additional evidence of the relevance of OSA symptom subtypes, particularly with respect to cardiovascular disease .

Participant-reported symptoms, such as difficulty falling and staying asleep, snoring, fatigue, drowsy driving and daytime sleepiness, and responses to the Epworth Sleepiness Scale were used to determine the patient’s subtype. Assessments including questionnaires and in-home polysomnography were conducted at baseline (between 1995 and 1998) and follow-up (between 2001 and 2003), while CV outcomes were assessed until the end of follow-up (between 2008 and 2011).

In all, 1,207 patients from the Sleep Heart Health Study met criteria for moderate to severe OSA (apnea-hypopnea index, or AHI, of 15 or greater) and were included in the final analysis. They were followed for a mean of 12 years. Based on the clustering of symptoms, the researchers identified four OSA symptom subtypes: disturbed sleep (12%), minimally symptomatic (33%), excessively sleepy (17%), and moderately sleepy (38%) – proportions that were similar to those observed in prior studies.

The disturbed sleep subtype presented with increased prevalence of “insomnialike” symptoms, such as difficulty initiating or maintaining sleep, according to Dr. Mazzotti. “On the other hand, the excessively sleepy subtype presented with a very high prevalence of several symptoms related to excessive daytime sleepiness, while the moderately sleepy showed a moderately high prevalence of such symptoms, but not as much when compared to the excessively sleepy subtype,” he explained. “Finally, the minimally symptomatic subtype was found to have the lowest prevalence of all investigated symptoms, suggesting that these patients have low symptom burden. They do not complain as much, even though they have moderate-to-severe OSA.”

Next, Dr. Mazzotti and colleagues used Kaplan-Meier survival analysis and Cox proportional hazards models to evaluate whether subtypes were associated with incident coronary heart disease (CHD), heart failure, and CV disease, including CV mortality. Similar analyses were performed comparing each symptom subtype with 2,830 individuals without OSA (AHI less than 5).

Compared with other subtypes, the excessively sleepy group had a more than threefold increased odds of prevalent heart failure, after adjustment for other CV risk factors. They also had a 1.7- to 2.3-fold increased risk for incident CV disease (P less than .001), CHD (P = .015) and heart failure (P = 0.018), after adjustment for other CV risk factors.

“Compared to individuals without OSA, the excessively sleepy subtype is the only subtype with increased risk of incident CV disease and CHD,” Dr. Mazzotti said. “It is possible that excessively sleepy OSA patients are more likely to benefit from CPAP therapy in preventing CV disease.” These results were published online earlier this year (Am J Respir Crit Care Med. 2019 Feb 15. doi: 10.1164/rccm.201808-1509OC).

Dr. Mazzotti reported having no financial disclosures.

dbrunk@mdedge.com

SOURCE: Mazzotti D et al. SLEEP 2019, Abstract 0586.

Acute exacerbations in chronic obstructive pulmonary disease could also trigger a cardiac event such as MI or stroke, particularly in older individuals, new research has found.

In Respirology, researchers report the outcomes of a nationwide, register-based study involving 118,807 patients with chronic obstructive pulmonary disease (COPD) who experienced a major adverse cardiac event after an exacerbation.

They found that the risk of any major cardiac adverse event increased 270% in the 4 weeks after the onset of an exacerbation (95% confidence interval, 3.60-3.80). The strongest association was seen for cardiovascular death, for which there was a 333% increase in risk, but there was also a 257% increase in the risk of acute MI and 178% increase in the risk of stroke.

The risk of major adverse cardiac events was even higher among individuals who were hospitalized because of their COPD exacerbation (odds ratio, 5.92), compared with a 150% increase in risk among those who weren’t hospitalized but were treated with oral corticosteroids and 108% increase among those treated with amoxicillin with enzyme inhibitors.

The risk of a major cardiac event after a COPD exacerbation also increased with age. Among individuals younger than 55 years, there was a 131% increase in risk, but among those aged 55-69 years there was a 234% increase, among those aged 70-79 years the risk increased 282%, and among those aged 80 years and older it increased 318%.

Mette Reilev, from the department of public health at the University of Southern Denmark, Odense, and coauthors suggested that acute exacerbations were associated with elevated levels of systemic inflammatory markers such as fibrinogen and interleukin-6, which were potently prothrombotic and could potentially trigger cardiovascular events.

“Additionally, exacerbations may trigger type II myocardial infarctions secondary to an imbalance in oxygen supply and demand,” they wrote.

The authors raised the question of whether cardiovascular prevention strategies should be part of treatment recommendations for people with COPD, and suggested that prevention of COPD exacerbations could be justified even on cardiovascular grounds alone.

“Studies investigating the effect of cardiovascular treatment on the course of disease among COPD exacerbators are extremely scarce,” they wrote. “Thus, it is currently unknown how to optimize treatment and mitigate the increased risk of [major adverse cardiovascular events] following the onset of exacerbations.”

However, they noted that prednisolone treatment for more severe exacerbations may have a confounding effect, as oral corticosteroids could induce dyslipidemia, hypertension, and hyperglycemia, and increase long-term cardiovascular risk.

Six authors declared funding from the pharmaceutical industry – three of which were institutional support – unrelated to the study.

SOURCE: Reilev M et al. Respirology. 2019 Jun 21. doi: 10.1111/resp.13620.

Acute exacerbations in chronic obstructive pulmonary disease could also trigger a cardiac event such as MI or stroke, particularly in older individuals, new research has found.

In Respirology, researchers report the outcomes of a nationwide, register-based study involving 118,807 patients with chronic obstructive pulmonary disease (COPD) who experienced a major adverse cardiac event after an exacerbation.

They found that the risk of any major cardiac adverse event increased 270% in the 4 weeks after the onset of an exacerbation (95% confidence interval, 3.60-3.80). The strongest association was seen for cardiovascular death, for which there was a 333% increase in risk, but there was also a 257% increase in the risk of acute MI and 178% increase in the risk of stroke.

The risk of major adverse cardiac events was even higher among individuals who were hospitalized because of their COPD exacerbation (odds ratio, 5.92), compared with a 150% increase in risk among those who weren’t hospitalized but were treated with oral corticosteroids and 108% increase among those treated with amoxicillin with enzyme inhibitors.

The risk of a major cardiac event after a COPD exacerbation also increased with age. Among individuals younger than 55 years, there was a 131% increase in risk, but among those aged 55-69 years there was a 234% increase, among those aged 70-79 years the risk increased 282%, and among those aged 80 years and older it increased 318%.

Mette Reilev, from the department of public health at the University of Southern Denmark, Odense, and coauthors suggested that acute exacerbations were associated with elevated levels of systemic inflammatory markers such as fibrinogen and interleukin-6, which were potently prothrombotic and could potentially trigger cardiovascular events.

“Additionally, exacerbations may trigger type II myocardial infarctions secondary to an imbalance in oxygen supply and demand,” they wrote.

The authors raised the question of whether cardiovascular prevention strategies should be part of treatment recommendations for people with COPD, and suggested that prevention of COPD exacerbations could be justified even on cardiovascular grounds alone.

“Studies investigating the effect of cardiovascular treatment on the course of disease among COPD exacerbators are extremely scarce,” they wrote. “Thus, it is currently unknown how to optimize treatment and mitigate the increased risk of [major adverse cardiovascular events] following the onset of exacerbations.”

However, they noted that prednisolone treatment for more severe exacerbations may have a confounding effect, as oral corticosteroids could induce dyslipidemia, hypertension, and hyperglycemia, and increase long-term cardiovascular risk.

Six authors declared funding from the pharmaceutical industry – three of which were institutional support – unrelated to the study.

SOURCE: Reilev M et al. Respirology. 2019 Jun 21. doi: 10.1111/resp.13620.

Acute exacerbations in chronic obstructive pulmonary disease could also trigger a cardiac event such as MI or stroke, particularly in older individuals, new research has found.

In Respirology, researchers report the outcomes of a nationwide, register-based study involving 118,807 patients with chronic obstructive pulmonary disease (COPD) who experienced a major adverse cardiac event after an exacerbation.

They found that the risk of any major cardiac adverse event increased 270% in the 4 weeks after the onset of an exacerbation (95% confidence interval, 3.60-3.80). The strongest association was seen for cardiovascular death, for which there was a 333% increase in risk, but there was also a 257% increase in the risk of acute MI and 178% increase in the risk of stroke.

The risk of major adverse cardiac events was even higher among individuals who were hospitalized because of their COPD exacerbation (odds ratio, 5.92), compared with a 150% increase in risk among those who weren’t hospitalized but were treated with oral corticosteroids and 108% increase among those treated with amoxicillin with enzyme inhibitors.

The risk of a major cardiac event after a COPD exacerbation also increased with age. Among individuals younger than 55 years, there was a 131% increase in risk, but among those aged 55-69 years there was a 234% increase, among those aged 70-79 years the risk increased 282%, and among those aged 80 years and older it increased 318%.

Mette Reilev, from the department of public health at the University of Southern Denmark, Odense, and coauthors suggested that acute exacerbations were associated with elevated levels of systemic inflammatory markers such as fibrinogen and interleukin-6, which were potently prothrombotic and could potentially trigger cardiovascular events.

“Additionally, exacerbations may trigger type II myocardial infarctions secondary to an imbalance in oxygen supply and demand,” they wrote.

The authors raised the question of whether cardiovascular prevention strategies should be part of treatment recommendations for people with COPD, and suggested that prevention of COPD exacerbations could be justified even on cardiovascular grounds alone.

“Studies investigating the effect of cardiovascular treatment on the course of disease among COPD exacerbators are extremely scarce,” they wrote. “Thus, it is currently unknown how to optimize treatment and mitigate the increased risk of [major adverse cardiovascular events] following the onset of exacerbations.”

However, they noted that prednisolone treatment for more severe exacerbations may have a confounding effect, as oral corticosteroids could induce dyslipidemia, hypertension, and hyperglycemia, and increase long-term cardiovascular risk.

Six authors declared funding from the pharmaceutical industry – three of which were institutional support – unrelated to the study.

SOURCE: Reilev M et al. Respirology. 2019 Jun 21. doi: 10.1111/resp.13620.

The ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV₁:FVC) at the recommended threshold of 0.70 effectively diagnosed individuals at risk for clinically significant COPD, a longitudinal study of more than 24,000 individuals has found.

Guidelines from respiratory societies have long recommended a diagnosis of airflow obstruction when the FEV₁:FVC is less than 0.70, but no rigorous, population-based studies have been conducted to support this recommendation, wrote Surya P. Bhatt, MD, of the University of Alabama at Birmingham, and colleagues.

“The selection of a threshold for defining airflow obstruction has major implications for patient care and public health as the prevalence of airflow obstruction can vary by as much as 33% depending on which threshold is selected,” they said.

In a study published in JAMA, the researchers reviewed data from 24,207 participants in the National Heart, Lung, and Blood Institute Pooled Cohorts Study to assess the accuracy of different thresholds in predicting COPD events in a large, multiethnic, U.S. population. All participants underwent spirometry; the average age at spirometry was 63 years, and 54% of the patients were women. Patients were enrolled during 1987-2000 and received follow-up longitudinally through 2016.

Overall, 3,925 participants experienced COPD-related events during an average of 15 years of follow-up (more than 340,757 person-years). These events included 3,563 hospitalizations and 447 deaths related to COPD.

The researchers compared three thresholds for FEV₁:FVC ratios: a fixed optimal threshold of 0.71, a lower limit of normal (LLN) defined as 0.034, and the currently recommended 0.70.

The optimal 0.71 was not significantly different from the recommended 0.70 but was significantly more accurate than the LLN of 0.034. In addition, the 0.70 value was the optimal predictor in a subgroup analysis of ever-smokers and in multivariate analysis.

The findings were limited by several factors including the use of prebronchodilator spirometry, lack of adjustment for medication use, and limitation of outcomes to COPD mortality or clinical events mainly caused by COPD, which might exclude patients with mild to moderate disease, the researchers noted.

However, the study “provides population-based evidence to support 0.70 as the optimal FEV₁:FVC threshold for defining clinically significant airflow obstruction,” to help clinicians identify patients at increased risk for significant COPD, they said.

Lead author Dr. Bhatt disclosed a National Institutes of Health grant, consulting fees from Sunovion and research funds from Proterix Bio. The study was supported by grants from multiple agencies of the National Institutes of Health, including the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

SOURCE: Bhatt SP et al. JAMA. 2019. 321:2438-47.

The ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV₁:FVC) at the recommended threshold of 0.70 effectively diagnosed individuals at risk for clinically significant COPD, a longitudinal study of more than 24,000 individuals has found.

Guidelines from respiratory societies have long recommended a diagnosis of airflow obstruction when the FEV₁:FVC is less than 0.70, but no rigorous, population-based studies have been conducted to support this recommendation, wrote Surya P. Bhatt, MD, of the University of Alabama at Birmingham, and colleagues.

“The selection of a threshold for defining airflow obstruction has major implications for patient care and public health as the prevalence of airflow obstruction can vary by as much as 33% depending on which threshold is selected,” they said.

In a study published in JAMA, the researchers reviewed data from 24,207 participants in the National Heart, Lung, and Blood Institute Pooled Cohorts Study to assess the accuracy of different thresholds in predicting COPD events in a large, multiethnic, U.S. population. All participants underwent spirometry; the average age at spirometry was 63 years, and 54% of the patients were women. Patients were enrolled during 1987-2000 and received follow-up longitudinally through 2016.

Overall, 3,925 participants experienced COPD-related events during an average of 15 years of follow-up (more than 340,757 person-years). These events included 3,563 hospitalizations and 447 deaths related to COPD.

The researchers compared three thresholds for FEV₁:FVC ratios: a fixed optimal threshold of 0.71, a lower limit of normal (LLN) defined as 0.034, and the currently recommended 0.70.

The optimal 0.71 was not significantly different from the recommended 0.70 but was significantly more accurate than the LLN of 0.034. In addition, the 0.70 value was the optimal predictor in a subgroup analysis of ever-smokers and in multivariate analysis.

The findings were limited by several factors including the use of prebronchodilator spirometry, lack of adjustment for medication use, and limitation of outcomes to COPD mortality or clinical events mainly caused by COPD, which might exclude patients with mild to moderate disease, the researchers noted.

However, the study “provides population-based evidence to support 0.70 as the optimal FEV₁:FVC threshold for defining clinically significant airflow obstruction,” to help clinicians identify patients at increased risk for significant COPD, they said.

Lead author Dr. Bhatt disclosed a National Institutes of Health grant, consulting fees from Sunovion and research funds from Proterix Bio. The study was supported by grants from multiple agencies of the National Institutes of Health, including the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

SOURCE: Bhatt SP et al. JAMA. 2019. 321:2438-47.

The ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV₁:FVC) at the recommended threshold of 0.70 effectively diagnosed individuals at risk for clinically significant COPD, a longitudinal study of more than 24,000 individuals has found.

Guidelines from respiratory societies have long recommended a diagnosis of airflow obstruction when the FEV₁:FVC is less than 0.70, but no rigorous, population-based studies have been conducted to support this recommendation, wrote Surya P. Bhatt, MD, of the University of Alabama at Birmingham, and colleagues.

“The selection of a threshold for defining airflow obstruction has major implications for patient care and public health as the prevalence of airflow obstruction can vary by as much as 33% depending on which threshold is selected,” they said.

In a study published in JAMA, the researchers reviewed data from 24,207 participants in the National Heart, Lung, and Blood Institute Pooled Cohorts Study to assess the accuracy of different thresholds in predicting COPD events in a large, multiethnic, U.S. population. All participants underwent spirometry; the average age at spirometry was 63 years, and 54% of the patients were women. Patients were enrolled during 1987-2000 and received follow-up longitudinally through 2016.

Overall, 3,925 participants experienced COPD-related events during an average of 15 years of follow-up (more than 340,757 person-years). These events included 3,563 hospitalizations and 447 deaths related to COPD.

The researchers compared three thresholds for FEV₁:FVC ratios: a fixed optimal threshold of 0.71, a lower limit of normal (LLN) defined as 0.034, and the currently recommended 0.70.

The optimal 0.71 was not significantly different from the recommended 0.70 but was significantly more accurate than the LLN of 0.034. In addition, the 0.70 value was the optimal predictor in a subgroup analysis of ever-smokers and in multivariate analysis.

The findings were limited by several factors including the use of prebronchodilator spirometry, lack of adjustment for medication use, and limitation of outcomes to COPD mortality or clinical events mainly caused by COPD, which might exclude patients with mild to moderate disease, the researchers noted.

However, the study “provides population-based evidence to support 0.70 as the optimal FEV₁:FVC threshold for defining clinically significant airflow obstruction,” to help clinicians identify patients at increased risk for significant COPD, they said.

Lead author Dr. Bhatt disclosed a National Institutes of Health grant, consulting fees from Sunovion and research funds from Proterix Bio. The study was supported by grants from multiple agencies of the National Institutes of Health, including the National Heart, Lung, and Blood Institute, the National Institute of Neurological Disorders and Stroke, and the National Institute on Aging.

SOURCE: Bhatt SP et al. JAMA. 2019. 321:2438-47.

When making prescribing decisions, health care professionals should assume that apps for depression and smoking cessation will share user data with third parties despite claims made in privacy policy statements, recent research shows.

“Mechanisms that potentially enable a small number of dominant online service providers to link information about the use of mental health apps, without either user consent or awareness, appear to be prevalent,” Kit Huckvale, MB ChB, MSc, PhD, of Black Dog Institute at the University of New South Wales Sydney in Randwick, New South Wales, Australia, and colleagues wrote in their study. “Mismatches between declared privacy policies and observed behavior highlight the continuing need for innovation around trust and transparency for health apps.” The study was published in JAMA Network Open.

Dr. Huckvale and colleagues examined the top 36 depression and smoking cessation apps for Android and iOS in the United States accessed in January 2018; Of the apps downloaded, 15 apps were Android-only, 14 apps were iOS-only, and 7 apps were available on both platforms. The apps were assessed over a series of two sessions while network traffic was captured during use, which allowed researchers to determine what personal information was in each data transmission and where the information was going.

There were 25 apps with a privacy policy (69%), 22 of 25 apps (88%) described how that app primarily collected data, and only 16 of 25 apps (64%) provided information on secondary uses of data. Despite 23 of 25 apps (92%) addressing “the possibility of transmission of data to any third party,” 33 of 36 apps overall (92%) transmitted data to third parties. The two most common entities that received third-party data for marketing, advertising, or analytic purposes were Google and Facebook (29 of 36 apps; 81%). However, 12 of 28 apps (43%) that sent data to Google and 6 of 12 apps (50%) that sent data to Facebook disclosed that they would share data with those companies.

The type of data sent to Google and Facebook consisted of a strong identifier to the device or a username (9 of 33 apps; 27%), or a weak identifier in the form of an advertising identifier or a pseudonymous profile that can link users to their behavior on the app and on other products and platforms (26 of 33 apps; 79%).

“As smartphones continue to gain capabilities to collect new forms of personal, biometric, and health information, it is imperative for the health care community to respond with new methods and processes to review apps and ensure they remain safe and protect personal health information,” the researchers concluded.

One of the investigators, Mark E. Larsen, DPhil, reported receiving grants from National Health and Medical Research Council. The other authors reported no relevant conflicts of interest.

SOURCE: Huckvale K et al. JAMA Netw Open. 2019. doi: 10.1001/jamanetworkopen.2019.2542.

When making prescribing decisions, health care professionals should assume that apps for depression and smoking cessation will share user data with third parties despite claims made in privacy policy statements, recent research shows.

“Mechanisms that potentially enable a small number of dominant online service providers to link information about the use of mental health apps, without either user consent or awareness, appear to be prevalent,” Kit Huckvale, MB ChB, MSc, PhD, of Black Dog Institute at the University of New South Wales Sydney in Randwick, New South Wales, Australia, and colleagues wrote in their study. “Mismatches between declared privacy policies and observed behavior highlight the continuing need for innovation around trust and transparency for health apps.” The study was published in JAMA Network Open.

Dr. Huckvale and colleagues examined the top 36 depression and smoking cessation apps for Android and iOS in the United States accessed in January 2018; Of the apps downloaded, 15 apps were Android-only, 14 apps were iOS-only, and 7 apps were available on both platforms. The apps were assessed over a series of two sessions while network traffic was captured during use, which allowed researchers to determine what personal information was in each data transmission and where the information was going.

There were 25 apps with a privacy policy (69%), 22 of 25 apps (88%) described how that app primarily collected data, and only 16 of 25 apps (64%) provided information on secondary uses of data. Despite 23 of 25 apps (92%) addressing “the possibility of transmission of data to any third party,” 33 of 36 apps overall (92%) transmitted data to third parties. The two most common entities that received third-party data for marketing, advertising, or analytic purposes were Google and Facebook (29 of 36 apps; 81%). However, 12 of 28 apps (43%) that sent data to Google and 6 of 12 apps (50%) that sent data to Facebook disclosed that they would share data with those companies.

The type of data sent to Google and Facebook consisted of a strong identifier to the device or a username (9 of 33 apps; 27%), or a weak identifier in the form of an advertising identifier or a pseudonymous profile that can link users to their behavior on the app and on other products and platforms (26 of 33 apps; 79%).

“As smartphones continue to gain capabilities to collect new forms of personal, biometric, and health information, it is imperative for the health care community to respond with new methods and processes to review apps and ensure they remain safe and protect personal health information,” the researchers concluded.

One of the investigators, Mark E. Larsen, DPhil, reported receiving grants from National Health and Medical Research Council. The other authors reported no relevant conflicts of interest.

SOURCE: Huckvale K et al. JAMA Netw Open. 2019. doi: 10.1001/jamanetworkopen.2019.2542.

When making prescribing decisions, health care professionals should assume that apps for depression and smoking cessation will share user data with third parties despite claims made in privacy policy statements, recent research shows.

“Mechanisms that potentially enable a small number of dominant online service providers to link information about the use of mental health apps, without either user consent or awareness, appear to be prevalent,” Kit Huckvale, MB ChB, MSc, PhD, of Black Dog Institute at the University of New South Wales Sydney in Randwick, New South Wales, Australia, and colleagues wrote in their study. “Mismatches between declared privacy policies and observed behavior highlight the continuing need for innovation around trust and transparency for health apps.” The study was published in JAMA Network Open.

Dr. Huckvale and colleagues examined the top 36 depression and smoking cessation apps for Android and iOS in the United States accessed in January 2018; Of the apps downloaded, 15 apps were Android-only, 14 apps were iOS-only, and 7 apps were available on both platforms. The apps were assessed over a series of two sessions while network traffic was captured during use, which allowed researchers to determine what personal information was in each data transmission and where the information was going.

There were 25 apps with a privacy policy (69%), 22 of 25 apps (88%) described how that app primarily collected data, and only 16 of 25 apps (64%) provided information on secondary uses of data. Despite 23 of 25 apps (92%) addressing “the possibility of transmission of data to any third party,” 33 of 36 apps overall (92%) transmitted data to third parties. The two most common entities that received third-party data for marketing, advertising, or analytic purposes were Google and Facebook (29 of 36 apps; 81%). However, 12 of 28 apps (43%) that sent data to Google and 6 of 12 apps (50%) that sent data to Facebook disclosed that they would share data with those companies.

The type of data sent to Google and Facebook consisted of a strong identifier to the device or a username (9 of 33 apps; 27%), or a weak identifier in the form of an advertising identifier or a pseudonymous profile that can link users to their behavior on the app and on other products and platforms (26 of 33 apps; 79%).

“As smartphones continue to gain capabilities to collect new forms of personal, biometric, and health information, it is imperative for the health care community to respond with new methods and processes to review apps and ensure they remain safe and protect personal health information,” the researchers concluded.

One of the investigators, Mark E. Larsen, DPhil, reported receiving grants from National Health and Medical Research Council. The other authors reported no relevant conflicts of interest.

SOURCE: Huckvale K et al. JAMA Netw Open. 2019. doi: 10.1001/jamanetworkopen.2019.2542.