Novotny, Paul J.

Background: Socioeconomic status (SES) is an important determinant of disparities in health care and may play a role in end-of-life care and decision-making. The SES is difficult to retrospectively abstract from current electronic medical records and data sets. Objective: Using a validated SES measuring tool derived from home address, the HOUsing-based SocioEconomic Status index, termed HOUSES we wanted to determine whether SES is associated with differences in end-of-life care and decision-making. Design/Setting/Participants: This cross-sectional study utilized a cohort of Olmsted County adult residents admitted to 7 intensive care units (ICUs) at Mayo Rochester between June 1, 2011, and May 31, 2014. Measurements: Multiple variables that reflect decision-making and care at end of life and during critical illness were evaluated, including presence of advance directives and discharge disposition. The SES was measured by individual housing-based SES index (HOUSES index; a composite index derived from real property as a standardized z-score) at the date of admission to the ICU which was then divided into 4 quartiles. The greater HOUSES, the higher SES, outcomes were adjusted for age, 24-hour Acute Physiology and Chronic Health Evaluation III score, sex, race/ethnicity, and insurance. Results: Among the eligible 4134 participants, the addresses of 3393 (82%) were successfully geocoded and formulated into HOUSES. The adjusted odds ratios comparing HOUSES 1 versus 2, 3, and 4 demonstrated lower likelihood of advance directives −0.77(95% CI: 0.63-0.93) and lower likelihood of discharge to home −0.60(95% CI: 1.0.5-0.72). Conclusion: Lower SES, derived from a composite index of housing attributes, was associated with lower rates of advance directives and lower likelihood of discharge to home.

Exercise capacity (EC) is a critical outcome in chronic obstructive lung disease (chronic obstructive pulmonary disease (COPD)). It measures the impact of the disease and the effect of specific interventions like pulmonary rehabilitation (PR). EC determines COPD prognosis and is associated with health-care utilization and quality of life. Field walking tests and cardiopulmonary exercise test (CPET) are two ways to measure EC. The 6-minute walking test (6MWT) is the commonest and easiest field test. CPET has the advantage of assessing maximal aerobic capacity. Determinants of EC include age, gender, breathlessness, and lung function. Previous research suggests that socioeconomic status (SES), a meaningful factor in COPD, may also be associated with EC. However, those findings have not been replicated. We aimed to determine whether SES is an independent factor associated with EC in COPD. For this analysis, we used the National Emphysema Treatment Trial (NETT) database. NETT was a multicenter clinical trial where severe COPD patients were randomized to lung volume reduction surgery or medical therapy. Measures used were taken at baseline, postrehabilitation. Patients self-reported their income and were divided in two groups whether it was less or above US$30,000. Patients with a lower income had worse results in 6MWT ( p < 0.0001). We found an independent association between income and the 6MWT in patients with severe COPD after adjusting for age, gender, lung function, dyspnea, and living conditions ( p < 0.0007). One previous publication stated the relationship between income and EC. Our research confirms and extends previous publications associating EC with income by studying a large and well characterized cohort of severe COPD patients, also addressing EC by two different methods (maximal watts and 6MWT). Our results highlight the importance of addressing social determinants of health such as income when assessing COPD patients.

Abstract Rationale Frailty represents an increased vulnerability to adverse health outcomes. The frailty phenotype conceptual model (three or more patient attributes of wasting, exhaustion, low activity, slowness, and weakness) is associated with increased morbidity and mortality in geriatric populations. Objectives Our objective was to describe the risks associated with frailty in patients with chronic obstructive pulmonary disease. Methods Data from the National Emphysema Treatment Trial (NETT) were retrospectively analyzed. The frailty phenotype conceptual model was operationalized as three or more frailty parameters (a body mass index decrease of ≥5% over 12 months, self-reported exhaustion, low 6-minute walk distance, or physical activity or respiratory muscle strength in the lowest quartile). Frail participants were compared with participants with two or fewer frailty parameters. Participants were followed starting 12 months after NETT randomization (to minimize surgical effect) for 24 months. Univariate, multivariate, Kaplan-Meier, and Cox proportional hazard analyses were performed, adjusting for treatment arm, age, modified Medical Research Council dyspnea scale, sex, and baseline forced expiratory volume in 1 second (FEV1). Multiple imputation was used for missing values. Results The participants (N = 902) were predominantly white (94.5%) males (59.5%), with a median age of 67 years (interquartile range, 63–70 yr) and a median FEV1% predicted of 26 (interquartile range, 20–33). Six percent of the participants (95% confidence interval [CI], 4.5 to 7.6) were frail. The incidence rate of frailty was 6.4 per 100 person-years. Frail participants reported significantly worse disease-specific and overall quality of life by St. George’s Respiratory Questionnaire total score (mean difference of 11.6; 95% CI, 7.6 to 15.6; P &lt; 0.001), mental composite on Medical Outcomes Survey Short Form-36 (mean difference −6.8; 95% CI, −10.0 to −3.6; P &lt; 0.001), and physical composite scores on Medical Outcomes Survey Short Form-36 (mean difference −16.7; 95% CI, −21.3 to −12.1; P = 0.001). Frail participants had an increased rate of hospitalization (adjusted hazard ratio, 1.6; 95% CI, 1.1 to 2.5; P = 0.02) and an adjusted increase in hospital use of 8.0 days (95% CI, 4.4 to 11.6; P &lt; 0.001) compared with nonfrail participants. Frail participants had a higher mortality rate (adjusted hazard ratio, 1.4; 95% CI, 0.97 to 2.0; P = 0.07). Conclusions Among adults with chronic obstructive pulmonary disease, our measure of frailty (modified from the Fried frailty phenotype) was associated with incident and longer-duration hospitalization, and with poor quality of life.

174 Background: Patient-reported outcomes (PROs), including physical function and quality of life (QOL), are important outcomes in cancer patients. Emoji are a near-universal, popular form of communication, understandable by diverse populations, including those with low health literacy. We aimed to explore whether emoji could be a valid, reliable scale for assessing PROs in cancer patients. Methods: To develop the emoji scale, 5 emoji faces were selected from the Apple emoji dictionary by study authors. 20 cancer patients participated in a card-sorting exercise to rank the emoji from negative to positive; 19 out of 20 selected the same order, which exceeded Coomb’s criteria for being a valid ordinal scale. Patients were recruited from Mayo Clinic practices. Eligibility included: adult patients with a diagnosis of lymphoma, multiple myeloma, brain, pancreatic, breast, and ovarian cancer within the past 5 years; life expectancy of > 6 months; and own an iPhone version ≥ 5.0. All patients were provided with an Apple Watch and downloaded the study app. Baseline PRO data was collected on the iPhone, including single-item linear analog self-assessments (LASA) and emoji scales for fatigue, physical function, emotional well-being, and overall QOL. Results: From 2/2017-8/2017, 294 eligible patients were recruited. 25% were male, and median age was 53 years (range 20-79). The median time since diagnosis was 8.4 months (range 0-60); 63% were on active therapy, 27% were in observation post-treatment, and 10% had not been treated. All patients were “extremely” confident filling out forms, 99% had used a computer in the past 12 months, and 27% had ever used a smart watch. Emoji responses were significantly associated with validated measures of PROs; the Spearman correlations between the ordinal emoji scales and LASAs were -0.83 for fatigue, 0.72 for physical well-being, 0.72 for emotional well-being, and 0.77 for overall QOL (all p < 0.0001). Of the 75 patients who have completed the study thus far, 92% reported they would use emoji scales again and 89% would recommend that others use emoji scales. Conclusions: A novel ordinal emoji scale is strongly associated with accepted measures of PROs in cancer patients and should be studied further.