CONTEXT: Clinical decision support systems (CDSSs) can help clinicians assess cardiovascular disease (CVD) risk and manage CVD risk factors by providing tailored assessments and treatment recommendations based on individual patient data. The goal of this systematic review was to examine the effectiveness of CDSSs in improving screening for CVD risk factors, practices for CVD-related preventive care services such as clinical tests and prescribed treatments, and management of CVD risk factors. EVIDENCE ACQUISITION: An existing systematic review (search period, January 1975-January 2011) of CDSSs for any condition was initially identified. Studies of CDSSs that focused on CVD prevention in that review were combined with studies identified through an updated search (January 2011-October 2012). Data analysis was conducted in 2013. EVIDENCE SYNTHESIS: A total of 45 studies qualified for inclusion in the review. Improvements were seen for recommended screening and other preventive care services completed by clinicians, recommended clinical tests completed by clinicians, and recommended treatments prescribed by clinicians (median increases of 3.8, 4.0, and 2.0 percentage points, respectively). Results were inconsistent for changes in CVD risk factors such as systolic and diastolic blood pressure, total and low-density lipoprotein cholesterol, and hemoglobin A1C levels. CONCLUSIONS: CDSSs are effective in improving clinician practices related to screening and other preventive care services, clinical tests, and treatments. However, more evidence is needed from implementation of CDSSs within the broad context of comprehensive service delivery aimed at reducing CVD risk and CVD-related morbidity and mortality.

BACKGROUND: Current asthma prevalence among adults in the United States has reached historically high levels. Although national-level estimates indicate that asthma prevalence among adults increased by 33% from 2000 to 2009, state-specific temporal trends of current asthma prevalence and their contributing risk factors have not been explored. METHODS: We used 2000-2009 Behavioral Risk Factor Surveillance System data from all 50 states and the District of Columbia (D.C.) to estimate state-specific current asthma prevalence by 2-year periods (2000-2001, 2002-2003, 2004-2005, 2006-2007, 2008-2009). We fitted a series of four logistic-regression models for each state to evaluate whether there was a statistically significant linear change in the current asthma prevalence over time, accounting for sociodemographic factors, smoking status, and weight status (using body mass index as the indicator). RESULTS: During 2000-2009, current asthma prevalence increased in all 50 states and D.C., with significant increases in 46/50 (92%) states and D.C. After accounting for weight status in the model series with sociodemographic factors, and smoking status, 10 states (AR, AZ, IA, IL, KS, ME, MT, UT, WV, and WY) that had previously shown a significant increase did not show a significant increase in current asthma prevalence. CONCLUSIONS: There was a significant increasing trend in state-specific current asthma prevalence among adults from 2000 to 2009 in most states in the United States. Obesity prevalence appears to contribute to increased current asthma prevalence in some states.

Currently in the U.S., approximately 7 million children (9.4%) have asthma (1), making it the most prevalent serious chronic illness among U.S. children. Clinically, the association of viral respiratory infections and asthma exacerbations has been understood for decades. More recently, infections with particular viruses have been identified as being particularly risky: respiratory syncytial virus, rhinovirus, and influenza virus are notable examples. In the spring of 2009, a new influenza virus (A(H1N1)pdm09 [2009 H1N1]) with pandemic potential was isolated from patients in the U.S. and around the world (2). Early data indicated that certain comorbid medical conditions increased the risk for hospitalization and intensive care unit admission (3). Persons with asthma appeared to bear a disproportionate risk, and local and state health departments along with Centers for Disease Control and Prevention (CDC) developed and disseminated guidance early in the outbreak for persons with asthma and their health care providers. Early diagnosis and use of antiviral medication, along with public health practices like self-distancing and hand-washing, were emphasized. Persons with comorbid conditions (including asthma) were prioritized to receive vaccine once it became available. These recommendations, however, were more re-iterations of existing practices and policies rather than de novo interventions. As was consistent with previous recommendations, vaccination of persons with asthma was to prevent influenza because of the risk of increased disease severity, rather than increased risk of becoming infected with influenza virus. Analysis of existing data did not, at that point in time, support (nor refute) an increased risk of infection among persons with asthma.

OBJECTIVE: For over three decades, the greatest burden of asthma deaths has occurred among persons aged 65 years and older. This study analyzed the association between increasing age and asthma prevalence among age groups within the US elderly population. METHODS: We analyzed aggregated data on 54,485 civilian, noninstitutionalized US adults aged 65 years and older from the 2001-2010 National Health Interview Survey (NHIS). We estimated the prevalence of current asthma, lifetime asthma, and chronic obstructive pulmonary disease (COPD) among US elderly by 5-year age groups and age stages ("young elderly" aged 65-84 years and "oldest old" aged ≥85 years). We calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) to identify asthma prevalence patterns among elderly populations. RESULTS: From 2001 to 2010, the estimated average annual prevalence of current asthma among US elderly was 7.0%. Estimates of lifetime asthma, COPD, and co-occurring current asthma and COPD were 9.9%, 9.7%, and 3.0%, respectively. Prevalence of asthma decreased with advancing age while prevalence of COPD increased with advancing age. When controlling for study variables and significant interactions (p = .05) with COPD, the odds of reporting current asthma decreased with advancing age: 0.87 (95% CI, 0.76-1.01) for 70- to 74-year-olds; 0.76 (95% CI, 0.66-0.87) for 75- to 79-year-olds; 0.62 (95% CI, 0.51-0.75) for 80- to 84-year-olds; and 0.45 (95% CI, 0.36-0.55) for ≥85-year-olds, as compared to 65- to 69-year-olds. CONCLUSIONS: Asthma continues to affect a substantial proportion of the US elderly population. Increased diagnosis of COPD may overshadow correct diagnosis and treatment in populations with advancing age. Treatment guidelines should focus on preventable risk behaviors to increase the quality of life within this population.

BACKGROUND: The 2009 pandemic influenza A (H1N1) virus (2009 H1N1) was first identified in April 2009 and quickly spread around the world. The first doses of influenza A (H1N1) 2009 monovalent vaccine (2009 H1N1 vaccine) became available in the U.S. in early October 2009. Because people with asthma are at increased risk of complications from influenza, people with asthma were included among the initial prioritized groups. PURPOSE: To evaluate 2009 H1N1 vaccination coverage and identify factors independently associated with vaccination among adults with asthma in the U.S. METHODS: Data from the 2009-2010 BRFSS (Behavioral Risk Factor Surveillance System) influenza supplemental survey were used; responses from March through June 2010 were analyzed to estimate vaccination levels of 2009 H1N1 vaccine among respondents aged 25-64 years with asthma. Multivariable logistic regression and predictive marginal models were performed to identify factors independently associated with vaccination. RESULTS: Among adults aged 25-64 years with asthma, 25.5% (95% CI=23.9%, 27.2%) received the 2009 H1N1 vaccination. Vaccination coverage ranged from 9.9% (95% CI=6.4%, 15.1%) in Mississippi to 46.1% (95% CI=33.3%, 61.2%) in Maine. Characteristics independently associated with an increased likelihood of vaccination among adults with asthma were as follows: had a primary doctor, had other high-risk conditions, and received seasonal influenza vaccination in the 2009-2010 season. CONCLUSIONS: Vaccination coverage among adults aged 25-64 years with asthma was only 25.5% and varied widely by state and demographic characteristics. National and state-specific 2009 H1N1 vaccination coverage data for adults with asthma are useful for evaluating the vaccination campaign and for planning and implementing strategies for increasing vaccination coverage in possible future pandemics.

TO THE EDITOR: In response to the emergence of pandemic (H1N1) 2009 virus (1), the Centers for Disease Control and Prevention (CDC) issued interim guidance for preventing spread of the pandemic virus in schools. Initial guidance recommended that dismissal of students be considered for schools with confirmed cases of pandemic (H1N1) 2009 infection. The guidance was subsequently revised to recommend monitoring for respiratory illness and exclusion of ill students until they were noninfectious, rather than dismissal.

RATIONALE: Occupational exposures can contribute to the exacerbation as well as the onset of asthma. However, work-exacerbated asthma (WEA) has received less attention than occupational asthma (OA) that is caused by work. OBJECTIVES: The purpose of this Statement is to summarize current knowledge about the descriptive epidemiology, clinical characteristics, and management and treatment of WEA; propose a case definition for WEA; and discuss needs for prevention and research. METHODS: Information about WEA was identified primarily by systematic searches of the medical literature. Statements about prevention and research needs were reached by consensus. MEASUREMENTS AND MAIN RESULTS: WEA is defined as the worsening of asthma due to conditions at work. WEA is common, with a median prevalence of 21.5% among adults with asthma. Different types of agents or conditions at work may exacerbate asthma. WEA cases with persistent work-related symptoms can have clinical characteristics (level of severity, medication needs) and adverse socioeconomic outcomes (unemployment, reduction in income) similar to those of OA cases. Compared with adults with asthma unrelated to work, WEA cases report more days with symptoms, seek more medical care, and have a lower quality of life. WEA should be considered in any patient with asthma that is getting worse or who has work-related symptoms. Management of WEA should focus on reducing work exposures and optimizing standard medical management, with a change in jobs only if these measures are not successful. CONCLUSIONS: WEA is a common and underrecognized adverse outcome resulting from conditions at work. Additional research is needed to improve the understanding of the risk factors for, and mechanisms and outcomes of, WEA, and to inform and evaluate preventive interventions.

TO THE EDITOR: On April 28, 2009, the Chicago Department of Public Health received notification of 1 student at an elementary school with a probable pandemic (H1N1) 2009 virus infection; the infection was subsequently laboratory confirmed. This case was one of the first pandemic (H1N1) 2009 cases in Chicago. To prevent transmission of influenza and with guidance from the Chicago Department of Public Health, the school closed on April 29; it reopened on May 6 after the Centers for Disease Control and Prevention (CDC) revised its recommendations (1). We conducted an investigation to evaluate psychosocial and economic effects of the school closure on the students' families and to assess whether students complied with mitigation recommendations. In the early pandemic, Chicago's number of pandemic (H1N1) 2009 cases was one of the highest in the United States (2).

BACKGROUND: For millions of adults, effective control of asthma requires a regimen of care that may be compromised by psychological factors such as anxiety and depression. This study estimated the prevalence and risk factors for serious psychological distress (SPD) and explored their relationship to health-related quality of life (HRQOL) among adults with asthma in the United States. METHODS: We analyzed data from 186,738 adult respondents from the 2001-2007 U.S. National Health Interview Survey. We calculated weighted average prevalence estimates of current asthma and SPD by demographic characteristics and health-related factors. We used logistic regression analysis to calculate odds ratios for factors that may have predicted asthma, SPD, and HRQOL. RESULTS: From 2001 to 2007, the average annual prevalence of current asthma was 7.0% and the average prevalence of SPD was 3.0%. Among adults with asthma, the prevalence of SPD was 7.5% (95% CI, 7.0-8.1%). A negative association between HRQOL and SPD was found for all adults, independent of asthma status. A similar pattern of risk factors predicted SPD and the co-occurrence of SPD and asthma, although adults with asthma who reported lower socioeconomic status, a history of smoking or alcohol use, and more comorbid chronic conditions had significantly higher odds of SPD. CONCLUSION: This research suggests the importance of mental health screening for persons with asthma and the need for clinical and community-based interventions to target modifiable lifestyle factors that contribute to psychological distress and make asthma worse.

BACKGROUND: Asthma prevalence among U.S. adults is estimated to be 6.7%. People with asthma are at increased risk of complications from influenza. Influenza vaccination of adults and children with asthma is recommended by the Advisory Committee on Immunization Practices. The Healthy People 2010 Objectives call for annual influenza vaccination of at least 60% of adults aged 18-64 years with asthma and other conditions associated with an increased risk of complications from influenza. PURPOSE: To assess influenza vaccination coverage among adults with asthma in the United States. METHODS: Data from the 2007 Behavioral Risk Factor Surveillance System restricted to individuals interviewed during February through August were analyzed in 2008 to estimate national and state prevalence of self-reported receipt of influenza vaccination among respondents aged 18-64 years with asthma. Logistic regression provided predictive marginal vaccination coverage for each covariate, adjusted for demographic and access to care characteristics. RESULTS: Among adults aged 18-64 years with asthma, influenza vaccination coverage was 39.9% (95% CI=38.3%, 41.5%) during the 2006-2007 season (coverage ranged from 26.9% [95% CI=19.8%, 35.3%] in California to 53.3% [95% CI=42.8%, 63.6%] in Tennessee). Influenza vaccination coverage was 33.9% (95% CI=31.9%, 35.9%) for adults aged 18-49 years with asthma compared to 54.7% (95% CI=52.4%, 57.0%) for adults aged 50-64 years with asthma. Among people aged 18-64 years, vaccination coverage was 28.8% among those without asthma. People with asthma who had an increased likelihood of vaccination were aged 50-64 years, female, non-Hispanic white, and had diabetes, activity limitations, health insurance, a regular healthcare provider, routine checkup in the previous year, and formerly smoked or never smoked. CONCLUSIONS: Influenza vaccination coverage continues to be below the national objective of 60% for people aged 18-64 years with asthma as a high-risk condition. Increased state and national efforts are needed to improve influenza vaccination levels among this population and particularly among those aged 18-49 years.