The utility of the Health Plan Employer Data and Information Set (HEDIS) asthma measure to predict asthma-related outcomes.

BACKGROUND: The Health Plan Employer Data and Information Set (HEDIS) measures are used extensively to measure quality of care. OBJECTIVE: To evaluate selected aspects of the HEDIS measure of appropriate use of asthma medications. METHODS: Claims data were analyzed for commercial health plan members who met HEDIS criteria for persistent asthma in 1999. The use of asthma medications was evaluated in the subsequent year with stratification by controller medication and a measure of adherence (days' supply). Multivariate logistic regressions were used to evaluate the association among long-term controller therapy for persistent asthma, adherence to therapy, and asthma-related hospitalizations or emergency department (ED) visits, controlling for demographic, preindex utilization, and other confounding characteristics. RESULTS: Of the 49,637 persistent asthma patients, approximately 35.7% were using 1 class of long-term controller medications, 18.4% were using more than 1 class, and 45.9% were not using such medication. More than 25% of the persistent asthma patients did not use any asthma medication in the subsequent year. Patients with low adherence to controller medication had a significantly higher risk (odds ratio [OR], 1.72; 95% confidence interval [CI], 1.42-2.08) of ED visit or hospitalization relative to patients not using any controllers compared with persons with moderate (OR, 0.84; 95% CI, 0.57-1.23) or high (OR, 0.70; 95% CI, 0.34-1.44) adherence. Patients receiving a high days' supply of inhaled corticosteroids had the lowest risk of ED visit or hospitalization (OR, 0.37; 95% CI, 0.05-2.69). CONCLUSIONS: Our findings suggest that refinements to the HEDIS measure method for identifying patients with persistent asthma may be needed.

Toxic mold: phantom risk vs science.

OBJECTIVE: To review the available literature on the subject of fungi (molds) and their potential impact on health and to segregate information that has scientific validity from information that is yet unproved and controversial. DATA SOURCES: This review represents a synthesis of the available literature in this area with the authors' collective experience with many patients presenting with complaints of mold-related illness. STUDY SELECTION: Pertinent scientific investigation on toxic mold issues and previously published reviews on this and related subjects that met the educational objectives were critically reviewed. RESULTS: Indoor mold growth is variable, and its discovery in a building does not necessarily mean occupants have been exposed. Human response to fungal antigens may induce IgE or IgG antibodies that connote prior exposure but not necessarily a symptomatic state. Mold-related disease has been discussed in the framework of noncontroversial and controversial disorders. CONCLUSIONS: When mold-related symptoms occur, they are likely the result of transient irritation, allergy, or infection. Building-related illness due to mycotoxicosis has never been proved in the medical literature. Prompt remediation of water-damaged material and infrastructure repair should be the primary response to fungal contamination in buildings.

Stachybotrys chartarum (chartarum = atra = alternans) and other problems caused by allergenic fungi.

Stachybotrys chartarum is a cellulose-decaying fungus with worldwide distribution. It grows well at room temperature and with humidity above 93%. S. chatarum requires special media high in cellulose and low in sugar and nitrogen to compete with Penicillium and Aspergillus. Ninety percent of field-collected spores are not culturable. S. chartarum can produce macrocyclic trichothecenes but is highly dependent on strain and environmental conditions. In strains implicated in mycotoxicosis, not all produce detectable trichothecenes. Therefore, the presence of S. chartarum is not proof of toxin presence. Trichothecenes are potent inhibitors of protein and DNA synthesis. By the inhalation route, occupational stachybotrytoxicosis causes chest and upper airway symptoms, fever, leucopenia, dermatitis; starts in 2-3 days of exposure; and lasts 3 weeks. Investigation of the environment of the cluster of pulmonary hemorrhage in 10 infants in Cleveland, Ohio, and similar cases elsewhere are presented. The Centers for Disease Control and Prevention considers S. chartarum a serious health threat. However, even though there are now techniques of measuring S. chartarum conidia and estimating trichothecene mycotoxin in indoor air samples, no standards exist that relate to health effects. Those standards available are numerical or comparison of indoor/outdoor counts or both. Upper limit of noncontaminated indoor environment is 100-1000 colony-forming units (CFU) m3. There is no compelling evidence that exposures expected in most mold-contaminated indoor environments are likely to result in measurable health effects. However, when the health care worker suspects a problem in the home environment, a questionnaire and home visit may be helpful. High indoor exposures are associated with infrequent ventilation or vacuuming, pets, visible mold, and old carpets. To screen the indoor air, an experienced pollen and mold counter could use a Burkard personal air sampler. Health-based exposure standards for molds and mycotoxins do not exist. When available data indicate extremely high mold levels, cleanup consisting of removal of all contaminated material, cleaning accessible heating, ventilation, and airconditioning parts and filters, and preventive maintenance are indicated. There is a brief summary of the diseases of plants, animals, and humans caused by several common allergenic fungi and the mycotoxins they produce.