Faculty Bibliography

INTRODUCTION/BACKGROUND:Smoking is a key determinant of mortality among people living with HIV (PLWH). METHODS:To better understand the effects of smoking cessation interventions in PLWH, we conducted a pooled analysis of four randomized controlled trials of hospital-initiated smoking interventions conducted through the Consortium of Hospitals Advancing Research on Tobacco (CHART). In each study, cigarette smokers were randomly assigned to usual care or a smoking cessation intervention. The primary outcome was self-reported past 30-day tobacco abstinence at 6-month follow-up. Abstinence rates were compared between PLWH and participants without HIV and by treatment arm, using both complete-case and intention-to-treat analyses. Multivariable logistic regression was used to determine the effect of HIV status on 6-month tobacco abstinence and to determine predictors of smoking cessation within PLWH. RESULTS:Among 5550 hospitalized smokers, there were 202 (3.6%) PLWH. PLWH smoked fewer cigarettes per day and were less likely to be planning to quit than smokers without HIV. At 6 months, cessation rates did not differ between intervention and control groups among PLWH (28.9% vs. 30.5%) or smokers without HIV (36.1% vs. 34.1%). In multivariable regression analysis, HIV status was not significantly associated with smoking cessation at 6 months. Among PLWH, confidence in quitting was the only clinical factor independently associated with smoking cessation (OR 2.0, 95% CI = 1.4 to 2.8, p < .01). CONCLUSIONS:HIV status did not alter likelihood of quitting smoking after hospital discharge, whether or not the smoker was offered a tobacco cessation intervention, but power was limited to identify potentially important differences. IMPLICATIONS/CONCLUSIONS:PLWH had similar quit rates to participants without HIV following a hospital-initiated smoking cessation intervention. The findings suggest that factors specific to HIV infection may not influence response to smoking cessation interventions and that all PLWH would benefit from efforts to assist in quitting smoking. TRIAL REGISTRATION/BACKGROUND:(1) Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial: NCT01305928. (2) Web-based smoking cessation intervention that transitions from inpatient to outpatient: NCT01277250. (3) Effectiveness of smoking-cessation interventions for urban hospital patients: NCT01363245. (4) Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (HelpingHAND2): NCT01714323.

Despite the efficacy of nicotine replacement therapy (NRT) in promoting smoking cessation, no studies have been done to evaluate NRT prescribing rates among immigrants, a vulnerable minority population in the United States. The aim of this study is to explore for differences in NRT prescribing behavior by immigrant status. Participants were enrolled in a smoking cessation trial for hospitalized patients between July 2011 and April 2014 at two NYC hospitals. For this analysis, we used baseline data from patient surveys and electronic medical-record reviews to examine associations between immigrant status and prescription of NRT in-hospital and on discharge, as well as acceptance of NRT in-hospital. We included age, gender, education, health literacy, race, ethnicity, English language ability, inpatient service, and site insurance in the models as potential confounders. Our study population included 1,608 participants, of whom 21% were not born in the United States. Bivariate analysis found that nonimmigrants were more likely than immigrants to be prescribed NRT in the hospital (46.1% vs. 35.7%, p = .0006) and similarly on discharge (19.4% vs. 15.3%, p = .09). Both groups were equally likely to accept NRT in-hospital when prescribed. On multivariable analysis, being an immigrant (OR 0.65), Black race (OR 0.52), and Hispanic ethnicity (OR 0.63) were associated with lower likelihood of being prescribed NRT in-hospital. Multivariable analysis for provision of NRT prescription at discharge showed no significant difference between immigrants and nonimmigrants. These findings show differences in in-hospital smoking cessation treatment between immigrants and nonimmigrants.

Hospital patients with serious mental illness (SMI) have high rates of smoking. There are few post-discharge treatment models available for this population and limited research on their treatment uptake following discharge. This study is a secondary analysis of an RCT that compared multi-session intensive telephone counseling versus referral to state quitline counseling at two safety net hospitals in New York City. For this analysis, we selected all trial participants with a history of schizophrenia, schizoaffective disorder or bipolar disorder (N = 384) and used multivariable logistic regression to compare groups on self-reported 30-day abstinence at 6 months and to identify patient factors associated with use of tobacco treatment. Analyses found no significant group differences in abstinence 6 months (28% quitline vs. 29% intervention, p > 0.05), use of cessation medications (42% quitline vs. 47% intervention, p > 0.05) or receipt of at least one counseling call (47% quitline vs. 42% intervention, p > 0.05). Patients with hazardous drinking (p = 0.04) or perceived good health (p = 0.03) were less likely to use cessation medications. Homeless patients were less likely to use counseling (p = 0.02). Most patients did not use cessation treatment after discharge, and the intensive intervention did not improve abstinence rates over quitline referral. Interventions are needed to improve use of cessation treatment and long-term abstinence in patients with SMI.

BACKGROUND AND OBJECTIVES: Missed visits are common in office-based buprenorphine treatment (OBOT). The feasibility of text message (TM) appointment reminders among OBOT patients is unknown. METHODS: This 6-month prospective cohort study provided TM reminders to OBOT program patients (N = 93). A feasibility survey was completed following delivery of TM reminders and at 6 months. RESULTS: Respondents reported that the reminders should be provided to all OBOT patients (100%) and helped them to adhere to their scheduled appointment (97%). At 6 months, there were no reports of intrusion to their privacy or disruption of daily activities due to the TM reminders. Most participants reported that the TM reminders were helpful in adhering to scheduled appointments (95%), that the reminders should be offered to all clinic patients (95%), and favored receiving only TM reminders rather than telephone reminders (95%). Barriers to adhering to scheduled appointment times included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic wait-times (9%), being hospitalized or sick (8%), feeling sad or depressed (6%), and child care (6%). CONCLUSIONS: This study demonstrated the acceptability and feasibility of TM appointment reminders in OBOT. Older age and longer duration in buprenorphine treatment did not diminish interest in receiving the TM intervention. Although OBOT patients expressed concern regarding the privacy of TM content sent from their providers, privacy issues were uncommon among this cohort. Scientific Significance Findings from this study highlighted patient barriers to adherence to scheduled appointments. These barriers included transportation difficulties (34%), not being able to take time off from school or work (31%), long clinic lines (9%), and other factors that may confound the effect of future TM appointment reminder interventions. Further research is also required to assess 1) the level of system changes required to integrate TM appointment reminder tools with already existing electronic medical records and appointment records software; 2) acceptability among clinicians and administrators; and 3) financial and resource constraints to healthcare systems. (Am J Addict 2017;XX:1-6).

BACKGROUND: Buprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, "home," buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings. METHODS: This prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results. RESULTS: Of the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0-320) for inductions, compared to 110 (0-354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006-2007), and baseline heroin abstinence were associated with increased treatment retention overall. CONCLUSIONS: Unobserved "home" buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.

BACKGROUND: While primary care work conditions are associated with adverse clinician outcomes, little is known about the effect of work condition interventions on quality or safety. DESIGN: A cluster randomized controlled trial of 34 clinics in the upper Midwest and New York City. PARTICIPANTS: Primary care clinicians and their diabetic and hypertensive patients. INTERVENTIONS: Quality improvement projects to improve communication between providers, workflow design, and chronic disease management. Intervention clinics received brief summaries of their clinician and patient outcome data at baseline. MAIN MEASURES: We measured work conditions and clinician and patient outcomes both at baseline and 6-12 months post-intervention. Multilevel regression analyses assessed the impact of work condition changes on outcomes. Subgroup analyses assessed impact by intervention category. KEY RESULTS: There were no significant differences in error reduction (19 % vs. 11 %, OR of improvement 1.84, 95 % CI 0.70, 4.82, p = 0.21) or quality of care improvement (19 % improved vs. 44 %, OR 0.62, 95 % CI 0.58, 1.21, p = 0.42) between intervention and control clinics. The conceptual model linking work conditions, provider outcomes, and error reduction showed significant relationships between work conditions and provider outcomes (p