Faculty Bibliography

OBJECTIVES/OBJECTIVE:In a longitudinal cohort of patients with HIV and chronic pain, we sought to (1) identify trajectories of opioid misuse and opioid use disorder (OUD) symptoms, and to (2) determine whether prescription opioid dose was associated with symptom trajectories. METHODS:We leveraged an existing 12-month longitudinal observational study, Project PIMENTO, of persons living with HIV and chronic pain who received care at a hospital system in the Bronx, New York. A quota sampling strategy was used to ensure variability of prescribed opioid use in the recruited sample. Research interviews occurred quarterly and assessed opioid behaviors and criteria for OUD. To describe symptom trajectories, we conducted 2 separate longitudinal latent class analyses to group participants into (1) opioid misuse and (2) OUD trajectories. Finally, we used multinomial logistic regression models to examine the relationship between baseline prescription opioid dose and symptom trajectories. RESULTS:Of 148 total participants, at baseline 63 (42.6%) had an active opioid prescription, 69 (46.6%) met the criteria for current opioid misuse, and 44 (29.7%) met the criteria for current OUD. We found 3 opioid misuse and 3 OUD symptom trajectories, none of which showed worsened symptoms over time. In addition, we found that higher prescription opioid dose at baseline was associated with a greater OUD symptom trajectory. CONCLUSIONS:Opioid misuse and OUD were common but stable or decreasing over time. Although these results are reassuring, our findings also support prior studies that high-dose opioid therapy is associated with greater OUD symptoms.

Background/UNASSIGNED:COVID-19 mortality disproportionately affects the Black population in the United States (US). To explore this association a cohort study was undertaken. Methods/UNASSIGNED:We assembled a cohort of 505,992 patients receiving ambulatory care at Bronx Montefiore Health System (BMHS) between 1/1/18 and 1/1/20 to evaluate the relative risk of hospitalization and death in two time-periods, the pre-COVID time-period (1/1/20-2/15/20) and COVID time-period (3/1/20-4/15/20). COVID testing, hospitalization and mortality were determined with the Black and Hispanic patient population compared separately to the White population using logistic modeling. Evaluation of the interaction of pre-COVID and COVID time periods and race, with respect to mortality was completed. Findings/UNASSIGNED: = 0.001). There was a significant increase in Black mortality risk from pre-COVID to COVID periods (p for interaction=0.02). Adjustment for relevant clinical and social indices attenuated but did not fully explain the observed difference in Black mortality. Interpretation/UNASSIGNED:The BMHS COVID experience demonstrates that Blacks do have a higher mortality with COVID incompletely explained by age, multiple reported comorbidities and available metrics of sociodemographic disparity. Funding/UNASSIGNED:N/A.

The Minimizing Error, Maximizing Outcome (MEMO) study of clinics in New York City, Chicago, and Wisconsin linked primary care work experiences to physician stress. We analyzed MEMO data to determine how chaos in the clinic was associated with work conditions and quality of care measures. Surveys and medical record audits determined practice characteristics and medical errors, respectively. Physicians rated clinic atmosphere on a scale of 1 (calm) to 5 (chaotic). Chaotic clinics were defined as practices rated either 4 or 5 by greater than 50% of clinic physicians. Forty of 112 MEMO clinics (36%) were chaotic. Compared with nonchaotic practices, these clinics served more minority and Medicaid patients and had a greater likelihood of clinic bottlenecks such as phone access (both p < .01). Physicians in chaotic clinics reported lower work control and job satisfaction, less emphasis on teamwork and professionalism, more stress and burnout, and a higher likelihood of leaving the practice within 2 years (all p < .05). Chaotic clinics had higher rates of medical errors and more missed opportunities to provide preventative services (both p < .05). More research should examine the effectiveness of organizational interventions to decrease chaos in the clinic and to mitigate its effects on patient safety.

BACKGROUND: Obesity disproportionately affects Latina women, but few targeted, technology-assisted interventions that incorporate tailored health information exist for this population. The Veterans Health Administration (VHA) uses an online weight management tool (MOVE!23) which is publicly available, but was not designed for use in non-VHA populations. METHODS: We conducted a qualitative study to determine how interactions between the tool and other contextual elements impacted task performance when the target Latina users interacted with MOVE!23. We sought to identify and classify specific facilitators and barriers that might inform design changes to the tool and its context of use, and in turn promote usability. Six English-speaking, adult Latinas were recruited from an inner city primary care clinic and a nursing program at a local university in the United States to engage in a "Think-Aloud" protocol while using MOVE!23. Sessions were recorded, transcribed, and coded to identify interactions between four factors that contribute to usability (Tool, Task, User, Context). RESULTS: Five themes influencing usability were identified: Technical Ability and Technology Preferences; Language Confusion and Ambiguity; Supportive Tool Design and Facilitator Guidance; Relevant Examples; and Personal Experience. Features of the tool, task, and other contextual factors failed to fully support participants at times, impeding task completion. Participants interacted with the tool more readily when its language was familiar and content was personally relevant. When faced with ambiguity and uncertainty, they relied on the tool's visual cues and examples, actively sought relevant personal experiences, and/or requested facilitator support. CONCLUSIONS: The ability of our participants to successfully use the tool was influenced by the interaction of individual characteristics with those of the tool and other contextual factors. We identified both tool-specific and context-related changes that could overcome barriers to the use of MOVE!23 among Latinas. Several general considerations for the design of eHealth tools are noted.

BACKGROUND: For adults who stutter, communication difficulties can impact many spheres of life. Previous studies have not examined how stuttering might impact patient's experiences with the medical system. OBJECTIVE: Our objective was to understand the range and depth of experiences with the medical system among adults who stutter. DESIGN: This was a qualitative study using age-stratified focus groups. PARTICIPANTS: Sixteen adults who stutter were recruited at a national conference about stuttering. APPROACH: We conducted three focus groups. Participants also completed a written questionnaire about sociodemographic characteristics, health status, and the impact of stuttering on their life [using the St. Louis Inventory of Life Perspectives Scale (SL-ILP-S) Total Effect Score]. We analyzed data using an iterative, thematic analysis, with an inductive approach, at a semantic level. KEY RESULTS: Participants were mostly (75 %) male and resided throughout the United States. The mean SL-ILP-S Total Effect Score was 27.3, indicating that stuttering caused minimal concern in participants' lives. Despite this, we identified five themes that characterize ways in which stuttering affects interactions with the medical system. Participants described (1) discomfort speaking with office staff and physicians, which resulted in (2) avoiding health care interactions because of stuttering, and (3) relying on a third party to navigate the medical system. During visits with physicians, participants felt that (4) discussing stuttering with physicians required trust and rapport, and (5) speaking assertively with physicians required self-acceptance of their stuttering. CONCLUSIONS: We identified ways in which stuttering affects medical interactions. These results highlight the need for increased awareness and training for medical staff and physicians when caring for persons who stutter. Future studies among diverse samples of stutterers can determine the effects of stuttering on medical interactions, and inform the development of interventions to provide high quality health care for adults who stutter.

INTRODUCTION: Leptomeningeal metastasis (LM), or leptomeningeal carcinomatosis, is a devastating complication of non-small cell lung cancer (NSCLC), and the optimal therapeutic approach remains challenging. A retrospective review was carried out to assess the impact of whole brain radiotherapy (WBRT), intrathecal therapy (IT), and epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) on outcomes. METHODS: Patients with newly diagnosed LM from NSCLC from January 2002 to December 2009 were identified through institutional databases and medical records reviewed. Survival was assessed by Kaplan-Meier and landmark analyses by administered treatment to minimize selection bias. RESULTS: We identified 125 patients (45 men, 80 women) with LM from NSCLC, median age 59 years (range, 28-87 years). Almost all (123 [98%]) patients have died and median overall survival was 3.0 months (95% confidence interval, 2.0-4.0). No differences in survival were seen between patients who were treated with WBRT (n =46) and those who were not (n =59, p =0.84) in a landmark analysis. In the seven patients selected to receive IT chemotherapy, median survival was 18 months (range, 5-33 months) and appeared superior to those not selected for this treatment (p =0.001) in a landmark analysis. The median survival of the nine patients with known EGFR mutations (all of whom received TKIs at some point) was 14 months (range, 1-28 months). CONCLUSIONS: This retrospective study, the largest published series, demonstrates the poor survival of LM from NSCLC. In this study, survival was not improved by WBRT. The survival of patients selected for IT chemotherapy and those with EGFR mutations treated with TKIs highlights the importance of developing novel agents.

The impact of social and economic determinants of health status and the existence of racial and ethnic health care access disparities have been well-documented. This paper describes a model, the Health Care Access Barriers Model (HCAB), which provides a taxonomy and practical framework for the classification, analysis and reporting of those modifiable health care access barriers that are associated with health care disparities. The model describes three categories of modifiable health care access barriers: financial, structural, and cognitive. The three types of barriers are reciprocally reinforcing and affect health care access individually or in concert. These barriers are associated with screening, late presentation to care, and lack of treatment, which in turn result in poor health outcomes and health disparities. By targeting those barriers that are measurable and modifiable the model facilitates root-cause analysis and intervention design.

In this article, we present a new pharmacovigilance data mining technique based on the biclustering paradigm, which is designed to identify drug groups that share a common set of adverse events (AEs) in the spontaneous reporting system (SRS) of the US Food and Drug Administration (FDA). A taxonomy of biclusters is developed, revealing that a significant number of bona fide adverse drug event (ADE) biclusters have been identified. Statistical tests indicate that it is extremely unlikely that the bicluster structures thus discovered, as well as their content, could have arisen by mere chance. Some of the biclusters classified as indeterminate provide support for previously unrecognized and potentially novel ADEs. In addition, we demonstrate the potential importance of the proposed methodology in several important aspects of pharmacovigilance such as providing insight into the etiology of ADEs, facilitating the identification of novel ADEs, suggesting methods and a rationale for aggregating terminologies, highlighting areas of focus, and providing an exploratory tool for data mining.

BACKGROUND: Diagnosis of leptomeningeal metastasis (LM) has become increasingly frequent. The diagnostic gold standard has been CSF cytology, but MRI is now used routinely for diagnosis. Diagnosis and prognosis of LM has not been studied in the MRI era. METHODS: Patients with LM from 2002 through 2004 were identified through a neurology database, as well as by reviewing all abnormal CSF cytologies from a pathology database. Diagnosis was made by malignant cytology or imaging; suspicious cases treated as LM were also included. RESULTS: A total of 187 patients with LM were analyzed in this retrospective review. Of these, 150 had solid and 37 had hematopoietic malignancies. Median age was 56.4 years, and median Karnofsky performance status (KPS) was 70. The most common types of solid tumor were breast (65 patients), lung (47), gastrointestinal (11), and melanoma (9). Of the hematopoietic tumors, 21 were lymphoma and 15 were leukemia. Fifty-three percent of patients were diagnosed by imaging, 23% by cytology, and 24% by both. Treatment included radiation therapy in 55%, intrathecal chemotherapy in 29%, and systemic chemotherapy in 18%; 21% received supportive care alone. Median overall survival was 2.4 (95% confidence interval 1.9-3.1) months. Median survival for patients with hematopoietic tumors was 4.7 months and for solid tumors was 2.3 months (p = 0.0006). In multivariate analysis, initial KPS and tumor type (solid vs hematopoietic) were significant predictors of survival. CONCLUSIONS: Despite enhanced diagnosis with MRI, prognosis remains poor in leptomeningeal metastasis. Those with hematopoietic tumors continue to fare better than those with solid tumors.