Faculty Bibliography

In response to fast-turnaround funding opportunities, collaborations have been forming across the country to address severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disparities. Here we describe the process, notes from the field, and evaluation results from a new collaboration involving multiple partners, formed in October 2020 in New York City as part of the Rapid Acceleration of Diagnostics initiative. We used the validated Research Engagement Survey Tool to evaluate the partnership. Results can inform future research and improve engagement efforts aimed at reducing SARS-CoV-2 disparities. (Am J Public Health. 2022;112(S9):S904-S908. https://doi.org/10.2105/AJPH.2022.307072).

BACKGROUND:Smoking rates remain high in Vietnam, particularly among people living with HIV/AIDS (PLWH), but tobacco cessation services are not available in outpatient HIV clinics (OPCs). The research team is conducting a type II hybrid randomized controlled trial (RCT) comparing the cost-effectiveness of three tobacco cessation interventions among PLWH receiving care in HIV clinics in Vietnam. The study is simultaneously evaluating the implementation processes and outcomes of strategies aimed at increasing the implementation of tobacco dependence treatment (TDT) in the context of HIV care. This paper describes the systematic, theory-driven process of adapting intervention components and implementation strategies with demonstrated effectiveness in high-income countries, and more recently in Vietnam, to a new population (i.e., PLWH) and new clinical setting, prior to launching the trial. METHODS:Data collection and analyses were guided by two implementation science frameworks and the socio-ecological model. Qualitative interviews were conducted with 13 health care providers and 24 patients in three OPCs. Workflow analyses were conducted in each OPC. Qualitative data were analyzed using rapid qualitative analysis procedures. Based on findings, components of the intervention and implementation strategies were adapted, followed by a 3-month pilot study in one OPC with 16 patients randomized to one of two intervention arms. RESULTS:The primary adaptations included modifying the TDT intervention counseling content to address barriers to quitting among PLWH and Vietnamese sociocultural norms that support smoking cessation. Implementation strategies (i.e., training and system changes) were adapted to respond to provider- and clinic-level determinants of implementation effectiveness (e.g., knowledge gaps, OPC resource constraints, staffing structure, compatibility). CONCLUSIONS:Adaptations were facilitated through a mixed method, stakeholder (patient and health care provider, district health leader)-engaged evaluation of context-specific influences on intervention and implementation effectiveness. This data-driven approach to refining and adapting components aimed to optimize intervention effectiveness and implementation in the context of HIV care. Balancing pragmatism with rigor through the use of rapid analysis procedures and multiple methods increased the feasibility of the adaptation process. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT05162911 . Registered on December 16, 2021.

BACKGROUND:Studies specifically focused on patients' perspectives on telemedicine visits in primary and behavioral health care are fairly limited and have often focused on highly selected populations or used overall satisfaction surveys. OBJECTIVE:To examine patient perspectives on the shift to telemedicine, the remote delivery of health care via the use of electronic information and communications technology, in primary and behavioral health care in Federally Qualified Health Centers (FQHCs) during COVID-19. DESIGN/METHODS:Semi-structured interviews were conducted using video conference with patients and caregivers between October and December 2020. PARTICIPANTS/METHODS:Providers from 6 FQHCs nominated participants. Eighteen patients and caregivers were interviewed: 6 patients with only primary care visits; 5 with only behavioral health visits; 3 with both primary care and behavioral health visits; and 4 caregivers of children with pediatric visits. APPROACH/METHODS:Using a protocol-driven, rapid qualitative methodology, we analyzed the interview data and assessed the quality of care, benefits and challenges of telemedicine, and use of telemedicine post-pandemic. KEY RESULTS/RESULTS:Respondents broadly supported the option of home-based synchronous telemedicine visits in primary and behavioral health care. Nearly all respondents appreciated remote visits, largely because such visits provided a safe option during the pandemic. Patients were generally satisfied with telemedicine and believed the quality of visits to be similar to in-person visits, especially when delivered by a provider with whom they had established rapport. Although most respondents planned to return to mostly in-person visits when considered safe to do so, they remained supportive of the continued option for remote visits as remote care addresses some of the typical barriers faced by low-income patients. CONCLUSIONS:Addressing digital literacy challenges, enhancing remote visit privacy, and improving practice workflows will help ensure equitable access to all patients as we move to a new post-COVID-19 "normal" marked by increased reliance on telemedicine and technology.

Synchronous home-based telemedicine for primary care experienced growth during the coronavirus disease 2019 pandemic. A review was conducted on the evidence reporting on the feasibility of synchronous telemedicine implementation within primary care, barriers and facilitators to implementation and use, patient characteristics associated with use or nonuse, and quality and cost/revenue-related outcomes. Initial database searches yielded 1,527 articles, of which 22 studies fulfilled the inclusion criteria. Synchronous telemedicine was considered appropriate for visits not requiring a physical examination. Benefits included decreased travel and wait times, and improved access to care. For certain services, visit quality was comparable to in-person care, and patient and provider satisfaction was high. Facilitators included proper technology, training, and reimbursement policies that created payment parity between telemedicine and in-person care. Barriers included technological issues, such as low technical literacy and poor internet connectivity among certain patient populations, and communication barriers for patients requiring translators or additional resources to communicate.

PURPOSE:Despite the growing popularity of stepped-wedge cluster randomized trials (SW-CRTs) for practice-based research, the design's advantages and challenges are not well documented. The objective of this study was to identify the advantages and challenges of the SW-CRT design for large-scale intervention implementations in primary care settings. METHODS:The EvidenceNOW: Advancing Heart Health initiative, funded by the Agency for Healthcare Research and Quality, included a large collection of SW-CRTs. We conducted qualitative interviews with 17 key informants from EvidenceNOW grantees to identify the advantages and challenges of using SW-CRT design. RESULTS:All interviewees reported that SW-CRT can be an effective study design for large-scale intervention implementations. Advantages included (1) incentivized recruitment, (2) staggered resource allocation, and (3) statistical power. Challenges included (1) time-sensitive recruitment, (2) retention, (3) randomization requirements and practice preferences, (4) achieving treatment schedule fidelity, (5) intensive data collection, (6) the Hawthorne effect, and (7) temporal trends. CONCLUSIONS:.

OBJECTIVE:To develop a screening tool to identify emergency department (ED) patients at risk of entering a homeless shelter, which could inform targeting of interventions to prevent future homelessness episodes. DATA SOURCES/METHODS:Linked data from (1) ED patient baseline questionnaires and (2) citywide administrative homeless shelter database. STUDY DESIGN/METHODS:Stakeholder-informed predictive modeling utilizing ED patient questionnaires linked with prospective shelter administrative data. The outcome was shelter entry documented in administrative data within 6 months following the baseline ED visit. Exposures were responses to questions on homelessness risk factors from baseline questionnaires. DATA COLLECTION/EXTRACTION METHODS/METHODS:Research assistants completed questionnaires with randomly sampled ED patients who were medically stable, not in police/prison custody, and spoke English or Spanish. Questionnaires were linked to administrative data using deterministic and probabilistic matching. PRINCIPAL FINDINGS/RESULTS:Of 1993 ED patients who were not homeless at baseline, 5.6% entered a shelter in the next 6 months. A screening tool consisting of two measures of past shelter use and one of past criminal justice involvement had 83.0% sensitivity and 20.4% positive predictive value for future shelter entry. CONCLUSIONS:Our study demonstrates the potential of using cross-sector data to improve hospital initiatives to address patients' social needs.

BACKGROUND:Several tools to improve reporting of implementation studies for evidence-based decision making have been created; however, no tool for critical appraisal of implementation outcomes exists. Researchers, practitioners, and policy makers lack tools to support the concurrent synthesis and critical assessment of outcomes for implementation research. Our objectives were to develop a comprehensive tool to (1) describe studies focused on implementation that use qualitative, quantitative, and/or mixed methodologies and (2) assess risk of bias of implementation outcomes. METHODS:A hybrid consensus-building approach combining Delphi Group and Nominal Group techniques (NGT) was modeled after comparative methodologies for developing health research reporting guidelines and critical appraisal tools. First, an online modified NGT occurred among a small expert panel (n = 5), consisting of literature review, item generation, round robin with clarification, application of the tool to various study types, voting, and discussion. This was followed by a larger e-consensus meeting and modified Delphi process with implementers and implementation scientists (n = 32). New elements and elements of various existing tools, frameworks, and taxonomies were combined to produce the ASSESS tool. RESULTS:The 24-item tool is applicable to a broad range of study designs employed in implementation science, including qualitative studies, randomized-control trials, non-randomized quantitative studies, and mixed methods studies. Two key features are a section for assessing bias of the implementation outcomes and sections for describing the implementation strategy and intervention implemented. An accompanying explanation and elaboration document that identifies and describes each of the items, explains the rationale, and provides examples of reporting and appraising practice, as well as templates to allow synthesis of extracted data across studies and an instructional video, has been prepared. CONCLUSIONS:The comprehensive, adaptable tool to support both reporting and critical appraisal of implementation science studies including quantitative, qualitative, and mixed methods assessment of intervention and implementation outcomes has been developed. This tool can be applied to a methodologically diverse and growing body of implementation science literature to support reviews or meta-analyses that inform evidence-based decision-making regarding processes and strategies for implementation.

Secondhand smoke (SHS) exposure remains a major public health concern in the United States. Homes have become the primary source of SHS exposure, with elevated risks for residents of multiunit housing. Though this differential risk is well-documented, little is known about whether SHS exposure varies by floor height. The aim of this study was to examine whether SHS accumulates in higher floors of multiunit housing. Using validated passive nicotine sampling monitors, we sampled air nicotine concentrations on multiple floors of 21 high-rise (>15 floors) buildings in New York City. Within the buildings, measurements were collected in three locations: non-smoking individual apartments, hallways and stairwells. Measurements were collected in two winter and two summer waves to account for potential seasonality effects. We analyzed the percent of filters with detectable nicotine and quantified nicotine concentration (µg/m³). Higher floor levels were positively associated with both airborne nicotine measures, with some variation by location and season observed. In winter, the trends were statistically significant in apartments (floors ≤7: 0.022 µg/m³; floors 8-14: 0.026 µg/m³; floors ≥15: 0.029 µg/m³; p = 0.011) and stairwells (floors ≤7: 0.18 µg/m³; floors 8-14: 0.19 µg/m³; floors ≥15: 0.59 µg/m³; p = 0.006). These findings can inform interventions to mitigate the SHS exposure of residents in multiunit housing.

Structures (context of care delivery) and processes (actions aimed at delivery care) are posited to drive patient outcomes. Despite decades of primary care research, there remains a lack of evidence connecting specific structures/processes to patient outcomes to determine which of the numerous recommended structures/processes to prioritize for implementation. The objective of this study was to identify structures/processes most commonly present in high-performing primary care practices for chronic care management and prevention. We conducted key informant interviews with a national sample of 22 high-performing primary care practices. We identified the 10 most commonly present structures/processes in these practices, which largely enable 2 core functions: mobilizing staff to conduct patient outreach and helping practices avoid gaps in care. Given the costs of implementing and maintaining numerous structures/processes, our study provides a starting list for providers to prioritize and for researchers to investigate further for specific effects on patient outcomes.

INTRODUCTION/BACKGROUND:Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs). METHODS:We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n=26) in Vietnam. Arm 1 included training and a tool kit (e.g., reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As+R). Provider surveys were conducted at baseline, six- and 12-months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As. RESULTS:Adoption of the 4As increased significantly across both study arms (all p<.001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling. CONCLUSION/CONCLUSIONS:The study demonstrated the effectiveness of a multicomponent and multilevel strategy (i.e., provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam. IMPLICATIONS/CONCLUSIONS:Improving implementation of evidence-based tobacco dependence treatment (TDT) guidelines is a necessary step towards reducing the growing burden of non-communicable disease (NCDs) and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam, and offers a potentially scalable model for meeting FCTC Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a community health worker for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.