Faculty Bibliography

BACKGROUND:We describe the rationale and study design for "TRUsted rEsidents and Housing Assistance to decrease Violence Exposure in New Haven (TRUE HAVEN)," a prospective type 1 hybrid effectiveness/implementation study of a multi-level intervention using a stepped wedge design. TRUE HAVEN aims to lower rates of community gun violence by fostering the stability, wealth, and well-being of individuals and families directly impacted by incarceration through the provision of stable housing and by breaking the cycle of trauma. DESIGN:TRUE HAVEN is an ongoing, multi-level intervention with three primary components: financial education paired with housing support (individual level), trauma-informed counseling (neighborhood level), and policy changes to address structural racism (city/state level). Six neighborhoods with among the highest rates of gun violence in New Haven, Connecticut, will receive the individual and neighborhood level intervention components sequentially beginning at staggered 6-month steps. Residents of these neighborhoods will be eligible to participate in the housing stability and financial education component if they were recently incarcerated or are family members of currently incarcerated people; participants will receive intense financial education and follow-up for six months and be eligible for special down payment and rental assistance programs. In addition, trusted community members and organization leaders within each target neighborhood will participate in trauma-informed care training sessions to then be able to recognize when their peers are suffering from trauma symptoms, to support these affected peers, and to destigmatize accessing professional mental health services and connect them to these services when needed. Finally, a multi-stakeholder coalition will be convened to address policies that act as barriers to housing stability or accessing mental healthcare. Interventions will be delivered through existing partnerships with community-based organizations and networks. The primary outcome is neighborhood rate of incident gun violence. To inform future implementation and optimize the intervention package as the study progresses, we will use the Learn As You Go approach to optimize and assess the effectiveness of the intervention package on the primary study outcome. DISCUSSION:Results from this protocol will yield novel evidence for whether and how addressing structural racism citywide leads to a reduction in gun violence. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT05723614. Registration date: February 01, 2023. Please refer to https://clinicaltrials.gov/ct2/show/NCT05723614 for public and scientific inquiries.

IMPORTANCE:Mortality from cardiovascular disease (CVD) varies across communities and is associated with known structural and population health factors. Still, a population's well-being, including sense of purpose, social relationships, financial security, and relationship to community, may be an important target to improve cardiovascular health. OBJECTIVE:To examine the association of population level measures of well-being with rates of CVD mortality in the US. DESIGN, SETTING, AND PARTICIPANTS:This cross-sectional study linked data from the Gallup National Health and Well-Being Index (WBI) survey to county-level rates of CVD mortality from the Centers for Disease Control and Prevention Atlas of Heart Disease and Stroke. Participants were respondents of the WBI survey, which was conducted by Gallup with randomly selected adults aged 18 years or older from 2015 to 2017. Data were analyzed from August 2022 to May 2023. MAIN OUTCOMES AND MEASURES:The primary outcome was the county-level rate of total CVD mortality; secondary outcomes were mortality rates for stroke, heart failure, coronary heart disease, acute myocardial infarction, and total heart disease. The association of population well-being (measured using a modified version of the WBI) with CVD mortality was assessed, and an analysis of whether the association was modified by county structural factors (Area Deprivation Index [ADI], income inequality, and urbanicity) and population health factors (percentages of the adult population who had hypertension, diabetes, or obesity; were currently smoking; and were physically inactive) was conducted. Population WBI and its ability to mediate the association of structural factors associated with CVD using structural equation models was also assessed. RESULTS:Well-being surveys were completed by 514 971 individuals (mean [SD] age 54.0 [19.2] years; 251 691 [48.9%] women; 379 521 [76.0%] White respondents) living in 3228 counties. Mortality rates for CVD decreased from a mean of 499.7 (range, 174.2-974.7) deaths per 100 000 persons in counties with the lowest quintile of population well-being to 438.6 (range, 110.1-850.4) deaths per 100 000 persons in counties with the highest quintile of population well-being. Secondary outcomes showed similar patterns. In the unadjusted model, the effect size (SE) of WBI on CVD mortality was -15.5 (1.5; P < .001), or a decrease of 15 deaths per 100 000 persons for each 1-point increase of population well-being. After adjusting for structural factors and structural plus population health factors, the association was attenuated but still significant, with an effect size (SE) of -7.3 (1.6; P < .001); for each 1-point increase in well-being, the total cardiovascular death rate decreased by 7.3 deaths per 100 000 persons. Secondary outcomes showed similar patterns, with mortality due to coronary heart disease and heart failure being significant in fully adjusted models. In mediation analyses, associations of income inequality and ADI with CVD mortality were all partly mediated by the modified population WBI. CONCLUSIONS AND RELEVANCE:In this cross-sectional study assessing the association of well-being and cardiovascular outcomes, higher well-being, a measurable, modifiable, and meaningful outcome, was associated with lower CVD mortality, even after controlling for structural and cardiovascular-related population health factors, indicating that well-being may be a focus for advancing cardiovascular health.

Communities of color are disproportionately impacted by gun violence. Unlocking potential community-led solutions could be the key to quelling the gun violence epidemic and its impact on these communities. In this qualitative study, we explored community perspectives on local assets that may prevent and mitigate gun violence. We conducted semi-structured, in-depth interviews (n = 45) among individuals not directly involved in gun violence (i.e., shooting victim or perpetrator) despite having a high probability of being involved in gun violence in New Haven, CT. Participants were asked to describe social structures that may deter local gun violence. Here, we report emergent themes to preventing gun violence across multiple levels, including role models (interpersonal), social cohesion and home ownership (neighborhood), and community-based organizations (organizational). Our findings suggest that investments in stable housing, efforts to build social cohesion, access to community-based mental health services, and youth activities are needed to curb the drivers of community gun violence.

PURPOSE/OBJECTIVE:We investigated the relationship between measures of self-reported health and well-being and concurrent and prospective healthcare utilization and costs to assess the added value of these self-reported measures in understanding utilization and cost. METHODS:Kaiser Permanente members (N = 6752) completed a 9-item survey measuring life evaluation, financial situation, social support, meaning and purpose, physical health, and mental health. Responses were linked to medical record information during the period 12 months before and after the survey. RESULTS:Correlations between health and well-being measures and healthcare utilization and cost variables were generally weak, with stronger correlations for future life evaluation and selected health measures (ρ = .20-.33, ps < .001). Better overall life evaluation had a significant but weak association with lower total cost and hospital days in the following year after controlling for age, sex, and race/ethnicity (p < .001). Full multivariate models, adjusting for age, sex, race/ethnicity, prior utilization, and relative risk models, showed weak associations between health and well-being measures and following year total healthcare cost and utilization, though the associations were relatively stronger for the health variables than the well-being variables. CONCLUSION/CONCLUSIONS:Overall, the health and well-being variables added little to no predictive utility for future utilization and cost beyond prior utilization and cost and the inclusion of predictive models based on clinical information. Perceptions of well-being may be associated with factors beyond healthcare utilization. When information about prior use is unavailable, self-reported health items have some predictive utility.

BACKGROUND:Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention. METHODS:Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis. DISCUSSION/CONCLUSIONS:This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Importance:Historically marginalized racial and ethnic groups are generally more likely to experience sleep deficiencies. It is unclear how these sleep duration disparities have changed during recent years. Objective:To evaluate 15-year trends in racial and ethnic differences in self-reported sleep duration among adults in the US. Design, Setting, and Participants:This serial cross-sectional study used US population-based National Health Interview Survey data collected from 2004 to 2018. A total of 429 195 noninstitutionalized adults were included in the analysis, which was performed from July 26, 2021, to February 10, 2022. Exposures:Self-reported race, ethnicity, household income, and sex. Main Outcomes and Measures:Temporal trends and racial and ethnic differences in short (<7 hours in 24 hours) and long (>9 hours in 24 hours) sleep duration and racial and ethnic differences in the association between sleep duration and age. Results:The study sample consisted of 429 195 individuals (median [IQR] age, 46 [31-60] years; 51.7% women), of whom 5.1% identified as Asian, 11.8% identified as Black, 14.7% identified as Hispanic or Latino, and 68.5% identified as White. In 2004, the adjusted estimated prevalence of short and long sleep duration were 31.4% and 2.5%, respectively, among Asian individuals; 35.3% and 6.4%, respectively, among Black individuals; 27.0% and 4.6%, respectively, among Hispanic or Latino individuals; and 27.8% and 3.5%, respectively, among White individuals. During the study period, there was a significant increase in short sleep prevalence among Black (6.39 [95% CI, 3.32-9.46] percentage points), Hispanic or Latino (6.61 [95% CI, 4.03-9.20] percentage points), and White (3.22 [95% CI, 2.06-4.38] percentage points) individuals (P < .001 for each), whereas prevalence of long sleep changed significantly only among Hispanic or Latino individuals (-1.42 [95% CI, -2.52 to -0.32] percentage points; P = .01). In 2018, compared with White individuals, short sleep prevalence among Black and Hispanic or Latino individuals was higher by 10.68 (95% CI, 8.12-13.24; P < .001) and 2.44 (95% CI, 0.23-4.65; P = .03) percentage points, respectively, and long sleep prevalence was higher only among Black individuals (1.44 [95% CI, 0.39-2.48] percentage points; P = .007). The short sleep disparities were greatest among women and among those with middle or high household income. In addition, across age groups, Black individuals had a higher short and long sleep duration prevalence compared with White individuals of the same age. Conclusions and Relevance:The findings of this cross-sectional study suggest that from 2004 to 2018, the prevalence of short and long sleep duration was persistently higher among Black individuals in the US. The disparities in short sleep duration appear to be highest among women, individuals who had middle or high income, and young or middle-aged adults, which may be associated with health disparities.

INTRODUCTION:Optimism is associated with better cardiovascular health, yet little is known about the underlying mechanisms and whether protective relationships are consistently observed across diverse groups. This study examines optimism's association with lipid profiles over time and separately among Black and White men and women. METHODS:Data were from 3,206 middle-aged adults in the Coronary Artery Risk Development in Young Adults study. Optimism was measured in 2000-2001 using the Revised Life Orientation Test. Triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol measurements were obtained at 5-year intervals through 2015-2016. Linear mixed models evaluated relationships between optimism and lipids, adjusting for covariates, including prebaseline lipids. Subgroup differences were examined using interaction terms and stratification. All analyses were conducted in 2020. RESULTS:Higher optimism was associated with both lower baseline total cholesterol (β= -2.33, 95% CI= -4.31, -0.36) and low-density lipoprotein cholesterol levels (β= -1.93, 95% CI= -3.65, -0.21) and a more rapid incremental increase in both markers over time (total cholesterol: β=0.09, 95% CI=0.00, 0.18; low-density lipoprotein cholesterol: β=0.09, 95% CI=0.01, 0.16). No associations were apparent with baseline triglycerides, high-density lipoprotein cholesterol, or changes in either lipid over time. Tests for interaction only found evidence of heterogeneous associations with baseline triglyceride levels, but stratified models hinted at stronger protective associations with baseline levels of total cholesterol and low-density lipoprotein cholesterol among White women. CONCLUSIONS:Optimism may help diverse individuals establish healthy total cholesterol and low-density lipoprotein cholesterol levels before midlife. Although associations were largely consistent across subgroups, stronger associations among White men and White women highlight a need to study optimism's health impact in diverse samples.