Faculty Bibliography

Introduction Cordon-based congestion policies have demonstrated air quality and health benefits in cities outside the United States (U.S.), yet selecting comparison areas to evaluate these policies remains a methodological challenge. Using two pre-policy administrative health datasets, we examined the feasibility of constructing local, state, and regional counterfactual populations to inform an evaluation of child health impacts of the recently implemented New York City (NYC) congestion pricing policy, focusing on pediatric asthma emergency department visits. Methods Our study population included children aged 0-17 years. Using a difference-in-differences approach for repeated measures, we evaluated crude pre-policy pediatric asthma trends between the congestion relief zone (CRZ) and three comparison areas: (1) NYC neighborhoods outside the CRZ, (2) nine major New York State cities, and (3) dense, heavily trafficked Northeast regional U.S. cities. We compared this approach with a generalized synthetic control method (G-SCM). Results Crude pre-policy pediatric asthma trends were most parallel between the CRZ and the local NYC comparison zone. Socioeconomic, built environment, and environmental exposure covariates varied across comparison areas at baseline. G-SCM improved visual pre-policy trend alignment across all three comparison areas; however, placebo tests revealed statistically significant parallel trend violations persisted for non-local comparison areas. Conclusions Local comparison populations may offer the most representative counterfactual for evaluating NYC congestion pricing child health impacts. Residual parallel trend violations in non-local areas underscore the methodological challenges of counterfactual selection for geographically concentrated urban policies, highlighting the value of triangulating findings across comparison areas and analytic approaches in future post-implementation evaluations.

IMPORTANCE/UNASSIGNED:Health care systems can help protect patients from the increasing threat of extreme heat-driven morbidity and mortality. Electronic health records (EHRs) provide insight into trends and local variation in thresholds above which extreme heat is associated with emergency department (ED) use among at-risk patient populations. OBJECTIVE/UNASSIGNED:To examine associations between extreme heat exposure and all-cause ED visits among patients aged 65 years and older. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This matched case-control study of patients seeking emergency care at an urban health care system during the summer (May 1 to September 30) from 2022 to 2024. Two New York City (NYC) EDs were included: (1) ED-1, predominantly serving Medicaid-enrolled patients from minoritized racial and ethnic groups, and (2) ED-2, predominantly serving White, privately insured patients. Included patients were aged 65 years or older and presented to ED-1 and ED-2 during the study period. Data were analyzed from April to August 2025. EXPOSURES/UNASSIGNED:Daily maximum heat index (HImax) values during the summer were calculated from the National Centers for Environmental Information monitor-derived recordings. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Daily all-cause ED use counts were derived from EHRs, and extreme heat exposure-outcome curves were calculated. Daily HImax anomalies were calculated based on a 30-year baseline average. The cumulative odds ratio (OR) and 95% CIs were calculated. RESULTS/UNASSIGNED:This study included 55 200 ED encounters and represented 15 092 unique patients at ED-1 and 19 559 at ED-2 with a mean (SD) age of 74.9 (8.92) years at ED-1 and 74.9 (8.72) years at ED-2. Compared with ED-2, more ED-1 patients were female (8589 [56.9%] vs 10 767 [55.0%]), Hispanic (3544 [23.5%] vs 2576 [13.2%]), and Medicaid-enrolled (1321 [8.8%] vs 824 [4.2%]). At ED-1, daily HImax associations increased after 66 °F (OR, 1.10 [95% CI, 1.01-1.21]), peaking at 101 °F (OR, 1.24 [95% CI, 1.11-1.39]), and were higher on days with HImax anomalies between 15 °F (OR, 1.07 [95% CI, 1.01-1.13]) and 18 °F (OR, 1.10 [95% CI, 1.01-1.20]) warmer than average. At ED-2, daily HImax ED use associations were not significant and were significantly negative for days with HImax anomalies above 16 °F, nadiring at 21 °F (0.84, 95% CI [0.73, 0.95]) warmer than average. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this case-control study of the association between heat exposure and ED use in adults aged 65 years and older, positive associations were only observed at ED-1, which served a predominantly lower-income population from minoritized racial and ethnic groups. These association thresholds were not fully captured by NYC heat advisories, which were triggered by 2 days above HImax 95 °F or any time above 100 °F, highlighting an opportunity for future research to develop targeted, risk-informed health care system-based heat warning strategies.

OBJECTIVE:To examine associations between patient-reported health-related social needs (HRSNs) and clinical quality measure (CQM) performance in an urban federally qualified health center (FQHC) network. METHODS:This cross-sectional study included adult patients (≥18 years) screened for HRSNs at a general internal medicine clinic, Clinic-1, and a prenatal healthcare clinic, Clinic-2, within a FQHC network, between January 1, 2018, and July 31, 2022. HRSNs were assessed across 9 domains. Performance was assessed for 13 process and 2 outcome-based CQMs at Clinic-1 and 5 process-based CQMs at Clinic-2. Prevalence ratios (PR) were estimated using logistic regression to compare CQM performance by HRSN status, adjusted for relevant demographic, clinical, and clinician factors. RESULTS:At Clinic-1, reporting a HRSN was associated with lower hemoglobin A1c control (PR, 0.81; 95%CI, 0.69, 0.95). At Clinic-2, reporting a HRSN was associated with higher cervical cancer screening (PR, 1.07; 95%CI, 1.03, 1.11). No other CQMs differed significantly by HRSN status. CONCLUSIONS:HRSNs were not associated with differences in performance for most CQMs at this FQHC network. Exceptions were observed negative associations with diabetes A1c control and positive associations with cervical cancer screening. Further research is needed to elucidate mechanisms through which unmet HRSNs impact CQMs across care settings.

INTRODUCTION/BACKGROUND:Hazardous working conditions fuel inequities in accidental-poisoning, suicide, and chronic-liver-disease mortality. Relational theories suggest such hazards flow from power imbalances between workers, managers, and employers - social classes demarcated by power over property and labor. However, to our knowledge, no US studies using relational measures have analyzed class inequities in the cause-specific mortality. METHODS:We used the Mortality Disparities in American Communities dataset, which links the 2008 American Community Survey to the National Death Index through December 31, 2019. We classified respondents as incorporated business owners, unincorporated business owners, managers, workers, or not in the labor force based on their employment, occupational, and business-ownership status. Then, using an inverse-probability-weighted Aalen-Johansen estimator, we estimated risk differences in the cause-specific mortality across classes at the end of follow-up, including by sex, race/ethnicity, and education. RESULTS:Our sample included 2,304,500 respondents and 10,870 accidental-poisoning, suicide, and chronic-liver-disease deaths. Compared to incorporated business owners, those not in the labor force, workers, and unincorporated business owners had, respectively, 8.9 (95 % CI: 8.0, 9.7), 0.9 (95 % CI: 0.4, 1.5), and 1.1 (95 % CI: 0.3, 1.9) greater 12-year age- and sex-adjusted risks of the cause-specific mortality per 1000. Managers' risks resembled incorporated business owners'. Inequities largely persisted after thorough sociodemographic adjustment. Among workers, risks were elevated among the unemployed and those with blue-collar or service occupations. Finally, inequities were greater among men and less-educated respondents than among women and more-educated respondents. DISCUSSION/CONCLUSIONS:We estimated considerable class inequities in the cause-specific mortality, adding to research connecting class relations to mortality inequities and worsening population health.

Extreme heat events are a growing health threat, but their impact is heterogeneous because different settings have different levels of heat adaptation. Previous reviews have assessed morbidity and mortality as a function of meteorological conditions such as air temperature. We aimed to conduct the first systematic review and meta-analysis of the association between meeting local definitions of extreme heat events and risks of hospitalization and mortality overall and by population segment. We searched PubMed, Web of Science, Scopus, ScienceDirect, and Google Scholar on February 05, 2025, with no restrictions on language or publication date. Data extraction and risk of bias assessment were conducted by multiple reviewers. We estimated the risk ratio (RR) for hospitalization and mortality when meeting local definitions of extreme heat events using a random effects model to account for heterogeneity. In subgroup analysis, we examined variations by date, global region, country income group, extreme heat event definition type (absolute thresholds, percentile-based, composite indices), and population characteristics including age, socioeconomic context, and urban versus rural settings. In sensitivity analysis, we assessed the robustness of results by excluding lower-quality studies and applying alternative regression models. From 6,015 initial records, 21 studies (n = 126,930,288 individuals) met inclusion criteria. The pooled RR for mortality associated with extreme heat events was 1.24 (95% CI: 1.06-1.46) with substantial heterogeneity across studies (I² = 99.8%), which was explored through subgroup, meta-regression, and sensitivity analysis. The meta-regression showed a significant increase in RR over time (p < 0.05). No significant publication bias was detected (Begg's test, p = 0.458). In subgroup analysis, higher RRs were observed in studies from Europe (RR range: 1.16-4.24) and low- and middle-income countries, in older adults (RR range: 1.16-2.24), in urban populations, in older populations, and in studies using absolute temperature thresholds or composite indices. Findings were similar when excluding lower-quality studies and applying alternative regression models. Extreme heat events were significantly associated with mortality, with risks increasing over time and elevated among older adults and urban populations. Municipal and health authorities should prioritize extreme heat adaptation, as mortality is likely to increase as the climate warms.

INTRODUCTION/BACKGROUND:), this study aimed to estimate the effect of chronic air pollutant exposures on the risk of COVID-19 morbidity and mortality and to determine whether these effects vary by neighborhood-level vulnerability as defined by social and structural factors. METHODS:) by using zip code-level 11-year averages based on data from the 2009-2019 New York City Community Air Survey. For each pollutant, we constructed Cox proportional hazards models to estimate the hazards of fatality (i.e., dying from COVID among individuals with COVID) and hospital length of stay. Additionally, for each pollutant, we constructed Poisson regression models to estimate RRs (RRs) for acute respiratory distress syndrome (ARDS), pneumonia, mechanical ventilation, and dialysis during hospitalization and risk of hospitalization among ED patients. Models were adjusted for age, sex, body mass index, smoking status, history of chronic disease, and a neighborhood environmental vulnerability index (NEVI). Interaction terms were used to evaluate effect modification between pollutant exposures and the NEVI metric. Additionally, we conducted supplementary analyses to determine the joint effects of air pollution and pre-existing chronic diseases and whether those relationships varied by NEVI tertile. To supplement the fatality analysis, we conducted an excess mortality analysis among the full urban population using all-cause mortality data from public health records for 2015-2020. Sensitivity analyses were performed to evaluate the effect of selection bias. RESULTS:, and BC exposures throughout the study period. Even after accounting for the NEVI metric and pre-existing chronic disease, racial disparities persisted in the effect of air pollution on risks of pneumonia and hospitalization, with the largest RRs among Black and Hispanic populations. Results of the all-cause mortality analysis also showed no evidence of greater excess mortality in areas with higher levels of air pollution. The greatest excess mortality was observed in areas with high NEVI metrics, regardless of air pollutant exposures. CONCLUSIONS:When limiting to individuals in the hospital's typical catchment areas, the observed positive associations between air pollutant exposures and COVID-19-related morbidities such as ARDS, pneumonia, and use of dialysis were strongest in areas with higher neighborhood-level environmental vulnerability. Inverse associations between air pollutant exposures and severe outcomes like death and use of mechanical ventilation were unexpected findings that highlighted challenges in examining such associations at the population level in NYC.

INTRODUCTION/BACKGROUND:Communities disproportionately burdened by adverse neighborhood-level social and structural factors may experience greater vulnerability to environmental exposures, contributing to health inequities, including adverse COVID-19. We assessed the effects of chronic air pollution on COVID-19 morbidities in NYC and examined whether these effects varied by neighborhood-level vulnerability. METHODS:)) was assigned using residential ZIP Code (NYC Community Air Survey; 2009-2019). Modified Poisson regression estimated risk of acute respiratory distress syndrome (ARDS), pneumonia, ventilation, and dialysis, and Cox regression estimated risk of discharge, adjusting for age, sex, BMI, smoking, asthma, diabetes, and hypertension. We assessed effect modification by neighborhood-level environmental vulnerability index (NEVI) tertiles. RESULTS:and pneumonia's relationship was stronger in individuals within higher NEVI tertiles (T1: aRR: 1.13, 95%CI: 1.02-1.25; T2: aRR: 2.11, 95%CI: 1.73-2.56; T3: aRR: 6.36, 95%CI: 4.71-8.60). DISCUSSION/CONCLUSIONS:Differences in neighborhood-level social and structural factors contribute to unequal health burdens associated with air pollution. Public health resources targeted toward neighborhoods with greater environmental vulnerability can encourage population-level pandemic preparedness.

PURPOSE/OBJECTIVE:We evaluated associations among long-term air pollution exposure, neighborhood-level social and structural drivers of environmental vulnerability, and COVID-19 death during the first pandemic year in New York City (NYC). METHODS:) exposures as 11-year mean concentrations. Social and structural factors were integrated into a neighborhood environmental vulnerability index (NEVI), with higher scores indicating greater vulnerability. RESULTS:(32.39) with high NEVI scores. CONCLUSIONS:, and COVID-19 death associations were unexpected, highlighting challenges in examining these associations in NYC. Future pandemic preparedness efforts should prioritize urban communities burdened by structurally rooted health vulnerabilities, even in areas with low air pollution exposure.

Growing evidence suggests exposure to high temperatures may result in increased urban crime, a known driver of health and health inequity. Theoretical explanations have been developed to describe the heat-crime relationship without consensus yet achieved among experts. This scoping review aims to summarize evidence of heat-crime associations in U.S. cities. Further examination of empirical and translational inconsistencies in this literature will ensure future studies of urban heat-crime relationships in the U.S., and their policy impacts are informed by a thorough understanding of existing evidence. We performed a comprehensive literature search of empirical studies on heat-crime relationships in U.S. cities published between January 2000 and August 2023. The included studies were qualitatively synthesized based on operationalized exposures, outcomes, covariates, methodologies, theoretical framing, and policy implications. In total, 46 studies were included in this review. Most studies (93%) reported significant, positive associations between urban heat exposure and both violent and non-violent crime outcomes. The shape and strength of these associations varied based on operational definitions of urban heat exposures, crime outcomes, and relevant covariates in employed methods. We also found inconsistencies in the theoretical explanations and policy implications reported across studies. Climate-driven extreme heat events are projected to increase in frequency and severity. Our findings underscore the urgency of refining the understanding and translation of the complex relationship between urban heat and crime. In this review, we highlight opportunities to improve the methodological quality and responsible policy translation of future research in U.S. cities, which has implications for research globally.