Faculty Bibliography

BACKGROUND: In the current report, we ask if targeting a cognitive behavioral therapy (CBT)-based intervention aimed at reducing hazardous alcohol consumption to HIV-infected persons in East Africa would have a favorable value at costs that are feasible for scale-up. METHODS: Using a computer simulation to inform HIV prevention decisions in East Africa, we compared 4 different strategies for targeting a CBT intervention-(i) all HIV-infected persons attending clinic; (ii) only those patients in the pre-antiretroviral therapy (ART) stages of care; (iii) only those patients receiving ART; and (iv) only those patients with detectable viral loads (VLs) regardless of disease stage. We define targeting as screening for hazardous alcohol consumption (e.g., using the Alcohol Use Disorders Identification Test and offering the CBT intervention to those who screen positive). We compared these targeting strategies to a null strategy (no intervention) or a hypothetical scenario where an alcohol intervention was delivered to all adults regardless of HIV status. RESULTS: An intervention targeted to HIV-infected patients could prevent 18,000 new infections, add 46,000 quality-adjusted life years (QALYs), and yield an incremental cost-effectiveness ratio of $600/QALY compared to the null scenario. Narrowing the prioritized population to only HIV-infected patients in pre-ART phases of care results in 15,000 infections averted, the addition of 21,000 QALYs and would be cost-saving, while prioritizing based on an unsuppressed HIV-1 VL test results in 8,300 new infections averted, adds 6,000 additional QALYs, and would be cost-saving as well. CONCLUSIONS: Our results suggest that targeting a cognitive-based treatment aimed at reducing hazardous alcohol consumption to subgroups of HIV-infected patients provides favorable value in comparison with other beneficial strategies for HIV prevention and control in this region. It may even be cost-saving under certain circumstances.

OBJECTIVE: The objective of our study was to perform a systematic review and meta-analysis of the test performance of DWI in the characterization of renal masses. MATERIALS AND METHODS: We performed searches of three electronic databases for studies on renal mass characterization using DWI. Methodologic quality was assessed for each study. We quantitatively analyzed test performance for three clinical problems: first, benign versus malignant lesions; second, clear cell renal cell carcinoma (RCC) versus other malignancies; and, third, high-versus low-grade clear cell RCCs. We summarized performance as a single pair of sensitivity and specificity values or a summary ROC curve. RESULTS: The studies in the literature were limited in both quantity and quality. For classification of benign versus malignant lesions, four studies with 279 lesions yielded a single summary estimate of 86% sensitivity and 78% specificity. For differentiation of clear cell RCC from other malignancies, five studies showed marked heterogeneity not conducive to meta-analysis. For differentiation of high-from low-grade clear cell RCCs, three studies with 110 lesions showed a threshold effect appropriate for summary ROC construction: The AUC was 0.83. CONCLUSION: Evidence suggests moderate accuracy of DWI for the prediction of malignancy and high-grade clear cell cancers, whereas DWI performance for ascertaining clear cell histologic grade remains unclear. To develop DWI as a noninvasive approach for the evaluation of solid renal masses, prospective studies with standardized test parameters are needed to better establish DWI performance and its impact on patient outcomes.

We identified the research areas related to HIV and alcohol consumption that were of highest priority to city, state, and federal policymakers. From June to July 2014, we conducted a 3-round Delphi study to elicit from experts a list of alcohol- and HIV-related clinical trial research questions that were important to fund and rank order the list to identify questions of highest priority. Translating evidence into practice must be improved because some questions that have been extensively studied with results published in peer-reviewed journals were identified by the panel as areas needing additional research. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e4. doi:10.2105/AJPH.2015.302799).

OBJECTIVES: We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence. METHODS: Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses. RESULTS: We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts. CONCLUSIONS: Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence. (Am J Public Health. Published online ahead of print July 16, 2015: e1-e8. doi:10.2105/AJPH.2015.302679).

BACKGROUND: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes. OBJECTIVE: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends. DESIGN AND PATIENTS: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders. MAIN MEASURES: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate. KEY RESULTS: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period. CONCLUSIONS: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting.

OBJECTIVES: Community viral load (CVL) estimates vary based on analytic methods. We extended the CVL concept and used data from the Veterans Health Administration (VA) to determine trends in the health care system viral load (HSVL) and its sensitivity to varying definitions of the clinical population and assumptions regarding missing data. METHODS: We included HIV-infected patients in the Veterans Aging Cohort Study, 2000-2010, with at least one documented CD4 count, HIV-1 RNA or antiretroviral prescription (n = 37 318). We created 6-month intervals including patients with at least one visit in the past 2 years. We assessed temporal trends in clinical population size, patient clinical status and mean HSVL and explored the impact of varying definitions of the clinical population and assumptions about missing viral load. RESULTS: The clinical population size varied by definition, increasing from 16 000-19 000 patients in 2000 to 23 000-26 000 in 2010. The proportion of patients with suppressed HIV-1 RNA increased over time. Over 20% of patients had no viral load measured in a given interval or the past 2 years. Among patients with a current HIV-1 RNA, mean HSVL decreased from 97 800 HIV-1 RNA copies/mL in 2000 to 2000 copies/mL in 2010. When current HIV-1 RNA data were unavailable and the HSVL was recalculated using the last available HIV-1 RNA, HSVL decreased from 322 300 to 9900 copies/mL. HSVL was underestimated when using only current data in each interval. CONCLUSIONS: The CVL concept can be applied to a health care system, providing a measure of health care quality. Like CVL, HSVL estimates depend on definitions of the clinical population and assumptions about missing data.

Aims: There has been a rise in hepatitis C virus (HCV) infection in HIV- positive (HIV+) men who have sex with men (MSM). HIV/HCV co-infection complicates management of HIV and HCV, and increases the risk of serious liver disease. The aim of this study was to carry out a systematic review and meta-analysis to characterize the epidemiology of sexually transmitted HCV infection in this population. Methods: The search encompassed EMBASE, PubMed and BIOSIS, plus proceedings of scientific conferences and footnote chasing. To be eligible, reports must be published or presented 1990-2013, and include data on HCV incidence or risk factors for infection in HIV +MSM who were not injecting drugs. Studies were assigned quality ratings based on the Newcastle-Ottawa Scale. Results: The search retrieved 687 abstracts after duplicates were removed. After screening, there were 12 eligible studies from Europe, Australia, North America and Asia including 10 cohort and 2 case-control studies. HCV seroconversion rates ranged between 0 and 1.18/100 person-years (PYs), median 0.39/100PYs (n = 67,426 PYs). Two studies reported that sex while high on methamphetamine (AOR 28.6) and rectal trauma or bleeding (AOR = 6.2) were significantly associated with HCV seroconversion. Few studies examined the role of non-injection drug use in HCV infection. Conclusions: Evidence points to blood as the medium of sexual HCV transmission in HIV +MSM, and the role of drug use appears to be via the facilitation of mucosally traumatic sexual practices. The shared use of implements to administer drugs intranasally has received little attention as a possible risk factor for HCV infection in this population