Faculty Bibliography

Background: Certain vulnerable patient groups including the homeless and those with Medicaid insurance are disproportionately represented among ED patients, yet little is known about ED patients' social determinants of health (SDOH). Objectives: This study seeks to quantify the presence of certain SDOH in ED patients. Methods: Using questions from previously validated or widelyused questionnaires, we conducted a cross-sectional survey of a random sample of patients presenting to an urban academic ED. Patients were excluded if they were physically or mentally unfit to participate, were intoxicated, were under police custody, or had already completed the study. Surveys were administered by trained research assistants (RAs) from June-August 2014 seven days a week from 8 am-11 pm and during eight 12 am-8 am shifts. RAs used a random number generator and patient whiteboard displays to select patients to approach. Survey responses were entered by RAs directly into a secure iPad survey platform. Multiple imputation was used for missing data. Results: 1,463 patients were assessed for eligibility, 592 were ineligible, and 246 of those eligible refused to participate, yielding 625 total participants. There were no statistically significant differences in gender or age between those who chose to participate and those who refused. 58.1% of participants were male, 39.8% were Hispanic, 25.9% were black, and 27.2% were white. The most common insurance status was uninsured (28.1%), followed by Medicaid (26.7%). 13.8% of patients were currently living in a homeless shelter or on the streets and 30.5% had been homeless at some point in their lives. In addition, 25.4% of patients reported concern about becoming homeless in the next 2 months and 9.1% had been evicted from their home in the past year. 42.0% of patients reported difficulty meeting essential expenses, 35.9% were worried about running out of food, and 27.7% had not seen a doctor or taken medications (24.5%) because of money concerns. Conclusion: Our survey found high rates of homelessness and other SDOH in ED patients and demonstrates the importance of further research on ED patients' SDOH. Addressing patients' SDOH will become increasingly important under new health care payment models that demand greater accountability for population health

Aims: Implementation of substance use screening in general medical settings is hindered by the lack of a brief yet precise and comprehensive screening tool that is compatible with clinical workflows. To address this need, we developed the Substance Use Brief Screen (SUBS); a 4-item screener for tobacco, alcohol, and drug use (illicit and prescription) that is self-administered and may be easily integrated with electronic health records. Methods: Adult patients were recruited consecutively in the waiting area of an urban safety net primary care clinic. The SUBS was self-administered in English on touchscreen tablet computers. Reference standard measures of unhealthy substance use and substance use disorders were then administered, including self reported measures and saliva drug tests. The SUBS was compared against the reference standards to determine its sensitivity, specificity, and area under the curve (AUC) for each substance class. Results: Among the 390 participants, rates of past year use reported on the SUBS were 37% tobacco, 43% alcohol (4+ drinks/day), 20% illicit drugs, and 12% prescription drugs. Sensitivity and specificity of the SUBS for detecting past year unhealthy use were: tobacco 99% and 91% (AUC = .95); alcohol 94% and 68% (AUC = .81); drugs (illicit or prescription) 84% and 89% (AUC = .86). Sensitivity was lower for prescription drugs (57%) than for illicit drugs (78%). For detecting a substance use disorder, sensitivity and specificity were: tobacco 100% and 73% (AUC = .87); alcohol 93% and 64% (AUC = .79); drugs 85% and 82% (AUC = .84). Conclusions: The SUBS accurately identified unhealthy tobacco, alcohol, and drug use in this primary care sample, and had high sensitivity but lower specificity for identifying substance use disorders. Individuals screening positive on the SUBS should receive further assessment. Our findings support use of the SUBS for substance use screening in primary care, but additional tools may be needed for prescription drugs

Few published studies describe processes in the development of mobile health interventions. This study reports data from a formative evaluation of a text messaging intervention being developed to increase adherence to smoking cessation medication (varenicline) among tobacco-dependent persons with HIV/AIDS. Four focus groups were conducted (N = 29) using a mixed-methods approach to assess: (a) beliefs and preferences regarding the use of varenicline, (b) preferences for receiving tobacco-related texts, and (c) the acceptability of draft text messages. Themes that emerged from the focus groups were that (a) participants were cautious and wanted to discuss varenicline carefully with health care providers, (b) participants preferred simple messages that were positive and encouraging, (c) messages should emphasize tobacco cessation and not varenicline adherence, and (d) texts would serve as a reminder about goals and foster support and connectedness with the health care team. Overall, 47 out of the 100 messages received a grade of C or less (rated on a 5-point grade scale: A, B, C, D, or F), the majority of which focused on medication adherence. All participants reported that they were likely to read the messages. The majority (64%) indicated that they preferred receiving 2 or more messages per day. Gathering systematic participant feedback provides critical input in intervention planning.

BACKGROUND: Despite high smoking rates, cessation services are largely unavailable in Vietnam. This study explored attitudes and beliefs of community health workers (CHWs) towards expanding their role to include delivering tobacco use treatment (TUT), and potential barriers and facilitators associated with implementing a strategy in which health centers would refer patients to CHWs for cessation services. METHODS: We conducted four focus groups with 29 CHWs recruited from four district community health centers (CHCs) in Hanoi, Vietnam. RESULTS: Participants supported expanding their role saying that it fit well with their current responsibilities. They further endorsed the feasibility of serving as a referral resource for providers in local CHCs expressing the belief that CHWs were "more suitable than their clinical colleagues" to offer cessation assistance. The most frequently cited barrier to routinely offering cessation services was that despite enacting a National Tobacco Control Action plan, cessation is not one of the national prevention priorities. As a result, CHWs have not been "assigned" to help smokers quit by the Ministry of Health. Additional barriers included lack of training and time constraints. CONCLUSION: Focus groups suggest that implementing a systems-level intervention that allows providers to refer smokers to CHWs is a promising model for extending the treatment of tobacco use beyond primary care settings and increasing access to smoking cessation services in Vietnam. There is a need to test the cost-effectiveness of this and other strategies for implementing TUT guidelines to support and inform national tobacco control policies in Vietnam and other low-and middle-income countries.

INTRODUCTION: Dental visits represent an opportunity to identify and help patients quit smoking, yet dental settings remain an untapped venue for treatment of tobacco dependence. The purpose of this analysis was to assess factors that may influence patterns of tobacco-use-related practice among a national sample of dental providers. METHODS: We surveyed a representative sample of general dentists practicing in the United States (N = 1,802). Multivariable analysis was used to assess correlates of adherence to tobacco use treatment guidelines and to analyze factors that influence providers' willingness to offer tobacco cessation assistance if reimbursed for this service. RESULTS: More than 90% of dental providers reported that they routinely ask patients about tobacco use, 76% counsel patients, and 45% routinely offer cessation assistance, defined as referring patients for cessation counseling, providing a cessation prescription, or both. Results from multivariable analysis indicated that cessation assistance was associated with having a practice with 1 or more hygienists, having a chart system that includes a tobacco use question, having received training on treating tobacco dependence, and having positive attitudes toward treating tobacco use. Providers who did not offer assistance but who reported that they would change their practice patterns if sufficiently reimbursed were more likely to be in a group practice, treat patients insured through Medicaid, and have positive attitudes toward treating tobacco dependence. CONCLUSION: Findings indicate the potential benefit of increasing training opportunities and promoting system changes to increase involvement of dental providers in conducting tobacco use treatment. Reimbursement models should be tested to assess the effect on dental provider practice patterns.

The purpose of this study was to evaluate the feasibility of using global positioning system (GPS) methods to understand the spatial context of obesity and hypertension risk among a sample of low-income housing residents in New York City (n = 120). GPS feasibility among participants was measured with a pre- and post-survey as well as adherence to a protocol which included returning the GPS device as well as objective data analysed from the GPS devices. We also conducted qualitative interviews with 21 of the participants. Most of the sample was overweight (26.7%) or obese (40.0%). Almost one-third (30.8%) was pre-hypertensive and 39.2% was hypertensive. Participants reported high ratings of GPS acceptability, ease of use and low levels of wear-related concerns in addition to few concerns related to safety, loss or appearance, which were maintained after the baseline GPS feasibility data collection. Results show that GPS feasibility increased over time. The overall GPS return rate was 95.6%. Out of the total of 114 participants with GPS, 112 (98.2%) delivered at least one hour of GPS data for one day and 84 (73.7%) delivered at least one hour on 7 or more days. The qualitative interviews indicated that overall, participants enjoyed wearing the GPS devices, that they were easy to use and charge and that they generally forgot about the GPS device when wearing it daily. Findings demonstrate that GPS devices may be used in spatial epidemiology research in low-income and potentially other key vulnerable populations to understand geospatial determinants of obesity, hypertension and other diseases that these populations disproportionately experience.