Faculty Bibliography

Background/Purpose : Psoriatic arthritis (PsA) is a heterogenous inflammatory disease affecting skin, joints, and other domains. While psychiatric diseases (i.e., depression and anxiety) are known comorbidities, little is known about their impact on disease severity and patient reported outcomes (PROs). The objective of this study was to characterize the prevalence of psychiatric comorbidities in an academic combined psoriasis-psoriatic arthritis center and determine their impact on PsA clinical and patient derived outcomes. Methods : Consecutive adult patients meeting CASPAR criteria for PsA (n=436) were prospectively recruited at the NYU Psoriatic Arthritis Center. All data was collected from clinical visits utilizing a standardized EPIC template. Depression was defined by established diagnosis and/or use of anti-depressant medications. Objective measures of disease severity included swollen and tender joint counts (SJC/TJC) and PROs including RAPID3 scores. Data was analyzed using statistical software R. Results : Our cohort was comprised of 436 patients: 54% male, mean age of 47 years, and mostly Caucasians (74.1%). Within our population, 19.5% had depression, 15.6% had anxiety, and 4.8% had ADHD (Table 1). Of those with depression, 71% were on anti-depressive medication. At the initial visit, patients with PsA and depression were more likely to be on medication(s) for PsA (80% vs 65%, p=.01) and had a trend towards higher rates of biologic use (47.5% vs 40.4%, p=.126). Those with depression had a similar TJC to their non-depressed counterparts, but had a trend towards fewer swollen joints and concomitant higher RAPID3 scores (Table 2). When analyzing repeated outcome measures over subsequent visits, individuals with depression were similarly more likely to have a higher TJC, a lower SJC, and a higher RAPID3 score (although only RAPID3 was found to be statistically significant, p=.004). Importantly, these findings persisted when analyzing participants that were matched with propensity scores to adjust for age, sex, comorbidities, and medication use. In addition to joint activity, psoriasis activity measured by body surface area (BSA) was lower in those who were depressed (1.4% vs 3.03%, p=.001) and these differences were maintained over subsequent visits. Conclusion : Our results expand on prior reports of significantly elevated rates of depression in PsA. Notably, individuals with depression were more likely to be on medication(s) for their PsA, had fewer swollen joints, and a lower BSA but, paradoxically reported higher RAPID3 scores. This discrepancy is likely a manifestation of how depression could affect the way patients experience their PsA despite apparent improvement in skin and joint symptoms. Depression should, therefore, be considered a critical comorbidity when addressing PsA care in routine visits. Further work is needed to understand whether modulation of psychiatric comorbidities can lead to improved PsA outcomes

BACKGROUND:Pay-for-performance (P4P) has been used expansively to improve quality of care delivered by physicians. However, to what extent P4P works through the provision of information versus financial incentives is poorly understood. OBJECTIVE:To determine whether an increase in information feedback without changes to financial incentives resulted in improved physician performance within an existing P4P program. INTERVENTION/EXPOSURE/UNASSIGNED:Implementation of a new registry enabling real-time feedback to physicians on quality measure performance. DESIGN/METHODS:Observational, predictive piecewise model at the physician-measure level to examine whether registry introduction associated with performance changes. We used detailed physician quality measure data 3 years prior to registry implementation (2010-2012) and 2 years after implementation (2014-2015). We also linked physician-level data including age, gender, and board certification; group-level data including registry click rates; and patient panel data including chronic conditions. PARTICIPANTS/METHODS:Four hundred thirty-four physicians continuously affiliated with Advocate from 2010 to 2015. MAIN MEASURES/METHODS:Physician performance on ten quality metrics. KEY RESULTS/RESULTS:We found no consistent pattern of improvement associated with the availability of real-time information across ten measures. Relative to predicted performance without the registry, average performance increased for two measures (childhood immunization status-rotavirus (p < 0.001) and diabetes care-medical attention for nephropathy (p = 0.024)) and decreased for three measures (childhood immunization status-influenza (p < 0.001) and diabetes care-HbA1c testing (p < 0.001) and poor HbA1c control (p < 0.001)). Results were consistent for subgroup analysis on those most able to improve, i.e., physicians in the bottom tertile of performance prior to registry introduction. Physicians who improved most were in groups that accessed the registry more than those who improved least (8.0 vs 10.0 times per week, p = 0.010). CONCLUSIONS:More frequent provision of information, provided in real-time, was insufficient to improve physician performance in an existing P4P program with high baseline performance. Results suggest that electronic registries may not themselves drive performance improvement. Future work should consider testing information feedback enhancements with financial incentives.

Changing physician behaviors is difficult. Electronic health record (EHR) clinical decision support (CDS) offers an opportunity to promote guideline adherence. Behavioral economics (BE) has shown success as an approach to supporting evidence-based decision-making with little additional cognitive burden. We applied a user-centered approach to incorporate BE "nudges" into a CDS module in two "vanguard" sites utilizing: (1) semi-structured interviews with key informants (n = 8); (2) a design thinking workshop; and (3) semi-structured group interviews with clinicians. In the 133 day development phase at two clinics, the navigator section fired 299 times for 27 unique clinicians. The inbasket refill alert fired 124 times for 22 clinicians. Fifteen prescriptions for metformin were written by 11 clinicians. Our user-centered approach yielded a BE-driven CDS module with relatively high utilization by clinicians. Next steps include the addition of two modules and continued tracking of utilization, and assessment of clinical impact of the module.

Background/UNASSIGNED:The purpose of this study was to evaluate baseline demographic characteristics which may be associated with worse health related quality of life (HRQOL) for patients with locally advanced non-small cell lung cancer (NSCLC) receiving definitive chemoradiation (CRT). Materials/UNASSIGNED:Patients with NSCLC were prospectively enrolled on an Institutional Review Board-approved clinical trial between 2009 and 2012. HRQOL assessments were collected pre-radiation therapy (RT), during RT, and within 3 months post-RT using Euroqol (EQ-5D), MD Anderson Symptom Inventory (MDASI), and Functional Assessment of Cancer Therapy General (FACT-G). HRQOL correlation was assessed with categorical variables by Wilcoxon rank sum tests and with continuous variables by Pearson correlation. P<0.05 was defined as statistically significant. Results/UNASSIGNED:Forty-three consecutive patients received definitive concurrent CRT and completed assessments at one or more time-points. Patients most commonly had stage IIIB disease (72%), were married or with a partner (70%) and Caucasian (91%). Median patient age was 65 (range: 39-79) years and Charlson comorbidity index (CCI) was 0 (range: 0-5). Female gender, African-American ethnicity, age, chemotherapy type, baseline hemoglobin, and CCI were associated with worse post-treatment HRQOL measures. Conclusions/UNASSIGNED:We have identified novel characteristics associated with worse quality of life following definitive CRT for lung cancer. Patients at risk for worse post-treatment quality of life may benefit from earlier follow-up and greater supportive measures following treatment.

Many health issues require adherence to recommended daily activities, such as taking medication to manage a chronic condition, walking a certain distance to promote weight loss, or measuring weights to assess fluid balance in heart failure. The cost of nonadherence can be high, with respect to both individual health outcomes and the healthcare system. Incentivizing adherence to daily activities can promote better health in patients and populations and potentially provide long-term cost savings. Multiple incentive structures are possible. We focus here on a daily lottery incentive in which payment occurs when both the participant's lottery number matches the number drawn and the participant adheres to the targeted daily behavior. Our objective is to model the lottery's effect on participants' probability to complete the targeted task, particularly over the short term. We combine two procedures for analyzing such binary time series: a parameter-driven regression model with an autocorrelated latent process and a comparative interrupted time series. We use the output of the regression model as the control generator for the comparative time series in order to create a quasi-experimental design.

Importance/UNASSIGNED:Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. Objective/UNASSIGNED:To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year. Design, Setting, and Participants/UNASSIGNED:Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter. Exposures/UNASSIGNED:Participation in the 3PC system. Main Outcomes and Measures/UNASSIGNED:The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes. Results/UNASSIGNED:In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, -3.9 percentage points [95% CI, -4.6 to -3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, -1.3% to 3.4%]; P = .39). Conclusions and Relevance/UNASSIGNED:In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.

Background Black men who have sex with men (BMSM) disproportionately report a history of traumatic life events including incarceration. Incarceration, by increasing distress and psychopathology, may increase risk-taking and infection. Pre-incarceration trauma may exacerbate the impact of incarceration on STI/HIV risk among BMSM. Methods Using data from HIV Prevention Trials Network (HPTN) 061, we used inverse probability of treatment weighted Poisson regression models to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for associations between recent incarceration and incident STI (gonorrhea, chlamydia, and syphilis) and sexual risk behavior (sex trade defined as selling/buying sex, multiple partnerships, condomless sex) measured six months after incarceration assessment (n=1189). We tested the significance of interaction terms between incarceration and trauma to assess whether associations differed significantly by trauma history (e.g., experiencing a robbery, natural disaster, sexual/physical assault). Results Approximately 93% reported at least one traumatic event and 14% had been recently incarcerated. Incarceration was associated with STI among those with prior trauma (RR: 1.10, 95% CI: 1.00-1.22) but not among those with no prior trauma (RR: 0.91, 95% CI: 0.75-1.09); associations differed significantly (interaction term p=0.036). Incarceration was linked to increased risk of sex trade involvement among those with prior trauma (RR: 1.08, 95% CI: 1.00-1.15) and decreased risk among those with no prior trauma (RR: 0.95, 95% CI: 0.90-1.00) (interaction term p=0.002). Incarceration was associated with increased risk of multiple partnerships among those with prior trauma (RR: 1.24; CI: 1.10, 1.40) but not among those with no prior trauma (RR: 0.85, 95% CI: 0.32-2.25), though the RRs were not significantly different (interaction term p=0.224). Incarceration was not associated with condomless sex, regardless of prior trauma. Conclusion BMSM with prior trauma appear to face disproportionate vulnerability to STI/HIV risk after release from incarceration. Trauma-informed STI/HIV care and prevention interventions for BMSM with recent justice involvement are warranted

Background Racial/ethnic and sexual minorities face elevated risk of policing and detainment. Dual minority status is linked to disproportionate incarceration; among black men who have sex with men (BMSM) in the HIV Prevention Trials Network (HPTN) study, 60% had been incarcerated. Incarceration disrupts networks and increases partnership exchange and STI. We lack understanding of the impact of incarceration on STI risk among BMSM. Methods We used data from HPTN 061 (N=1553) conducted in Atlanta, Boston, New York, Los Angeles, San Francisco, and Washington DC to measure longitudinal associations between incarceration within six months and twelve-month risk of multiple partnerships and biologically-confirmed STI gonorrhea, chlamydia, syphilis). Using inverse probability of treatment weighted (IPTW) regression to account for preincarceration poverty, psychopathology, drug use, and STI risk, we estimated risk ratios (RRs) and 95% confidence intervals (CIs) for associations between incarceration and outcomes and assessed differences by city. Results Approximately 14% had been incarcerated in the past six months. Controlling for site, incarceration predicted multiple partnerships (RR: 1.20, 95% CI: 1.06-1.36) and incident STI (RR: 1.08, 95% CI: 1.00-1.16). Associations with multiple partnerships and STI differed by city (joint test of interaction, p value <0.05). Incarceration was most strongly associated with multiple partnerships (RR: 1.69, 95% CI: 1.38-2.04) and STI (RR: 1.31, 95% CI: 1.04-1.64) in Washington DC. In other cities, STI RRs ranged from 0.95 to 1.08 and were not significant at the 0.05 level. Incarceration was associated with multiple partnerships in New York (RR: 1.25, 95% CI: 1.01-1.55) and Boston (RR: 1.31, 95% CI: 1.08- 1.58), while RRs ranged from 0.87 to 1.08 and were not significant in other cities. Conclusion Recent incarceration impacts STI risk among BMSM in Washington DC and the northeastern United States

Antidepressants are frequently prescribed in first episode schizophrenia (FES) patients for negative symptoms or for subsyndromal depressive symptoms, but therapeutic benefit has not been established, despite evidence of efficacy in later-stage schizophrenia. We conducted a 52 week, placebo-controlled add-on trial of citalopram in patients with FES who did not meet criteria for major depression to determine whether maintenance therapy with citalopram would improve outcomes by preventing or improving negative and depressive symptoms. Primary outcomes were negative symptoms measured by the Scale for Assessment of Negative Symptoms and depressive symptoms measured by the Calgary Depression Scale for Schizophrenia; both were analyzed by an intent-to-treat, mixed effects, area-under-the-curve analysis to assess the cumulative effects of symptom improvement and symptom prevention over a one-year period. Ninety-five patients were randomized and 52 (54%) completed the trial. Negative symptoms were reduced with citalopram compared to placebo (p = .04); the effect size of citalopram versus placebo was 0.32 for participants with a duration of untreated psychosis (DUP) of <18 weeks (median split) and 0.52 with a DUP >18 weeks. Rates of new-onset depression did not differ between groups; improvement in depressive symptoms was greater with placebo than citalopram (p = .02). Sexual side effects were more common with citalopram, but overall treatment-emergent side effects were not increased compared to placebo. In conclusion, citalopram may reduce levels of negative symptoms, particularly in patients with longer DUP, but we found no evidence of benefit for subsyndromal depressive symptoms.