Faculty Bibliography

PURPOSE/OBJECTIVE:Tobacco-use is a causative or exacerbating risk factor for benign and malignant urologic disease. However, it is not well known how often urologists screen for tobacco use and provide tobacco cessation treatment at the population level. Therefore, we sought to evaluate how often urologists see patients for tobacco-related diagnoses in the outpatient setting and how often these visits include tobacco-use screening and treatment. MATERIALS AND METHODS/METHODS:We used the National Ambulatory Medical Care Survey (NAMCS) public use files for the years 2014-2016 to identify all outpatient urology visits with adults 18 years and older. Clinic visit reasons were categorized according to diagnoses associated with the encounter: all urologic diagnoses, a tobacco-related urologic condition, or a urologic cancer. Our primary outcome was the percentage of visits during which tobacco screening was reported. Secondary outcomes included reported delivery of cessation counseling and provision of cessation pharmacotherapy. RESULTS:We identified 4,625 unique urologic outpatient encounters, representing a population-weighted estimate of 63.9 million visits over three years. Approximately a third of all urology visits were for a tobacco-related urologic diagnoses and 15% were for urologic cancers. An estimated 1.1 million visits over three years were with patients who identified as current tobacco users. Of all visits, 70% included tobacco screening. However, only 7% of visits with current smokers included counseling and only 3% were prescribed medications. No differences in screening and treatment were observed between visit types. CONCLUSIONS:Urologists regularly see patients for tobacco-related conditions and frequently, though not universally, screen patients for tobacco. However, urologists rarely offer counseling or cessation treatment. These findings may represent missed opportunities to decrease the morbidity associated with tobacco use.

OBJECTIVE:Individuals with posttraumatic stress disorder (PTSD) smoke at higher rates compared to the general population and experience significant barriers to initiating cessation treatment. Proactive outreach addresses these barriers by directly engaging with smokers and facilitating access to treatment. The objective of the present study was to evaluate a proactive outreach intervention for increasing rates of treatment utilization and abstinence among veteran smokers with and without PTSD. METHOD/METHODS:= 1,583) a diagnosis of PTSD. Logistic regressions modeled cessation treatment utilization (counseling, nicotine replacement therapy [NRT], and combination treatment) and abstinence (7-day point prevalence and 6-month prolonged at 6- and 12-month follow-ups) among participants randomized to proactive outreach versus usual care in the PTSD and non-PTSD subgroups, respectively. RESULTS:= 1.61, [1.11, 2.34]). CONCLUSIONS:Proactive outreach increased treatment utilization and abstinence among smokers with and without PTSD. Smokers with PTSD may need additional facilitation to initiate cessation treatment but are receptive when it is offered proactively. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

BACKGROUND:It is unknown whether transcatheter valves will have similar durability as surgical bioprosthetic valves. Definitions of structural valve deterioration (SVD), based on valve related reintervention or death, underestimate the incidence of SVD. OBJECTIVES:This study sought to determine and compare the 5-year incidence of SVD, using new standardized definitions based on echocardiographic follow-up of valve function, in intermediate-risk patients with severe aortic stenosis given transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) in the PARTNER (Placement of Aortic Transcatheter Valves) 2A trial and registry. METHODS:In the PARTNER 2A trial, patients were randomly assigned to receive either TAVR with the SAPIEN XT or SAVR, whereas in the SAPIEN 3 registry, patients were assigned to TAVR with the SAPIEN 3. The primary endpoint was the incidence of SVD, that is, the composite of SVD-related hemodynamic valve deterioration during echocardiographic follow-up and/or SVD-related bioprosthetic valve failure (BVF) at 5 years. RESULTS:Compared with SAVR, the SAPIEN-XT TAVR cohort had a significantly higher 5-year exposure adjusted incidence rates (per 100 patient-years) of SVD (1.61 ± 0.24% vs. 0.63 ± 0.16%), SVD-related BVF (0.58 ± 0.14% vs. 0.12 ± 0.07%), and all-cause (structural or nonstructural) BVF (0.81 ± 0.16% vs. 0.27 ± 0.10%) (p ≤ 0.01 for all). The 5-year rates of SVD (0.68 ± 0.18% vs. 0.60 ± 0.17%; p = 0.71), SVD-related BVF (0.29 ± 0.12% vs. 0.14 ± 0.08%; p = 0.25), and all-cause BVF (0.60 ± 0.15% vs. 0.32 ± 0.11%; p = 0.32) in SAPIEN 3 TAVR were not significantly different to a propensity score matched SAVR cohort. The 5-year rates of SVD and SVD-related BVF were significantly lower in SAPIEN 3 versus SAPIEN XT TAVR matched cohorts. CONCLUSIONS:Compared with SAVR, the second-generation SAPIEN XT balloon-expandable valve has a higher 5-year rate of SVD, whereas the third-generation SAPIEN 3 has a rate of SVD that was not different from SAVR. (The PARTNER II Trial: Placement of AoRTic TraNscathetER Valves - PII A [PARTNERII A]; NCT01314313; The PARTNER II Trial: Placement of AoRTic TraNscathetER Valves II - PARTNER II - PARTNERII - S3 Intermediate [PARTNERII S3i]; NCT03222128).

BACKGROUND:Most hookah use studies have not included racial and ethnic minorities which limits our understanding of its use among these growing populations. This study aimed to investigate the individual characteristics of hookah use patterns and associated risk behaviors among an ethnically diverse sample of college students. METHODS:A cross-sectional survey of 2460 students (aged 18-25) was conducted in 2015, and data was analyzed in 2017. Descriptive statistics were used to present the sociodemographic characteristics, hookah use-related behavior, and binge drinking and marijuana use according to the current hookah use group, including never, exclusive, dual/poly hookah use. Multivariate logistic regression was conducted to examine how hookah related behavior and other risk behaviors varied by sociodemographics and hookah use patterns. RESULTS:Among current hookah users (n = 312), 70% were exclusive hookah users and 30% were dual/poly hookah users. There were no statistically significant differences in sociodemographic characteristics except for race/ethnicity (p < 0.05). Almost half (44%) of the exclusive hookah users reported having at least five friends who also used hookah, compared to 30% in the dual/poly use group. Exclusive users were less likely to report past year binge drinking (17%) and past year marijuana use (25%) compared to those in the dual/poly use group (44 and 48% respectively); p < 0.001. CONCLUSIONS:The socialization aspects of hookah smoking seem to be associated with its use patterns. Our study calls for multicomponent interventions designed to target poly tobacco use as well as other substance use that appears to be relatively common among hookah users.

INTRODUCTION/BACKGROUND:People with serious mental illness (SMI) have a high smoking prevalence and low quit rates. Few cessation treatments are tested in smokers with SMI. Mental health (MH) providers are reluctant to address smoking. Proactive tobacco cessation treatment strategies reach out directly to smokers to offer counseling and medication and improve treatment utilization and quit rates. The current study is a secondary analysis of a randomized controlled trial of proactive outreach for tobacco cessation treatment in VA MH patients. METHODS:Participants (N=1938, 83% male, mean age 55.7) across 4 recruitment sites, who were current smokers and had a MH visit in the past 12 months, were identified using the electronic medical record. Participants were randomized to Intervention (telephone outreach call plus invitation to engage in MH tailored telephone counseling and assistance obtaining nicotine replacement therapy [NRT]) or Control (usual care). The current study assessed outcomes in participants with SMI (N=982). RESULTS:Compared to the Control group, participants assigned to the Intervention group were more likely to engage in telephone counseling (22% vs. 3%) and use NRT (51% vs. 41%). Participants in the Intervention group were more likely to be abstinent (7-day point prevalence; 18%) at 12 months than participants in the Control group; 11%) but equally likely to make quit attempts. CONCLUSIONS:Proactive tobacco cessation treatment is an effective strategy for tobacco users with SMI. Proactive outreach had a particularly strong effect on counseling utilization. Future randomized clinical trials examining proactive tobacco treatment approaches in SMI treatment settings are needed. IMPLICATIONS/CONCLUSIONS:Few effective treatment models exist for smokers with serious mental illness. Proactive tobacco cessation outreach with connections to mental health tailored telephone counseling and medication promotes tobacco abstinence among smokers with serious mental illness and is an effective treatment strategy for this underserved population.

INTRODUCTION/BACKGROUND:Practice facilitation is a promising practice transformation strategy, but further examination of its effectiveness in improving adoption of guidelines for multiple cardiovascular disease risk factors is needed. The objective of the study is to determine whether practice facilitation is effective in increasing the proportion of patients meeting the Million Hearts ABCS outcomes: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation intervention. DESIGN/METHODS:The study used a stepped-wedge cluster RCT design with 4 intervention waves. Data were extracted for 13 quarters between January 1, 2015 and March 31, 2018, which encompassed the control, intervention, and follow-up periods for all waves, and analyzed in 2019. SETTING/PARTICIPANTS/METHODS:A total of 257 small independent primary care practices in New York City were randomized into 1 of 4 waves. INTERVENTION/METHODS:The intervention consisted of practice facilitators conducting at least 13 practice visits over 1 year, focused on capacity building and implementing system and workflow changes to meet cardiovascular disease care guidelines. MAIN OUTCOME MEASURES/METHODS:The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (1) proportion of tobacco users who received a cessation intervention (smokers counseled) and (2) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). RESULTS:The S measure improved when comparing follow-up with the control period (incidence rate ratio=1.152, 95% CI=1.072, 1.238, p<0.001) and when comparing follow-up with intervention (incidence rate ratio=1.060, 95% CI=1.013, 1.109, p=0.007). Smokers counseled improved when comparing the intervention period with control (incidence rate ratio=1.121, 95% CI=1.037, 1.211, p=0.002). CONCLUSIONS:Increasing the impact of practice facilitation programs that target multiple risk factors may require a longer, more intense intervention and greater attention to external policy and practice context. TRIAL REGISTRATION/BACKGROUND:This study is registered at www.clinicaltrials.gov NCT02646488.

BACKGROUND:Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE:To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN/METHODS:Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS/METHODS:15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES/METHODS:Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS/RESULTS:Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS:Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

PURPOSE/UNASSIGNED:To identify rates and sociodemographic correlates of food insecurity among low-income smokers. DESIGN/UNASSIGNED:Cross-sectional analysis of baseline survey data from a randomized controlled trial (N = 403) testing a smoking cessation intervention for low-income smokers. SETTING/UNASSIGNED:Two safety-net hospitals in New York City. SAMPLE/UNASSIGNED:Current smokers with annual household income <200% of the federal poverty level. MEASURES/UNASSIGNED:Food insecurity was measured using the United States Department of Agriculture 6-item food security module. Participant sociodemographics were assessed by self-reported survey responses. ANALYSIS/UNASSIGNED:We used frequencies to calculate the proportion of smokers experiencing food insecurity and multivariable logistic regression to identify factors associated with being food insecure. RESULTS/UNASSIGNED:Fifty-eight percent of participants were food insecure, with 29% reporting very high food insecurity. Compared to married participants, separated, widowed, or divorced participants were more likely to be food insecure (adjusted odds ratio [AOR] = 2.33, 95% confidence interval [CI]: 1.25-4.33), as were never married participants (AOR = 2.81, 95% CI: 1.54-5.14). CONCLUSIONS/UNASSIGNED:food access) may be needed for low-income populations. Interventions which seek to alleviate food insecurity may benefit from targeting socially isolated smokers.

Tobacco use is rarely addressed in community mental healthcare despite high patient smoking prevalence. Community mental health centers have systems in place that could be used to comprehensively address tobacco use. This study tested feasibility of, satisfaction with, and safety of proactive tobacco treatment (tobacco outreach to offer connection to tobacco cessation treatment). Behavioral health home patients who smoke were randomly assigned to usual care (UC; N = 11) or proactive care (PC; N = 9). All participants were called 3-months post-randomization for follow-up. PC patients reported high satisfaction with the program and experienced no adverse events or mental health symptom exacerbation during treatment. PC patients reported greater reductions in cigarettes per day, more quit attempts, and more cessation medication utilization than UC patients. Proactive outreach for tobacco cessation is feasible in a behavioral health home, acceptable to patients, and may reduce smoking heaviness and promote quit attempts.