Faculty Bibliography

YouTube is a social media platform with more than 1 billion users and >600000 videos about prostate cancer. Two small studies examined the quality of prostate cancer videos on YouTube, but did not use validated instruments, examine user interactions, or characterize the spread of misinformation. We performed the largest, most comprehensive examination of prostate cancer information on YouTube to date, including the first 150 videos on screening and treatment. We used the validated DISCERN quality criteria for consumer health information and the Patient Education Materials Assessment Tool, and compared results for user engagement. The videos in our sample had up to 1.3 million views (average 45223) and the overall quality of information was moderate. More videos described benefits (75%) than harms (53%), and only 50% promoted shared decision-making as recommended in current guidelines. Only 54% of the videos defined medical terms and few provided summaries or references. There was a significant negative correlation between scientific quality and viewer engagement (views/month p=0.004; thumbs up/views p=0.015). The comments section underneath some videos contained advertising and peer-to-peer medical advice. A total of 115 videos (77%) contained potentially misinformative and/or biased content within the video or comments section, with a total reach of >6 million viewers. PATIENT SUMMARY: Many popular YouTube videos about prostate cancer contained biased or poor-quality information. A greater number of views and thumbs up on YouTube does not mean that the information is trustworthy.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC/UNASSIGNED:Rapid response to witnessed, pulseless cardiac arrest is associated with increased survival. WHAT THIS ARTICLE TELLS US THAT IS NEW/UNASSIGNED:Assessment of witnessed, pulseless cardiac arrests occurring at 538 hospitals during a 9-yr period indicates that CPR did not occur immediately at 0 min in 5.7% of patients despite guidelines for instantaneous initiation. Delay in initiation of CPR was associated with significantly decreased survival.Time to initiation of CPR and subsequent time to initiation of administration of defibrillation shock (for shockable arrhythmias) and epinephrine were both associated with reduced patient survival. BACKGROUND:Because the extent to which delays in initiating cardiopulmonary resuscitation (CPR) versus the time from CPR to defibrillation or epinephrine treatment affects survival remains unknown, it was hypothesized that all three independently decrease survival in in-hospital cardiac arrest. METHODS:Witnessed, index cases of cardiac arrest from the Get With The Guidelines-Resuscitation Database occurring between 2000 and 2008 in 538 hospitals were included in this analysis. Multivariable risk-adjusted logistic regression examined the association of time to initiation of CPR and time from CPR to either epinephrine treatment or defibrillation with survival to discharge. RESULTS:In the overall cohort of 57,312 patients, there were 9,802 survivors (17.1%). Times to initiation of CPR greater than 2 min were associated with a survival of 14.7% (91 of 618) as compared with 17.1% (9,711 of 56,694) if CPR was begun in 2 min or less (adjusted odds ratio [95% CI], 0.68 [0.54 to 0.87]; P < 0.002). Times from CPR to either defibrillation or epinephrine treatment of 2 min or less were associated with a survival of 18.0% (7,654 of 42,475), as compared with 15.0% (1,680 of 11,227) for 3 to 5 min (reference, 0 to 2 min; adjusted odds ratios [95% CI], 0.83 [0.78 to 0.88]; P < 0.001), 12.8% (382 of 2,983) for 6 to 8 min (0.67 [0.60 to 0.76], P < 0.001), and 13.7% (86 of 627) for 9 to 11 min (0.54 [0.42 to 0.69], P < 0.001). CONCLUSIONS:Delays in the initiation of CPR and from CPR to defibrillation or epinephrine treatment were each associated with lower survival.

Three quarters of new HIV infections in the US are among men who have sex with men (MSM). In other populations, incarceration is a social determinant of elevations in viral load and HIV-related substance use and sex risk behavior. There has been limited research on incarceration and these HIV transmission risk determinants in HIV-positive MSM. We used the Veterans Aging Cohort Study (VACS) 2011-2012 follow-up survey to measure associations between past year and prior (more than one year ago) incarceration and HIV viral load and substance use and sex risk behavior among HIV-positive MSM (N = 532). Approximately 40% had ever been incarcerated, including 9% in the past year. In analyses adjusting for sociodemographic factors, past year and prior incarceration were strongly associated with detectable viral load (HIV-1 RNA >500 copies/mL) (past year adjusted odds ratio (AOR): 3.50 95% confidence interval (CI): 1.59, 7.71; prior AOR: 2.48 95% CI: 1.44, 4.29) and past 12 month injection drug use (AORs > 6), multiple sex partnerships (AORs > 1.8), and condomless sex in the context of substance use (AORs > 3). Past year incarceration also was strongly associated with alcohol and non-injection drug use (AOR > 2.5). Less than one in five HIV-positive MSM recently released from incarceration took advantage of a jail/prison re-entry health care program available to veterans. We need to reach HIV-positive MSM leaving jails and prisons to improve linkage to care and clinical outcomes and reduce transmission risk upon release.

Purpose To compare the effectiveness of personalized treatment for small (≤4 cm) renal tumors versus routine partial nephrectomy (PN), accounting for various competing causes of mortality. Materials and Methods A state-transition microsimulation model was constructed to compare life expectancy of management strategies for small renal tumors by using 1 000 000 simulations in the following ways: routine PN or personalized treatment involving percutaneous ablation for risk factors for worsening chronic kidney disease (CKD), and otherwise PN; biopsy, with triage of renal cell carcinoma (RCC) to PN or ablation depending on risk factors for worsening CKD; active surveillance for growth; and active surveillance when MRI findings are indicative of papillary RCC. Transition probabilities were incorporated from the literature. Effects of parameter variability were assessed in sensitivity analysis. Results In patients of all ages with normal renal function, routine PN yielded the longest life expectancy (eg, 0.67 years in 65-year-old men with nephrometry score [NS] of 4). Otherwise, personalized strategies extended life expectancy versus routine PN: in CKD stages 2 or 3a, moderate or high NS, and no comorbidities, MRI guidance for active surveillance extended life expectancy (eg, 2.60 years for MRI vs PN in CKD 3a, NS 10); and with Charlson comorbidity index of 1 or more, biopsy or active surveillance for growth extended life expectancy (eg, 2.70 years for surveillance for growth in CKD 3a, NS 10). CKD 3b was most effectively managed by using MRI to help predict papillary RCC for surveillance. Conclusion For patients with chronic kidney disease and small renal tumors, personalized treatment selection likely extends life expectancy. © RSNA, 2019 Online supplemental material is available for this article.

Background. Reference life expectancies inform frequently used health metrics, which play an integral role in determining resource allocation and health policy decision making. Existing reference life expectancies are not able to account for variation in geographies, populations, and disease states. Using a computer simulation, we developed a reference life expectancy estimation that considers competing causes of mortality, and is tailored to population characteristics. Methods. We developed a Monte Carlo microsimulation model that explicitly represented the top causes of US mortality in 2014 and the risk factors associated with their onset. The microsimulation follows a birth cohort of hypothetical individuals resembling the population of the United States. To estimate a reference life expectancy, we compared current circumstances with an idealized scenario in which all modifiable risk factors were eliminated and adherence to evidence-based therapies was perfect. We compared estimations of years of potential years life lost with alternative approaches. Results. In the idealized scenario, we estimated that overall life expectancy in the United States would increase by 5.9 years to 84.7 years. Life expectancy for men would increase from 76.4 years to 82.5 years, and life expectancy for women would increase from 81.3 years to 86.8 years. Using age-75 truncation to estimate potential years life lost compared to using the idealized life expectancy underestimated potential health gains overall (38%), disproportionately underestimated potential health gains for women (by 70%) compared to men (by 40%), and disproportionately underestimated the importance of heart disease for white women and black men. Conclusion. Mathematical simulations can be used to estimate an idealized reference life expectancy among a population to better inform and assess progress toward targets to improve population health.

BACKGROUND:A study of a comprehensive HIV Care Coordination Program (CCP) showed effectiveness in increasing viral load suppression (VLS) among PLWH in New York City (NYC). We evaluated the cost-effectiveness of a scale-up of the CCP in NYC. METHODS:We incorporated observed effects and costs of the CCP into a computer simulation of HIV in NYC, comparing strategy scale-up with no implementation. The simulation combined a deterministic compartmental model of HIV transmission with a stochastic microsimulation of HIV progression, and was calibrated to NYC HIV epidemiological data from 1997 to 2009. We assessed incremental cost-effectiveness from a health sector perspective using 2017 $US, a 20-year time horizon, and a 3% annual discount rate. We explored two scenarios: (1) two-year average enrollment and (2) continuous enrollment. RESULTS:In scenario 1, scale-up resulted in a cost-per-infection-averted of $898,104 and a cost-per-QALY-gained of $423,721. In sensitivity analyses, scale-up achieved cost-effectiveness if effectiveness increased from RR1.11 to RR1.37 or costs decreased by 41.7%. Limiting the intervention to persons with unsuppressed viral load prior to enrollment (RR1.32) attenuated the cost reduction necessary to 11.5%. In scenario 2, scale-up resulted in a cost-per-infection-averted of $705,171 and cost-per-QALY-gained of $720,970. In sensitivity analyses, scale-up achieved cost-effectiveness if effectiveness increased from RR1.11 to RR1.46 or program costs decreased by 71.3%. Limiting the intervention to persons with unsuppressed viral load attenuated the cost reduction necessary to 38.7%. CONCLUSION/CONCLUSIONS:Cost-effective CCP scale-up would require reduced costs and/or focused enrollment within NYC, but may be more readily achieved in cities with lower background VLS levels.

BACKGROUND:Hepatocelluar cancer (HCC) is the leading cause of death among people with hepatitis C virus (HCV)-related cirrhosis. Our aim was to determine the optimal surveillance frequency for patients with HCV-related compensated cirrhosis. METHODS:We developed a decision analytic Markov model and validated it against data from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) study group and published epidemiologic studies. Four strategies of different surveillance intervals were compared: no surveillance and ultrasound surveillance every 12, 6, and 3 months. We estimated lifetime survival, life expectancy, quality adjusted life years (QALY), total costs associated with each strategy, and incremental cost effectiveness ratios. We applied a willingness to pay threshold of $100,000. Analysis was conducted for two scenarios: a scenario reflecting current HCV and HCC surveillance compliance rates and treatment use and an aspirational scenario. RESULTS:In the current scenario the preferred strategy was 3-month surveillance with an incremental cost-effectiveness ratio (ICER) of $7,159/QALY. In the aspirational scenario, 6-month surveillance was preferred with an ICER of $82,807/QALY because treating more people with HCV led to a lower incidence of HCC. Sensitivity analyses suggested that surveillance every 12 months would suffice in the particular circumstance when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available. Compared with the current scenario, the aspirational scenario resulted in a 1.87 year gain in life expectancy for the cohort because of large reductions in decompensated cirrhosis and HCC incidence. CONCLUSIONS:HCC surveillance has good value for money for patients with HCV-related compensated cirrhosis. Investments to improve adherence to surveillance should be made when rates are suboptimal. Surveillance every 12 months will suffice when patients are very likely to return regularly for testing and when appropriate HCV and HCC treatment is readily available.

Shared decision making (SDM) has increasingly become appreciated as a method to enhance patient involvement in health care decisions, patient-provider communication, and patient-centered care. Compared with cancer, the literature on SDM for hypertension is more limited. This is notable because hypertension is the leading risk factor for cardiovascular disease and both conditions disproportionately affect certain subgroups of patients. However, SDM holds promise for improving health equity by better engaging patients in their health care. For example, many reasonable options exist for treating uncomplicated stage-1 hypertension. These options include medication and/or lifestyle changes such as healthy eating, physical activity, and weight management. Deciding on "the best" plan of action for hypertension management can be challenging because patients have different goals and preferences for treatment. As hypertension management may be considered a preference-sensitive decision, adherence to treatment plans may be greater if those plans are concordant with patient preferences. SDM can be implemented in a broad array of care contexts, from patient-provider dyads to interprofessional collaborations. In this article, we argue that SDM has the potential to advance health equity and improve clinical care. We also propose a process to evaluate whether SDM has occurred and suggest future directions for research.

Background. Despite the high efficacy of PrEP, it continues to be underutilized. We examined the extent to which patients with a documented positive test for STIs were provided PrEP at an urban municipal medical center. Methods. We reviewed data of all patients seen between January 1, 2014 and July 30, 2017 who were > 18 years old and had an initial HIV negative test and >=1 positive test for Chlamydia, Gonorrhea, or Syphilis. We examined PrEP prescription data by gender, race/ethnicity, and clinic location. Differences between groups were compared using Chi-squared analysis and logistic regression. Results. Of 1,142 initially HIV- patients who were identified as having a positive STI result, 52% were female, 89% either Black or Hispanic, with a median age of 40 years (quartiles 30, 47). 58% had Medicare/Medicaid and 34% were self-pay or uninsured (Table 1). Only 25 (2.1%) of 1,142 patients who had >=1 STI test positive were prescribed PrEP. No women received PrEP. Whites (aOR: 21.7 [95% CI:4.4, 107, P < 0.001] and Hispanics (aOR:6.64 [95% CI:1.35, 32.8, P = 0.02] were both more likely to receive PrEP than Blacks, after adjusting for age, sex, marital status, and insurance. All PrEP prescriptions originated from the Medicine, Emergency, or HIV specialty clinics although most STI testing was obtained in Emergency and Obstetrical/Gynecological clinics (Table 2). Conclusion. There were significant missed opportunities for HIV prevention among patients with STIs within the medical center, particularly among Hispanic and Black patients. Enrichment programs to educate providers and increase PrEP prescriptions may have a major impact on expanding HIV prevention, especially for women. (Figure Presented)