Faculty Bibliography

OBJECTIVES: The current study sought to characterise the tobacco retail environment of supportive housing facilities for persons with mental health (MH) conditions in New York City (NYC) and to estimate the potential impact of a tobacco retail ban near public schools on the retail environment of MH housing in NYC. METHODS: Texas A&M Geocoding Services was used to geocode the addresses of housing programmes for patients with MH conditions, non-MH residences, public schools and tobacco retailers in NYC. ESRI ArcMap was used to calculate the number of tobacco retailers within a 500-foot radius around each housing programme and school address point, and the Euclidean distance to the nearest retailer. Generalised linear models were used to compare retail counts and distance between MH and non-MH residences. RESULTS: The mean number of tobacco retailers within 500 feet of an MH housing programme was 2.9 (SD=2.3) and the mean distance to nearest tobacco retailer was 370.6 feet (SD=350.7). MH residences had more retailers within 500 feet and a shorter distance to the nearest retailer compared with non-MH residences in Brooklyn, the Bronx and Staten Island (p<0.001). Banning tobacco licences within 350, 500 or 1000 feet of a school would significantly improve the tobacco retail environment of MH housing programmes and reduce disparities between MH and non-MH residences in some boroughs. CONCLUSIONS: People with MH conditions residing in supportive housing in NYC encounter a heavy tobacco retail environment in close proximity to their home, and in some boroughs, one worse than non-MH residences. Implementing a ban on tobacco retail near public schools would improve the tobacco retail environment of MH housing programmes in NYC.

INTRODUCTION: Individuals with (vs. without) mental illness use tobacco at higher rates and have more difficulty quitting. Treatment models for smokers with mental illness are needed. METHODS: This secondary analysis of the Victory Over Tobacco study [a pragmatic randomized clinical trial (N=5123) conducted in 2009-2011 of Proactive Care (proactive outreach plus connection to smoking cessation services) vs. Usual Care] tests the effectiveness of treatment assignment in participants with and without a mental health diagnosis on population-level, 6month prolonged abstinence at one year follow-up. RESULTS: Analyses conducted in 2015-6 found that there was no interaction between treatment group and mental health group on abstinence (F(1,3300=1.12, p=0.29)). Analyses stratified by mental health group showed that those without mental illness, assigned to Proactive Care, had a significantly higher population-level abstinence rate than those assigned to Usual Care (OR=1.40, 95% CI=1.17-1.67); in those with mental illness, assignment to Proactive Care produced a non-significant increase in abstinence compared to Usual Care (OR=1.18, 95% CI=0.98-1.41). Those with mental illness reported more medical visits, cessation advice and treatment (p<0.001), similar levels of abstinence motivation (p>0.05), but lower abstinence self-efficacy (p<0.001). CONCLUSIONS: Those with a mental health diagnosis benefitted less from proactive outreach regarding tobacco use. VA primary care patients with mental illness may not need additional outreach because they are connected to cessation resources during medical appointments. This group may also require more intensive cessation interventions targeting self-efficacy to improve cessation rates. Clinicaltrials.gov registration # NCT00608426.

OBJECTIVES: To estimate the impact of tobacco cessation on household spending on non-tobacco goods in the USA. METHODS: Using 2006-2015 Consumer Expenditure Survey data, 9130 tobacco-consuming households were followed for four quarters. Households were categorised during the fourth quarter as having: (1) recent tobacco cessation, (2) long-term cessation, (3) relapsed cessation or (4) no cessation. Generalised linear models were used to compare fourth quarter expenditures on alcohol, food at home, food away from home, housing, healthcare, transportation, entertainment and other goods between the no-cessation households and those with recent, long-term or relapsed cessation. The full sample was analysed, and then analysed by income quartile. RESULTS: In the full sample, households with long-term and recent cessation had lower spending on alcohol, food, entertainment and transportation (p<0.001). Recent cessation was further associated with reduced spending on food at home (p<0.001), whereas relapsed cessation was associated with higher spending on healthcare and food away from home (p<0.001). In the highest income quartile, long-term and recent cessations were associated with reduced alcohol spending only (p<0.001), whereas in the lowest income quartile, long-term and recent cessations were associated with lower spending on alcohol, food at home, transportation and entertainment (p<0.001). CONCLUSIONS: Households that quit tobacco spend less in areas that enable or complement their tobacco cessation, most of which may be motivated by financial strain. The most robust association between tobacco cessation and spending was the significantly lower spending on alcohol.

Persons with mental health diagnoses use tobacco at alarming rates, yet misperceptions remain about the effect of quitting on mental health outcomes. This article examines the relationship between tobacco cessation and changes in severity of mental illness. Participants were N = 577 veterans with a history of mental health treatment enrolled in a tobacco cessation study. The effects of abstinence and time on Behavior and Symptom Identification Scale-24 summary scores and subscales were examined. Abstinence at both 2 and 6 months post-baseline was related (p < .0001) to lower Behavior and Symptom Identification Scale-24 summary scores and improvement on three Behavior and Symptom Identification Scale-24 subscales. Providers should recommend and provide tobacco treatment to all mental health patients to improve their physical and mental health functioning.

BACKGROUND: In the Spring and Summer of 2016, a text-messaging intervention to titrate basal insulin in patients with type 2 diabetes and poor glycemic control was implemented at two safety net health care systems in New York City. The goal of the current study was to conduct a qualitative evaluation assessing barriers to, and facilitators of, implementation of the mobile insulin titration intervention (called "MITI"). METHODS: We conducted in-depth qualitative interviews with patients (N = 36) and physician, nursing and administrative staff (N = 19) at the two health care systems implementing MITI. Interviews were transcribed and coded by two study investigators using a codebook guided by the Consolidated Framework for Implementation Research and through iterative, consensus driven content analysis. RESULTS: Patients and staff perceived MITI as convenient and timesaving for patients, easy to use, and effective at achieving its clinical goals. Patients were comfortable sharing health information via text, and felt good about communicating with their health team remotely. Interviewees across stakeholder groups felt that MITI was helpful beyond insulin titration by reminding and motivating patients to engage in healthy behaviors and improving medication adherence. Staff felt MITI worked well with existing workflows and expressed a desire to see MITI expanded to other chronic conditions. Nurses responsible for weekly titration reported initial concerns over safety/liability, time required to deliver the program, difficulties reaching patients for titration calls and the need for ongoing support/training in using the online texting platform. Perceived barriers to MITI implementation reported by providers included perceived lack of patient cell phone access or texting capabilities and patient language barriers. There was also a theme that emerged across interviewees of an unmet need for additional diabetes management support among this population, beyond insulin support provided by MITI. The project team made several modifications to MITI operations in response to these findings. CONCLUSIONS: Patients and staff were overwhelmingly supportive of MITI and believed it had many benefits. Initial implementation of MITI should address nurse comfort, workload and training, and sites should provide ongoing support and training for nurses after implementation. Future research should explore options for integrating additional diabetes support for patients enrolled in MITI or after they are discharged from the program

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): T2D patients needing insulin adjustments require multiple clinic visits for titration, but face barriers (missed work, transportation costs, clinic co-pays) all of which disproportionately affect vulnerable populations. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): MITI aims to be clinically efficacious, patientcentered, and highly accessible (only requires text messaging and phone calls). DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): MITI is an efficacious, patient-centered, accessible program that remotely guides T2D patients to their correct basal insulin dose (glargine, detemir). Eligible patients have T2D, an A1c >8%, a phone that can text, and need titration of basal insulin. Patients referred by their providers are enrolled on a secure website which sends a weekday text message asking 'What was your fasting blood sugar this morning?' Each day the MITI nurse checks the website for alarm values (extreme high or low values). Once a week, the MITI nurse calls patients and, using the MITI titration algorithm, advises them on dose adjustments. The goal of the program is to find the optimal basal insulin dose (OID), which is the dose that achieves a fasting blood sugar between 80 and 130 (or the maximal dose of 50 units). MITI lasts a maximum of 12 weeks. When the program ends, patients return to usual care. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): Using a single-group, quasiexperimental approach, we examined the proportion of patients reaching OID within 12 weeks, the mean number of days required to reach OID, and reductions in fasting glucose and A1c. We described participant response rates, staff time required to deliver the intervention, and patient time saved. Qualitative interviews were also conducted. FINDINGS TO DATE (IT IS NOT SUFFICIENT TOSTATE FINDINGS WILL BE DISCUSSED): Of the 71 participants who completed the program, 86% reached OID, 5.6% did not reach OID, and 8.5% terminated the program early. Those reaching OID did so in a mean of 21 (SD 21) days. Fasting glucose levels decreased from 209 (SD 77) mg/dl to 140 (SD 45), and mean A1c (for those with follow up labs thus far) decreased from 11.6% (SD 1.9) to 10.0% (SD 2.2). Ninety-one percent of text prompts received a response from the participant. Mean staff time required to deliver MITI was 16 min (SD 5) per participant per week, and patients reported a mean time saving of 150 (SD 74) min each time an in-person visit was averted. Qualitative interviews suggest that clinical staff perceived MITI to be a preferred alternative to clinic-based insulin titration, one that resulted in good care without interfering with clinic flow. Patients reported that the enrollment process was easy and that MITI motivated them to eat healthier food, take their insulin, and check their blood sugars. Because of MITI they reported feeling more connected to their medical team. KEYLESSONS FORDISSEMINATION(WHAT CANOTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY?): MITI is a clinically efficacious, patient-centered and accessible program for the titration of basal insulin for T2D patients. By eliminating the need for in-person access, MITI proves especially helpful for vulnerable populations. Patients and staff found MITI to be convenient, time-saving, and motivating for patients

Hospital patients with serious mental illness (SMI) have high rates of smoking. There are few post-discharge treatment models available for this population and limited research on their treatment uptake following discharge. This study is a secondary analysis of an RCT that compared multi-session intensive telephone counseling versus referral to state quitline counseling at two safety net hospitals in New York City. For this analysis, we selected all trial participants with a history of schizophrenia, schizoaffective disorder or bipolar disorder (N = 384) and used multivariable logistic regression to compare groups on self-reported 30-day abstinence at 6 months and to identify patient factors associated with use of tobacco treatment. Analyses found no significant group differences in abstinence 6 months (28% quitline vs. 29% intervention, p > 0.05), use of cessation medications (42% quitline vs. 47% intervention, p > 0.05) or receipt of at least one counseling call (47% quitline vs. 42% intervention, p > 0.05). Patients with hazardous drinking (p = 0.04) or perceived good health (p = 0.03) were less likely to use cessation medications. Homeless patients were less likely to use counseling (p = 0.02). Most patients did not use cessation treatment after discharge, and the intensive intervention did not improve abstinence rates over quitline referral. Interventions are needed to improve use of cessation treatment and long-term abstinence in patients with SMI.

OBJECTIVE: This study sought to identify rates and predictors of obesity counseling performed by outpatient psychiatrists in the United States. METHODS: The 2005-2010 National Ambulatory Medical Care Surveys provided data from 7,309 outpatient psychiatry visits. Logistic regression was used to examine associations between patient, visit, and practice characteristics and outcomes. RESULTS: Most (81%) visits occurred in a private practice setting. Nine percent (N=657) of visits included measurement of patient body mass index (BMI); 30% of these visits were with patients who met the obesity criterion (BMI >/=30.0 kg/m2). Among visits with obese patients, 16% included exercise counseling, 22% included weight reduction counseling, and 24% included diet or nutrition counseling. Patients with obesity were more likely than patients without obesity to receive diet or nutrition counseling (p<.05) and weight reduction counseling (p<.05), but not exercise counseling. Black patients were significantly less likely to receive any form of counseling (p<.05). CONCLUSIONS: There is a significant need to improve psychiatrists' obesity counseling.

INTRODUCTION: Hospitalization is a unique opportunity for smoking cessation, but prior interventions have measured efficacy with narrowly defined populations. The objective of this study was to enroll smokers admitted to two "safety net" hospitals and compare the effectiveness of two post-discharge cessation interventions. DESIGN: A randomized comparative effectiveness trial was conducted. SETTING/PARTICIPANTS: At two New York City public hospitals, every hospitalized patient identified as a smoker (based on admission records) was approached. Inclusion criteria were: smoked cigarettes in the past 30 days; spoke English, Spanish, or Mandarin; had a U.S. phone number; not discharged to an institution where follow-up or smoking was limited; and not pregnant/breastfeeding. Of 18,797 patients identified as current smokers between July 2011 and April 2014, a total of 3,047 (16%) were discharged before being approached, 3,273 (17%) were not current smokers, 4,026 (21%) had no U.S. phone number, 2,831 (15%) were ineligible for other reasons, and 3,983 (21%) refused participation. In total, 1,618 (9%) participants enrolled in the study. During follow-up, 69% of participants were reached at 2 months and 68% at 6 months. INTERVENTION: At discharge, participants were randomized to multisession telephone counseling from study staff (n=804) or referral to the state quitline for proactive outreach and counseling (n=814). MAIN OUTCOME MEASURES: Self-reported abstinence at 6 months was measured. Analyses were conducted in late 2015. RESULTS: One quarter of participants were homeless or in unstable housing, 60% had a history of substance abuse, 43% reported current hazardous drinking, and half had a psychiatric diagnosis other than substance abuse. At follow-up, the rate of abstinence (30-day point prevalence) was higher in the intensive counseling arm than the quitline arm at 2 months (29.0% vs 20.7%; relative risk=1.40; 95% CI=1.13, 1.73) and 6 months (37.4% vs 31.5%; relative risk=1.19; 95% CI=1.01, 1.40). CONCLUSIONS: Intensive counseling was more effective than referral to the state quitline. Long-term abstinence was excellent in both groups. Many patients were not eligible for enrollment despite minimal exclusion criteria. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01363245.