Faculty Bibliography

IMPORTANCE/UNASSIGNED:Food insecurity (FI) is associated with poor health and has risen in the US. The Supplemental Nutrition Assistance Program (SNAP) is the largest US food-purchasing assistance program. Policies related to eligibility assessment and administrative burden that impact SNAP participation vary between states. How such policies influence FI is not well known. OBJECTIVES/UNASSIGNED:To evaluate the association between changes in state SNAP policies and county FI rates. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This repeated cross-sectional study used annual county-level FI estimates from the Feeding America Map the Meal Gap dataset, state-level SNAP policy data from the US Department of Agriculture from 2009 to 2019, and data on economic and demographic measures from the US Census Bureau for county residents. Data were analyzed from August 2024 to August 2025. EXPOSURES/UNASSIGNED:Changes in state SNAP policies from 2009 to 2019. Due to incomplete policy data, the analysis was not extended beyond 2019. MAIN OUTCOMES AND MEASURES/UNASSIGNED:County-level FI rates for individuals. An annual index of SNAP policy adoption was calculated, scaled from 0.1 to 10, with a higher level indicating a greater adoption of policies associated with SNAP participation. G-computation, a robust causal inference methodology, was used to evaluate the association between change in the SNAP index and state-level SNAP participation rates and county-level FI rates. The model accounted for demographic and clinical factors, state and year fixed effects, and baseline SNAP index levels. RESULTS/UNASSIGNED:Of a total of 3143 US counties, 3134 were included in the analysis. A 1-point increase in the SNAP policy index was associated with a 0.7-percentage point (pp; 95% CI, 0.3-1.2 pp; P = .002) higher state-level SNAP participation rate and a 0.1-pp (95% CI, 0.02-0.2 pp; P = .02) lower county-level FI rate from 2009 to 2019. In 2019, an estimated 6.5 million (95% CI, 3.8-9.1 million) fewer individuals would have experienced FI if all states had adopted policies equivalent to the most generous state in each year compared to if all states had adopted policies equivalent to the least generous state. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, adoption of state-level policies associated with higher SNAP participation was also associated with lower county-level FI rates. Policies that lower barriers to SNAP participation may help address rising FI rates observed in 2022 and 2023.

OBJECTIVE:This study examined racial and ethnic differences in percent total weight loss (%TWL) and glycemic improvement following sleeve gastrectomy (SG) and explored the role of socioeconomic and psychosocial factors in postsurgical outcomes. METHODS:This longitudinal study included patients who underwent SG between 2017 and 2020, with follow-up visits over 24 months. RESULTS:Non-Hispanic Black (NHB) participants had lower %TWL at 3, 12, and 24 months compared with Hispanic (H) and non-Hispanic White (NHW) participants. Fat mass index was initially lower in NHB, with smaller reductions over time and significant group differences persisting at 24 months. NHB participants had higher baseline fat-free mass index values; by 24 months, fat-free mass index values were lower in H participants. Hemoglobin A1c decreased across all groups but remained consistently higher in NHB and H compared with NHW at 24 months. NHB participants reported higher perceived discrimination, sleep disturbance, and perceived stress than H and NHW participants at all time points. Employment status predicted %TWL at 12 months. There was a significant interaction between race and ethnicity and employment status observed at 12 and 24 months, suggesting that employment-related disparities could impact surgical outcomes. CONCLUSIONS:NHB participants experienced less favorable outcomes following SG, emphasizing the need for tailored interventions addressing socioeconomic and psychosocial disparities.

BACKGROUND:Tobacco use continues to take the lives of many, and targeted interventions can counter this health burden. One possible target population is patients who have had a smoking-related diagnosis, as they may have a greater drive to quit. OBJECTIVE:To assess whether patients with previous cardiac or pulmonary conditions directly attributable to smoking have greater rates of abstinence post-discharge from hospitalization in the CHART-NY trial. DESIGN/METHODS:CHART-NY was a randomized comparative effectiveness trial comparing a more intensive versus a less intensive smoking cessation intervention after hospital discharge. We divided the 1618 CHART-NY participants into a smoking-related history group of 597 and a nonsmoking-related history group of 1021 based on cardiac or pulmonary conditions in a retrospective chart review. We conducted chi-squared analyses on baseline characteristics. Using follow-up survey data, we conducted chi-squared analyses on abstinence outcomes and made logistic regression models for the predictive value of smoking-related conditions on abstinence. PARTICIPANTS/METHODS:A total of 1059 and 1084 participants in CHART-NY who completed both 2- and 6-month follow-up surveys respectively. MAIN MEASURES/METHODS:Self-reported 30-day abstinence at 2- and 6-month follow-up and survey data for baseline characteristics. KEY RESULTS/RESULTS:Those abstinent at 6-month follow-up were more likely to have a smoking-attributable history (OR = 1.40, 95% CI 1.09-1.81). When stratified based on intervention, only the intensive counseling group was significant (OR = 1.53, 95% CI 1.08-2.17). The regression model using a smoking-related comorbidity score was significant at 6 months (OR = 1.29, p = 0.03), and the multivariate logistic regression model analyzing each smoking-related condition separately demonstrated significance for myocardial infarction at 6 months (OR = 1.66, p = 0.03). CONCLUSIONS:People who smoke who have experienced smoking-related conditions may be more likely to benefit from smoking cessation interventions, especially intensive telephone-based counseling. Multiple conditions had an additive effect in predicting long-term abstinence after intervention, and myocardial infarction had the greatest predictive value.

BACKGROUND:Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores. METHODS:BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase. RESULTS:Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection). CONCLUSIONS:The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.

Epidemiologic studies have identified many biochemical risk factors for chronic kidney disease (CKD) progression that are correlates of kidney function, termed here 'CKD-associated physiologic factors'. Uncertainty remains if these factors are risk factors or risk markers accounting for aspects of kidney function not otherwise captured. We aimed to use flexible machine learning, a dynamic covariate history including kidney function informative markers, and generalized propensity score (GPS) weighting, to better control confounding for such exposures. We studied 3,052 adults with CKD in the Chronic Renal Insufficiency Cohort Study. We established a 2-year run-in period and assembled 90 variables that characterize variability and trends of selected CKD-associated physiologic factors and confounders. Using SuperLearner, we created a GPS for each CKD-associated physiologic factor and performed GPS-weighted Cox regressions. For context, we also evaluated results from traditional multivariable Cox proportional hazards models as in prior studies. Similar to traditional approaches, bicarbonate, calcium, potassium, hemoglobin, and PTH were each associated with risk of kidney failure using GPS weighting. The GPS approach detected non-linear associations in many factors, some of which were not detected with traditional models. We conclude that many associations between CKD-associated physiologic factors and kidney outcomes remain strong after GPS weighting.

PURPOSE/OBJECTIVE:We undertook a trial to test the efficacy of a technology-assisted health coaching intervention for weight management, called Goals for Eating and Moving (GEM), within primary care. METHODS:). The primary outcome (weight change at 12 months) and exploratory outcomes (eg, program attendance, diet, physical activity) were analyzed according to intention to treat. RESULTS:= .48). There were no statistically significant differences in secondary outcomes. Exploratory analyses showed that the GEM arm had a greater change than the EUC arm in mean number of weekly minutes of moderate to vigorous physical activity other than walking, a finding that may warrant further exploration. CONCLUSIONS:The GEM intervention did not achieve clinically important weight loss in primary care. Although this was a negative study possibly affected by health system resource limitations and disruptions, its findings can guide the development of similar interventions. Future studies could explore the efficacy of higher-intensity interventions and interventions that include medication and bariatric surgery options, in addition to lifestyle modification.

BACKGROUND:Variation in operative setting and surgical technique exists when treating specialty site melanomas. There are limited data comparing costs among surgical modalities. OBJECTIVE:To evaluate the costs of head and neck melanoma surgery performed with Mohs micrographic surgery or conventional excision in the operating room or office-based settings. METHODS:A retrospective cohort study was performed on patients aged 18 years and older with surgically treated head and neck melanoma in 2 cohorts, an institutional cohort and an insurance claims cohort, for the years 2008-2019. The primary outcome was total cost of care for a surgical encounter, provided in the form of insurance reimbursement data. A generalized linear model was used to adjust for covariates affecting differences between treatment groups. RESULTS:In the institutional and insurance claims cohorts, average adjusted treatment cost was highest in the conventional excision-operating room treatment group, followed by the Mohs surgery and conventional excision-office setting ( p < .001). CONCLUSION:These data demonstrate the important economic role the office-based setting has for head and neck melanoma surgery. This study allows cutaneous oncologic surgeons to better understand the costs of care involved in head and neck melanoma treatment. Cost awareness is important for shared decision-making discussions with patients.

Health policy decisions regarding patient treatment strategies require consideration of both treatment effectiveness and cost. We propose a two-step approach for identifying an optimally cost-effective and interpretable dynamic treatment regime. First, we develop a combined Q-learning and policy-search approach to estimate optimal list-based regimes under a constraint on expected treatment costs. Second, we propose an iterative procedure to select an optimally cost-effective regime from a set of candidate regimes corresponding to different cost constraints. Our approach can estimate optimal regimes in the presence of time-varying confounding, censoring, and correlated outcomes. Through simulation studies, we examine the operating characteristics of our approach under flexible modelling approaches. We also apply our methodology to identify optimally cost-effective treatment strategies for assigning adjuvant therapies to endometrial cancer patients.

BACKGROUND:Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care. METHODS:We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios. RESULTS:The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care. CONCLUSIONS:Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.