Faculty Bibliography

OBJECTIVE:This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients' risk of subsequent ED visits for self-harm. METHOD:Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n = 480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm. RESULTS:Self-harm patients (n = 5539) were significantly more likely than control patients (n = 16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk. CONCLUSIONS:A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.

BACKGROUND:Incarceration and HIV disproportionately impact African American communities. The mass incarceration of African American men is hypothesized to increase HIV acquisition risk for African American women. Interventions optimizing HIV care engagement and minimizing sexual risk behaviors for men living with HIV post-incarceration may decrease HIV incidence. METHODS:Using an agent-based model, we simulated a sexual and injection drug using network representing the African American population of Philadelphia. We compared intervention strategies for men living with HIV post-incarceration by the number of averted HIV transmissions to women within the community. Three interventions were evaluated: a 90-90-90 scenario scaling up HIV testing, ART provision, and ART adherence; a behavioral intervention decreasing sexual risk behaviors; and a combination intervention involving both. RESULTS:The status quo scenario projected 2,836 HIV transmissions to women over twenty years. HIV transmissions to women decreased by 29% with the 90-90-90 intervention, 23% with the behavioral intervention, and 37% with both. The number of men living with HIV receiving the intervention needed in order to prevent a single HIV transmission ranged between 6 and 10. CONCLUSION:Interventions to improve care engagement and decrease sexual risk behaviors post-incarceration for men living with HIV have the potential to decrease HIV incidence within African American heterosexual networks.

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

BACKGROUND:The United States has the highest incarceration rate in the world. Incarceration can increase HIV risk behaviors for individuals involved with the criminal justice system and may be a driver of HIV acquisition within the community. METHODS:We used an agent-based model to simulate HIV transmission in a sexual-contact network representing heterosexual African American men and women in Philadelphia to identify factors influencing the impact of male mass incarceration on HIV acquisition in women. The model was calibrated using surveillance data and assumed incarceration increased the number of sexual contacts and decreased HIV care engagement for men post-release. Incarceration of a partner increased the number of sexual contacts for women. We compared a counterfactual scenario with no incarceration to scenarios varying key parameters to determine what factors drove HIV acquisition in women. RESULTS:Setting the duration of male high-risk sexual behavior to two years post-release increased the number of HIV transmissions to women by more than 20%. Decreasing post-release HIV care engagement and increasing HIV acquisition risk attributable to sexually transmitted infections (STIs) also increased the number of HIV transmissions to women. Changing the duration of risk behavior for women, the proportion of women engaging in higher risk behavior, and the relative risk of incarceration for HIV-infected men had minimal impact. CONCLUSION/CONCLUSIONS:The mass incarceration of African American men can increase HIV acquisition in African American women on a population-level through factors including post-release high-risk behaviors, disruption of HIV care engagement among formerly incarcerated men, and increased STI prevalence. These findings suggest that the most influential points of intervention may be programs seeking to reduce male risk behaviors and promote HIV care engagement post-release, as well as STI testing and treatment programs for recently incarcerated men, as well as women with incarcerated partners.

Given globalization and other social phenomena, controlling the spread of infectious diseases has become an imperative public health priority. A plethora of interventions that in theory can mitigate the spread of pathogens have been proposed and applied. Evaluating the effectiveness of such interventions is costly and in many circumstances unrealistic. Most important, the community effect (i.e., the ability of the intervention to minimize the spread of the pathogen from people who received the intervention to other community members) can rarely be evaluated. Here we propose a study design that can build and evaluate evidence in support of the community effect of an intervention. The approach exploits molecular evolutionary dynamics of pathogens in order to track new infections as having arisen from either a control or an intervention group. It enables us to evaluate whether an intervention reduces the number and length of new transmission chains in comparison with a control condition, and thus lets us estimate the relative decrease in new infections in the community due to the intervention. We provide as an example one working scenario of a way the approach can be applied with a simulation study and associated power calculations.

OBJECTIVES/OBJECTIVE:To estimate the effect of California's prescription drug monitoring program's (PDMP) registration mandate on use of the PDMP. METHODS:We evaluated the effect of California's mandatory PDMP registration law by fitting time series models on the percentage of clinicians registered for California's PDMP and the percentage of clinicians who were active PDMP users (users who created ≥ 1 patient prescription reports in a given month) from 2010 through 2017. We also compared PDMP use among early PDMP adopters (clinicians who registered > 8 months before the mandatory registration deadline) versus late adopters (clinicians who registered ≤ 8 months before the deadline). RESULTS:Mandatory registration was associated with increases in active PDMP users: 53.5% increase for prescribers and 17.9% for pharmacists. Early adopters were 4 times more likely to be active PDMP users than were late adopters. CONCLUSIONS:Mandatory registration was associated with increases in PDMP registration and use, but most new registrants did not become active users. Public Health Implications. Mandatory PDMP registration increases PDMP use but does not result in widespread PDMP usage by all clinicians prescribing controlled substances.

BACKGROUND:Comprehensive background check (CBC) policies are hypothesised to reduce firearm-related violence because they extend background checks to private party firearm sales, but no study has determined whether these policies actually increase background checks, an expected intermediary outcome. We evaluate the association between CBC policies and the rates of firearm background checks in three states that recently implemented these policies: Delaware (July 2013), Colorado (July 2013) and Washington (December 2014). METHODS:We used the synthetic control group method to estimate the difference from estimated counterfactual postintervention trends in the monthly rate of background checks per 1 00 000 people for handguns, long guns and both types combined, using data for January 1999 through December 2016. Inference was based on results from permutation tests. We conducted multiple sensitivity analyses to assess the robustness of our results. RESULTS:Background check rates increased in Delaware, by 22%-34% depending on the type of firearm, following enactment of its CBC law. No overall changes were observed in Washington and Colorado. Our results were robust to changes in the comparison group and statistical methods. CONCLUSIONS:The enactment of CBC policies was associated with an overall increase in firearm background checks only in Delaware. Data external to the study suggest that Washington experienced a modest, but consistent, increase in background checks for private party sales, and Colorado experienced a similar increase in checks for sales not at gun shows. Non-compliance may explain the lack of an overall increase in background checks in Washington and Colorado.

BACKGROUND:Frequent emergency department (ED) visits often suggest inappropriate use for low acuity needs and multiple comorbidities, including substance use disorders. OBJECTIVE:This study examines associations of individuals and their social networks with high frequency ED use among persons reporting substance use. METHODS:Information was obtained from interview responses from the first 6-month follow-up visit of a longitudinal. Prevalence ratios for the outcome of high frequency ED visits (≥2 in 6 months) were determined with a generalized linear model, log link, Poisson distribution and robust standard errors. RESULTS:Of 653 participants, 131 (20%) had ≥2 ED visits. In multivariable analysis, greater likelihood of high frequency ED visits over 6 months was associated with being homeless (PR: 1.58; 95% CI: 1.19, 2.10), taking ≥3 medications (PR: 1.58; 95% CI: 1.19, 2.10) and having had a hospitalization over the same period (PR: 4.33; 95% CI: 3.26, 7.56). Among social network factors, lower likelihood of high frequency visits was associated with each increasing year of mean alter age (PR: 0.98; 95% CI: 0.6, 0.99) and greater likelihood with having received health-related informational support from ≥2 alters (PR: 1.62; 95% CI: 1.04, 2.53). Conclusions/Importance: Social network factors may play an important role in ED use. Interventions to promote health behaviors through social influence may be helpful in reducing high frequency ED visits.

Implementation trials often involve clustering via risk networks, where only some participants directly receive the intervention. The individual effect is that among directly treated persons beyond being in an intervention network; the disseminated effect is that among persons engaged with those directly treated. In this article, we employ a causal inference framework and discuss assumptions and estimators for individual and disseminated effects and apply them to the HIV Prevention Trials Network 037 Study. HIV Prevention Trials Network 037 was a phase III, network-level, randomized controlled human immunodeficiency virus (HIV) prevention trial conducted in the United States and Thailand from 2002 to 2006 that recruited injection drug users, who were assigned to either an intervention group or a control group, and their risk network members, who received no direct intervention. Combining individual and disseminated effects, we observed a 35% composite rate reduction in the adjusted model (risk ratio = 0.65, 95% confidence interval: 0.47, 0.90). Methodology is now available for estimating the full set of these effects, enhancing knowledge gained from network-randomized trials. Although the overall effect gains validity from network randomization, we show that it will generally be less than the composite effect. Additionally, if only index participants benefit from the intervention, as the network size increases, the overall effect tends toward the null-an unfortunate and misleading conclusion.