Faculty Bibliography

BACKGROUND:Remote patient monitoring (RPM) and telehealth improve hypertension management but remain underutilized in resource-constrained settings. The Advancing Long-term Improvements in Hypertension Outcomes through a Team-based Care Approach (ALTA) intervention integrates RPM and virtual health coaching into routine care across a large urban FQHC network and has improved blood pressure outcomes. OBJECTIVE:Explore contextual and mechanistic factors shaping ALTA's implementation outcomes from the perspective of intervention deliverers. DESIGN/METHODS:Following 1 year of ALTA implementation, we conducted a realist-informed qualitative evaluation to examine factors influencing intervention uptake using semi-structured interviews and focus groups conducted from September to November 2023. PARTICIPANTS/METHODS:Practice leadership, clinicians, and staff. APPROACH/METHODS:Participants were recruited through convenience sampling. Transcripts were analyzed using a stepwise deductive and inductive coding approach. Deductive codes were drawn from Proctor's taxonomy of implementation outcomes. Themes were developed using context-mechanism-outcome (C-M-O) configurations. KEY RESULTS/RESULTS:Analysis of 32 semi-structured interviews and four focus groups with a total of 46 intervention deliverers revealed five primary C-M-O-oriented themes: (1) Appropriateness, determined by perceptions of fit, drives acceptability. (2) Demanding workflows raise concerns around ALTA's additional burden, influencing perceptions of appropriateness. (3) Intervention challenges are mitigated by practice facilitation and team-based problem-solving, enhancing acceptability, feasibility, and fidelity. (4) Repeated exposure promotes workflow optimizations, fostering intervention penetration over time. (5) Staff desire insight into ALTA's impact, and communication about intervention progress increases motivation and buy-in. Five of Proctor's implementation outcomes emerged most prominently: appropriateness, acceptability, feasibility, fidelity, and penetration. Notably, these outcomes were interdependent, with one acting as an important contextual factor or mechanistic element for another. CONCLUSIONS:This evaluation highlights important contextual factors, mechanisms, and interconnected outcomes underlying implementation of ALTA. Shared understanding and peer learning, workflow optimization, and communication of outcomes with frontline staff improve reach, equity, and sustainability of RPM-enabled interventions for hypertension management in FQHCs. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018, https://classic. CLINICALTRIALS/RESULTS:gov/ct2/show/NCT03713515.

BACKGROUND:Graduate medical education (GME) on diversity, equity, and inclusion rarely teaches strategies for developing anti-racist mindsets and behaviors, and understanding of the impact of these programs and particular curricular components is lacking. OBJECTIVE:To evaluate the format, content, and impact of a longitudinal anti-racism conference series (ARC) on resident physicians within an urban internal medicine program through a qualitative analysis, with the goal of informing the development and implementation of other evidence-based anti-racism curricula in graduate medical education (GME). DESIGN/METHODS:The ARC consisted of eight mandatory, 60-min virtual conferences held between August 2020 and June 2021 within an internal medicine residency program's primary care track sub-group. The conference's content synthesized previous anti-racism curricula, scholarly readings, and practical experiences, and emphasized internal reflection and behavior change. PARTICIPANTS/METHODS:Thirty internal medicine resident physicians and six faculty members. MAIN MEASURES/METHODS:Seven voluntary, semi-structured, hour-long focus groups were conducted to document resident perspectives on the ARC's format, content, and impact of the curriculum on learner's professional and personal development. Constructivist grounded theory was used to analyze resident responses. KEY RESULTS/RESULTS:In total, 17/30 (57%) residents participated in focus groups. Analysis of course format, content, and impact revealed the following: (1) The most valued aspect of the course's instructional format was its perceived psychological safety. (2) Residents desired course content with more outward action steps than were offered. (3) Residents noted personal and professional impact across three main domains: intrapersonal, interpersonal, and institutional. CONCLUSIONS:In this longitudinal GME internal medicine anti-racism curriculum, participants felt that the curriculum format provided safe spaces to engage with topics on systemic racism and patient care, but content lacked sufficient action-oriented strategies. The curriculum's impact was multi-dimensional and could be studied more deeply in the future through simulation or direct observation.

IMPORTANCE/UNASSIGNED:Hispanic men experience higher rates of diabetes compared with non-Hispanic White men but remain underrepresented in preventive lifestyle interventions. OBJECTIVE/UNASSIGNED:To identify unique reasons for Hispanic men's low engagement in the National Diabetes Prevention Program (NDPP) compared with those with high engagement to inform strategies for improving participation. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative study recruited Hispanic men aged 18 years and older and at risk for diabetes per electronic medical records from June 2023 to February 2024 from primary care sites affiliated with hospital-associated Montefiore Health Systems related to an ongoing clinical trial called Power Up. Patients were invited to participate in one-time phone interviews. Interviews were analyzed deductively, guided by behavior change frameworks. EXPOSURE/UNASSIGNED:Participant's level of engagement varied with representation balanced between those demonstrating low and high engagement in the NDPP (attendance at <4 and ≥4 sessions, respectively). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Planned study outcomes included NDPP notable factors associated with low engagement. RESULTS/UNASSIGNED:Of 32 Hispanic men who completed interviews (20 patients [62.5%]aged >50 years), 15 had low engagement in the NDPP, 13 (87%) were not born in the US, 12 (80%) had limited English proficiency, and 8 (53%) did not complete high school. Three major themes and 11 subthemes emerged. Hispanic men with low engagement discussed limited awareness of their prediabetes diagnosis, lifestyle change self-sufficiency, and skepticism about their diabetes risk and the benefits of NDPP. Also mentioned were financial barriers, restricted access to the program, and the perceived negatives of participation outweighing potential benefits. CONCLUSIONS AND RELEVANCE/UNASSIGNED:Addressing the unique barriers faced by Hispanic men in engaging with the NDPP is critical to reducing diabetes-related inequities and may require tackling knowledge gaps, financial barriers, and perceptions of program relevance before, during, and after enrollment. Future research should explore how to tailor recruitment strategies and program content to Hispanic men's specific identities, motivations, and challenges.

IMPORTANCE/UNASSIGNED:Health-related social needs (HRSN) influence health outcomes and health care utilization. Clinicians face challenges addressing HRSN due to limited skills, expertise, and time. Further insight is needed on how patients and clinicians navigate HRSN in clinical encounters. OBJECTIVE/UNASSIGNED:This study examines outpatient primary care encounters predating widespread HRSN screening to identify how discussions on HRSN are initiated and addressed. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative analysis was conducted on transcripts of 97 audiotaped English-speaking patient encounters from 3 clinics in New York City within a municipal health care system from January 2011 through April 2015. Patients were eligible if they were older than 18 years, self-identified as Black or White, had a diagnosis of hypertension, and had at least one prior encounter with the participating clinician. Codes were developed from social needs domains addressed by the Accountable Health Communities HRSN Screening Tool. Codes were added for further social needs identified, whether a patient or clinician initiated the HRSN discussion, and how a social need was addressed, if at all. Encounters were analyzed between June 2023 and February 2024. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Characterization of the content and nature of HRSN discussions during clinical encounters within safety-net clinics. RESULTS/UNASSIGNED:A total of 97 patients (55 [56.7%] women, 58 [59.8%] Black, mean [SD] age, 59.7 [10.6] years) had audiotaped encounters with 27 clinicians (18 [66.7%] women, 15 [55.6%] White, mean [SD] age, 36 [5.8] years). Physical activity (36% of encounters), financial strain (35%), mental health (34%), and substance use (28%) were the most discussed HRSN domains across the 97 encounters. Patients introduced financial strain most often (70% of the time), while clinicians led substance use (75%), physical activity (51%) and mental health (51%) discussions. Patients initiated conversations on employment (77%), food insecurity (62%), and housing instability (52%). Interventions included prescriptions, forms, counseling, and referrals. Domains frequently intervened on included health care navigation needs (85% of discussions), substance use (33%), and mental health (27%). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this qualitative study of HRSN discussions in primary care encounters, clinicians were more likely to initiate discussions on substance use, physical activity, and mental health, behaviors routinely assessed in primary care, but different from topics introduced by patients. Findings underscore the need for standardized screening to improve identification of domains less frequently addressed by clinicians. Additional interventions are also needed, including clinician training for how to address HRSN in resource-constrained settings and integration of other health care team members, to enhance HRSN identification and intervention.

Tools to briefly assess diet among US Spanish-speaking adults are needed to identify individuals at risk for cardiometabolic disease (CMD) related to diet. Two registered dietitian nutritionists (RDNs) recruited bilingual medical students to translate the validated Diet Risk Score (DRS) into Spanish (DRS-S). Participants were recruited from a federally qualified health center. Students administered the DRS-S and one 24-h recall (Automated Self-Administered 24-Hour (ASA24^®) Dietary Assessment Tool) on one day; a second recall was administered within 1 week. Recalls were scored using the Healthy Eating Index (HEI)-2015, a measure of adherence to the Dietary Guidelines for Americans. Spearman correlations, weighted kappa, and ANOVA were conducted using SAS 9.4 to assess the relative validity of the DRS-S. Thirty-one Spanish-speaking adults (female: n = 17, 53%; mean age: 58 (42-69)) completed assessments. The mean DRS-S was 9 (SD = 4.2) (max: 27; higher score = higher risk) and the mean HEI-2015 score was 65.7 (SD = 9.7) (max: 100; higher score = lower risk), with significant agreement between measures (r: -0.45 (p = 0.01)), weighted kappa: -0.3 (p = 0.03). The DRS-S can be used in resource-constrained settings to assess diet for intervention and referral to RDNs. The DRS-S should be tested in clinical care to assess the impact of dietary changes to reduce CMD risk.

BACKGROUND:Research demonstrates the importance of documenting adaptations to implementation strategies that support integration of evidence-based interventions into practice. While studies have utilized the FRAME-IS [Framework for Reporting Adaptations and Modifications for Implementation Strategies] to collect structured adaptation data, they are limited by a focus on discrete implementation strategies (e.g., training), which do not reflect the complexity of multifaceted strategies like practice facilitation. In this paper, we apply the FRAME-IS to our trial evaluating the effectiveness of PF on implementation fidelity of an evidence-based technology-facilitated team care model for improved hypertension control within a federally qualified health center (FQHC). METHODS:Three data sources are used to document adaptations: (1) implementation committee meeting minutes, (2) narrative reports completed by practice facilitators, and (3) structured notes captured on root cause analysis and Plan-Do-Study-Act worksheets. Text was extracted from the data sources according to the FRAME-IS modules and inputted into a master matrix for content analysis by two authors; a third author conducted member checking and code validation. RESULTS:We modified the FRAME-IS to include part 2 of module 2 (what is modified) to add greater detail of the modified strategy, and a numbering system to track adaptations across the modules. This resulted in identification of 27 adaptations, of which 88.9% focused on supporting practices in identifying eligible patients and referring them to the intervention. About half (52.9%) of the adaptations were made to modify the context of the PF strategy to include a group-based format, add community health workers to the strategy, and to shift the implementation target to nurses. The adaptations were often widespread (83.9%), affecting all practices within the FQHC. While most adaptations were reactive (84.6%), they resulted from a systematic process of reviewing data captured by multiple sources. All adaptations included the FQHC in the decision-making process. CONCLUSION/CONCLUSIONS:With modifications, we demonstrate the ability to document our adaptation data across the FRAME-IS modules, attesting to its applicability and value for a range of implementation strategies. Based on our experiences, we recommend refinement of tracking systems to support more nimble and practical documentation of iterative, ongoing, and multifaceted adaptations. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov NCT03713515, Registration date: October 19, 2018.

BACKGROUND:Despite decades of evidence demonstrating the efficacy of hypertension care delivery in reducing morbidity and mortality, a majority of hypertension cases remain uncontrolled. There is an urgent need to elucidate and address multilevel facilitators and barriers clinical staff face in delivering evidence-based hypertension care, patients face in accessing it, and clinical systems face in sustaining it. Through a rigorous pre-implementation evaluation, we aimed to identify facilitators and barriers bearing the potential to affect the planned implementation of a multilevel technology-facilitated hypertension management trial across six primary care sites in a large federally qualified health center (FQHC) in New York City. METHODS:During a dedicated pre-implementation period (3-9 months/site, 2021-2022), a capacity assessment was conducted by trained practice facilitators, including (1) online anonymous surveys (n = 124; 70.5% of eligible), (2) hypertension training analytics (n = 69; 94.5% of assigned), and (3) audio-recorded semi-structured interviews (n = 67; 48.6% of eligible) with FQHC leadership and staff. Surveys measured staff sociodemographic characteristics, adaptive reserve, evidence-based practice attitudes, and implementation leadership scores via validated scales. Training analytics, derived from end-of-course quizzes, included mean score and number attempts needed to pass. Interviews assessed staff-reported facilitators and barriers to current hypertension care delivery and uptake; following audio transcription, trained qualitative researchers employed a deductive coding approach, informed by the Consolidated Framework for Implementation Research (CFIR). RESULTS:Most survey respondents reported moderate adaptive reserve (mean = 0.7, range = 0-1), evidence-based practice attitudes (mean = 2.7, range = 0-4), and implementation leadership (mean = 2.5, range = 0-4). Most staff passed training courses on first attempt and demonstrated high scores (means > 80%). Findings from interviews identified potential facilitators and barriers to implementation; specifically, staff reported that complex barriers to hypertension care, control, and clinical communication exist; there is a recognized need to improve hypertension care; in-clinic challenges with digital tool access imposes workflow delays; and despite high patient loads, staff are motivated to provide high-quality cares. CONCLUSIONS:This study serves as one of the first to apply the CFIR to a rigorous pre-implementation evaluation within the understudied context of a FQHC and can serve as a model for similar trials seeking to identify and address contextual factors known to impact implementation success. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03713515 , date of registration: October 19, 2018.

Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.