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Disparities in routine healthcare utilization disruptions during COVID-19 pandemic among veterans with type 2 diabetes

Adhikari, Samrachana; Titus, Andrea R; Baum, Aaron; Lopez, Priscilla; Kanchi, Rania; Orstad, Stephanie L; Elbel, Brian; Lee, David C; Thorpe, Lorna E; Schwartz, Mark D
BACKGROUND:While emerging studies suggest that the COVID-19 pandemic caused disruptions in routine healthcare utilization, the full impact of the pandemic on healthcare utilization among diverse group of patients with type 2 diabetes is unclear. The purpose of this study is to examine trends in healthcare utilization, including in-person and telehealth visits, among U.S. veterans with type 2 diabetes before, during and after the onset of the COVID-19 pandemic, by demographics, pre-pandemic glycemic control, and geographic region. METHODS:We longitudinally examined healthcare utilization in a large national cohort of veterans with new diabetes diagnoses between January 1, 2008 and December 31, 2018. The analytic sample was 733,006 veterans with recently-diagnosed diabetes, at least 1 encounter with veterans administration between March 2018-2020, and followed through March 2021. Monthly rates of glycohemoglobin (HbA1c) measurements, in-person and telehealth outpatient visits, and prescription fills for diabetes and hypertension medications were compared before and after March 2020 using interrupted time-series design. Log-linear regression model was used for statistical analysis. Secular trends were modeled with penalized cubic splines. RESULTS:In the initial 3 months after the pandemic onset, we observed large reductions in monthly rates of HbA1c measurements, from 130 (95%CI,110-140) to 50 (95%CI,30-80) per 1000 veterans, and in-person outpatient visits, from 1830 (95%CI,1640-2040) to 810 (95%CI,710-930) per 1000 veterans. However, monthly rates of telehealth visits doubled between March 2020-2021 from 330 (95%CI,310-350) to 770 (95%CI,720-820) per 1000 veterans. This pattern of increases in telehealth utilization varied by community type, with lowest increase in rural areas, and by race/ethnicity, with highest increase among non-hispanic Black veterans. Combined in-person and telehealth outpatient visits rebounded to pre-pandemic levels after 3 months. Despite notable changes in HbA1c measurements and visits during that initial window, we observed no changes in prescription fills rates. CONCLUSIONS:Healthcare utilization among veterans with diabetes was substantially disrupted at the onset of the pandemic, but rebounded after 3 months. There was disparity in uptake of telehealth visits by geography and race/ethnicity.
PMID: 36647113
ISSN: 1472-6963
CID: 5410652

A matched analysis of the association between federally-mandated smoke-free housing policies and health outcomes among Medicaid-enrolled children in subsidized housing, 2015-2019, New York City

Titus, Andrea R; Mijanovich, Tod N; Terlizzi, Kelly; Ellen, Ingrid G; Anastasiou, Elle; Shelley, Donna; Wyka, Katarzyna; Elbel, Brian; Thorpe, Lorna E
Smoke-free housing policies are intended to reduce the deleterious health effects of secondhand smoke (SHS) exposure, but there is limited evidence regarding their health impacts. We examined associations between implementation of a federal smoke-free housing rule by the New York City Housing Authority (NYCHA) and pediatric Medicaid claims for asthma, lower respiratory infections (LRIs), and upper respiratory infections (URIs) in the early post-policy period. We used geocoded address data to match children living in tax lots with NYCHA buildings (exposed to policy) to children living in lots with other subsidized housing (unexposed to policy). We constructed longitudinal difference-in-differences models to assess relative changes in monthly rates of claims between November 1, 2015 and December 31, 2019 (policy introduction was July 30, 2018). We also examined effect modification by baseline age group (0-2, 3-6, 7-15). In NYC, introduction of a smoke-free policy was not associated with lower rates of Medicaid claims for any outcomes in the early post-policy period. Exposure to the smoke-free policy was associated with slightly higher than expected rates of outpatient URI claims (IRR=1.05, 95% CI=1.01, 1.08), a result most pronounced among children ages 3-6. Ongoing monitoring is essential to understanding long-term health impacts of smoke-free housing policies.
PMID: 35551590
ISSN: 1476-6256
CID: 5214782

Response to Widome

Titus, Andrea R; Elbel, Brian; Shelley, Donna; Anastasiou, Elle; Thorpe, Lorna E
PMID: 36269016
ISSN: 1476-6256
CID: 5360602

Long-term Trends in secondhand smoke exposure in high-rise housing serving low-income residents in New York City: Three-Year Evaluation of a federal smoking ban in public housing, 2018-2021

Anastasiou, Elle; Gordon, Terry; Wyka, Katarzyna; Tovar, Albert; Gill, Emily; Rule, Ana M; Elbel, Brian; Kaplan, Sue; Shelley, Donna; Thorpe, Lorna E
INTRODUCTION/BACKGROUND:In July 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. We measured secondhand smoke (SHS) exposure immediately before, and repeatedly up to 36 months post-SFH policy implementation in a purposeful sample of 21 New York City (NYC) high-rise buildings (>15 floors): 10 NYC Housing Authority (NYCHA) buildings subject to the policy and 11 privately managed buildings in which most residents received housing vouchers (herein 'Section 8'). METHODS:We invited participants from non-smoking households (NYCHA n=157, Section 8 n=118) to enroll into a longitudinal air monitoring study, measuring (1) nicotine concentration with passive, bi-sulfate-coated filters, and (2) particulate matter (PM2.5) with low-cost particle sensors. We also measured nicotine concentrations and counted cigarette butts in common areas (n=91 stairwells and hallways). We repeated air monitoring sessions in households and common areas every 6 months, totaling six post-policy sessions. RESULTS:After three years, we observed larger declines in nicotine concentration in NYCHA hallways than in Section 8, [difference-in-difference (DID) = -1.92 µg/m 3 (95% CI -2.98, -0.87), p=0.001]. In stairwells, nicotine concentration declines were larger in NYCHA buildings, but the differences were not statistically significant [DID= -1.10 µg/m 3 (95% CI -2.40, 0.18), p=0.089]. In households, there was no differential change in nicotine concentration (p=0.093) or in PM2.5 levels (p=0.385). CONCLUSIONS:Nicotine concentration reductions in NYCHA common areas over three years may be attributable to the SFH policy, reflecting its gradual implementation over this time. IMPLICATIONS/CONCLUSIONS:Continued air monitoring over multiple years has demonstrated that SHS exposure may be declining more rapidly in NYCHA common areas as a result of SFH policy adherence. This may have positive implications for improved health outcomes among those living in public housing, but additional tracking of air quality and studies of health outcomes are needed. Ongoing efforts by NYCHA to integrate the SFH policy into wider healthier-homes initiatives may increase policy compliance.
PMID: 36041039
ISSN: 1469-994x
CID: 5337652

Exposure to local violent crime and childhood obesity and fitness: Evidence from New York City public school students

Laurito, Agustina; Schwartz, Amy Ellen; Elbel, Brian
This paper estimates the relationship between neighborhood violent crime and child and adolescent weight and fitness. It uses detailed data from the Fitnessgram assessments of public school students in New York City matched to point specific crime data geocoded to students' residential location. Our empirical approach compares the weight and fitness outcomes of students exposed to a violent crime on their residential H-block with those living in the same census tract but not exposed to violent crime in close proximity to their home. We find for adolescent girls, increases in BMI that range from 0.01 to 0.035 standard deviations and an increase in the probability of overweight of 0.5 to 1.7 percentage points. We find little evidence that BMI, obesity, and overweight change as a result of violent crime for adolescent boys, and younger children. Results are not explained by declines in physical fitness.
PMID: 36401938
ISSN: 1873-2054
CID: 5382752

Age-Specific Differences in Online Grocery Shopping Behaviors and Attitudes among Adults with Low Income in the United States in 2021

Rummo, Pasquale E; Roberto, Christina A; Thorpe, Lorna E; Troxel, Andrea B; Elbel, Brian
BACKGROUND:Online grocery shopping has surged in popularity, but we know little about online grocery shopping behaviors and attitudes of adults with low income, including differences by age. METHODS:= 3526). Participants completed an online survey designed to assess diet and online food shopping behaviors. Using logistic regression, we examined the relationship between participant characteristics, including age, and the likelihood of online grocery shopping, and separately examined variation in the reasons for online grocery shopping by age. RESULTS:< 0.001)). CONCLUSION/CONCLUSIONS:Strategies for making online grocery shopping more affordable for adults with lower income may be promising, especially online produce. For older adults, additional support may be needed to make online shopping a suitable replacement for in-store shopping, such as education on technology and combining it with opportunities for social support.
PMID: 36297112
ISSN: 2072-6643
CID: 5358122

Analysis of School-Level Vaccination Rates by Race, Ethnicity, and Geography in New York City

Elbel, Brian; Zhou, Geng Eric; Lee, David C; Chen, Willy; Day, Sophia E; Konty, Kevin J; Schwartz, Amy Ellen
PMID: 36107432
ISSN: 2574-3805
CID: 5332912

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial

Rogers, Erin S; Rosen, Marc I; Elbel, Brian; Wang, Binhuan; Kyanko, Kelly; Vargas, Elizabeth; Wysota, Christina N; Sherman, Scott E
BACKGROUND:Financial distress is a barrier to cessation among low-income smokers. OBJECTIVE:To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers. DESIGN/METHODS:Randomized waitlist control trial conducted from 2017 to 2019. PARTICIPANTS/METHODS:Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community. INTERVENTION/METHODS:The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period. MAIN MEASURES/METHODS:Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months. KEY RESULTS/RESULTS:At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (β, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (β, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (β, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (β, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (β, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (β, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05). CONCLUSIONS:Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community. TRIAL REGISTRATION/ Identifier: NCT03187730.
PMID: 35018561
ISSN: 1525-1497
CID: 5118702

The Relationship between School Infrastructure and School Nutrition Program Participation and Policies in New York City

Prescott, Melissa Pflugh; Gilbride, Judith A; Corcoran, Sean P; Elbel, Brian; Woolf, Kathleen; Ofori, Roland O; Schwartz, Amy Ellen
School nutrition programs (SNP) provide much needed access to fruits, vegetables, and other healthy foods at low or no cost. Yet, the infrastructure of school kitchens and cafeteria vary across schools, potentially contributing to systematic barriers for SNP operation and equity. The purpose of this paper is to examine the association between school infrastructure and outcomes including meal participation, untraditional lunch periods, and having an open campus. Regression analyses were conducted using administrative data for 1804 schools and school nutrition manager survey data (n = 821) in New York City (NYC). Co-location was significantly associated with open campus status (OR = 2.84, CI: 1.11, 7.26) and high school breakfast participation (β = -0.056, p = 0.003). Overcrowding was associated with breakfast (elementary: β = -0.046, p = 0.03; middle: β = 0.051, p = 0.04; high: β = 0.042, p = 0.04) and lunch participation (elementary: β = -0.031, p = 0.01) and untraditional lunchtimes (elementary: OR = 2.47, CI: 1.05, 5.83). Higher enrollment to cafeteria capacity ratios was associated with breakfast (elementary: β = -0.025, p = 0.02) and lunch (elementary: β = -0.015, p = 0.001; high: β = 0.014, p = 0.02) participation and untraditional lunchtimes (middle: OR = 1.66, CI: 1.03, 2.68). Infrastructure characteristics are an important source of variation across NYC schools that may hinder the equity of school nutrition programs across the city.
PMID: 35955003
ISSN: 1660-4601
CID: 5287262

Area Characteristics and Consumer Nutrition Environments in Restaurants: an Examination of Hispanic Caribbean Restaurants in New York City

Fuster, Melissa; Kodali, Hanish; Ray, Krishnendu; Elbel, Brian; Handley, Margaret A; Huang, Terry T-K; Johnson, Glen
Hispanics in the USA, particularly those of Caribbean descent, experience high levels of diet-related diseases and dietary risk factors. Restaurants are an increasingly important yet understudied source of food and may present opportunities to positively influence urban food environments. We sought to explore food environments further, by examining the association between neighborhood characteristics and restaurant consumer nutrition environments within New York City's Hispanic Caribbean (HC) restaurant environments. We applied an adapted version of the Nutrition Environment Measurements Survey for Restaurants (NEMS-R) to evaluate a random sample of HC restaurants (n=89). NEMS-HCR scores (continuous and categorized as low, medium, and high based on data distribution) were examined against area sociodemographic characteristics using bivariate and logistic regression analysis. HC restaurants located in Hispanic geographic enclaves had a higher proportion of fried menu items (p<0.01) but presented fewer environmental barriers to healthy eating, compared with those in areas with lower Hispanic concentrations. No significant differences in NEMS-R scores were found by other neighborhood characteristics. Size was the only significant factor predicting high NEMS-HCR scores, where small restaurants were less likely to have scores in the high category (NEMS-HCR score>6), compared with their medium (aOR: 6.6, 95% CI: 1.8-24.6) and large counterparts (aOR: 5.6, 95% CI: 1.5-21.4). This research is the first to examine the association between restaurant location and consumer nutrition environments, providing information to contribute to future interventions and policies seeking to improve urban food environments in communities disproportionately affected by diet-related conditions, as in the case of HC communities in New York City.
PMID: 34152587
ISSN: 2196-8837
CID: 4918172