Faculty Bibliography

BACKGROUND:Despite substantial increases in dental benefits and improvements in the use of dental services among children and adolescents in the United States, oral health disparities according to dental insurance payer type persist. METHODS:The authors used an all-payer claims (2013-2017) database to perform a comparative analysis of the provision and treatment outcomes of an endodontic procedure (root canal therapy) in the permanent teeth of a pediatric population aged 6 through 18 years, according to dental insurance payer type. Statistical analyses, including logistic regression, Cox proportional hazards regression, and the Kaplan-Meier method, were performed at person and tooth levels. RESULTS:Compared with privately insured children and adolescents, public-payer children and adolescent beneficiaries were more likely to have had root canal therapy (adjusted odds ratio, 1.91; 95% CI, 1.73 to 2.11) and had poorer treatment outcomes associated with the procedure (adjusted hazard ratio, 2.19; 95% CI, 1.53 to 3.14; P < .0001) during the study period. Those enrolled in private insurance were more likely to receive treatment from an endodontist (specialist in providing root canal therapy) (P < .0001). Amounts allowed and paid by the insurer were significantly higher for private payers (P < .001). CONCLUSIONS:There were significant differences in the provision and outcomes of endodontic treatment between privately and publicly insured children and adolescents. PRACTICAL IMPLICATIONS:Despite ostensibly equal access to care, differences in the provision of oral health care exist between privately and publicly insured patients. These differences may be contributing to persisting oral health disparities.

Introduction: Prostate cancer is the second leading cause of cancer deaths among men in the United States and harms Black men disproportionately. Most US men are uninformed about many key facts important to make an informed decision about prostate cancer. Most experts agree that it is important for men to learn about these problems as early as possible in their lifetime. Objectives: To compare the effect of a community health worker (CHW)-led educational session with a physician-led educational session that counsels Black men about the risks and benefits of prostate-specific antigen (PSA) screening. Methods: One hundred eighteen Black men recruited in 8 community-based settings attended a prostate cancer screening education session led by either a CHW or a physician. Participants completed surveys before and after the session to assess knowledge, decisional conflict, and perceptions about the intervention. Both arms used a decision aid that explains the benefits, risks, and controversies of PSA screening and decision coaching. Results: There was no significant difference in decisional conflict change by group: 24.31 physician led versus 30.64 CHW led (P¼.31). The CHW-led group showed significantly greater improvement on knowledge after intervention, change (SD): 2.6 (2.81) versus 5.1 (3.19), P,.001). However, those in the physician-led group were more likely to agree that the speaker knew a lot about PSA testing (P,.001) and were more likely to trust the speaker (P,.001). Conclusions: CHW-led interventions can effectively assist Black men with complex health decision-making in community-based settings. This approach may improve prostate cancer knowledge and equally minimize decisional conflict compared with a physician-led intervention.

INTRODUCTION/UNASSIGNED:Prostate cancer is the second leading cause of cancer deaths among men in the United States and harms Black men disproportionately. Most US men are uninformed about many key facts important to make an informed decision about prostate cancer. Most experts agree that it is important for men to learn about these problems as early as possible in their lifetime. OBJECTIVES/UNASSIGNED:To compare the effect of a community health worker (CHW)-led educational session with a physician-led educational session that counsels Black men about the risks and benefits of prostate-specific antigen (PSA) screening. METHODS/UNASSIGNED:One hundred eighteen Black men recruited in 8 community-based settings attended a prostate cancer screening education session led by either a CHW or a physician. Participants completed surveys before and after the session to assess knowledge, decisional conflict, and perceptions about the intervention. Both arms used a decision aid that explains the benefits, risks, and controversies of PSA screening and decision coaching. RESULTS/UNASSIGNED:There was no significant difference in decisional conflict change by group: 24.31 physician led versus 30.64 CHW led (P=.31). The CHW-led group showed significantly greater improvement on knowledge after intervention, change (SD): 2.6 (2.81) versus 5.1 (3.19), P<.001). However, those in the physician-led group were more likely to agree that the speaker knew a lot about PSA testing (P<.001) and were more likely to trust the speaker (P<.001). CONCLUSIONS/UNASSIGNED:CHW-led interventions can effectively assist Black men with complex health decision-making in community-based settings. This approach may improve prostate cancer knowledge and equally minimize decisional conflict compared with a physician-led intervention.

BACKGROUND:Previously published epidemiological outcome studies of root canal therapy (NSRCT) in the Unites States utilize data only from a single, private dental insurer for adult populations. AIM/OBJECTIVE:This study aimed to investigate outcomes of initial NSRCT, performed on permanent teeth, in a publicly insured pediatric population. DESIGN/METHODS:New York State Medicaid administrative claims were used to follow 77,741 endodontic procedures in 51,545 patients aged 6-18, from the time of initial NSRCT until occurrence of an untoward event (retreatment, apicoectomy, extraction). Initial treatment and untoward events were identified by Current Dental Terminology codes. Kaplan-Meier survival estimates were calculated at 1, 3, and 5 years. Hazard ratios for time to permanent restoration and restoration type were calculated using Cox proportional hazard models. RESULTS:Median follow-up time was 44 months [range:12-158 months]. Procedural, NSRCT, survival was 98% at 1 year, 93% at 3 years, and 88% at 5 years. Extraction was the most common untoward event. Teeth permanently restored with cuspal coverage had the most favorable treatment outcomes. CONCLUSIONS:Overall, 89% of teeth were retained and remained functional over a minimum follow-up time of 5 years. These results elucidate expected outcomes of NSRCT in permanent teeth for pediatric patients with public-payer dental benefits.

To determine whether an opt-out approach is effective for referral to treatment for tobacco use, we designed a clinical reminder for nurses in a primary care setting that provides a referral for patients who smoke cigarettes. We will use a two-arm, cluster-randomized design to assign nurses at the VA New York Harbor Healthcare System to test which mode of referral (opt-in vs opt-out) is more effective. All patients will be referred to evidence-based treatment for tobacco cessation including counseling from the New York State Quitline, and VetsQuit, a text messaging-based system for tobacco cessation counseling. We will measure patient engagement with the referral both in the short and long term to determine if referral modality had an impact on tobacco cessation treatment. We will also measure nurse engagement with the referral before, during, and after the implementation of the reminder to determine whether an opt-out approach is cost effective at the health system level. At the conclusion of this project, we expect to have developed and tested an opt-out system for increasing tobacco cessation treatment for Veterans in VA primary care and to have a thorough understanding of factors associated with implementation. Trial Registration:Clinicaltrials.govIdentifierNCT03477435.

A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs-the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.

PURPOSE/OBJECTIVE:The omission of radiation therapy (RT) in elderly women with stage 1 estrogen-receptor positive (ER+) breast cancer receiving endocrine therapy (ET) is an acceptable strategy based on randomized trial data. Less is known about the omission of ET +/- RT. PATIENT AND METHODS/METHODS:We analyzed SEER-Medicare data for 13,321 women ≥ 66 years with stage I ER+ breast cancer from 2007-2012 who underwent breast conserving surgery. Patients were classified into 4 groups: 1) ET+RT (reference) 2) ET alone (ET), 3) RT alone (RT) and 4) neither RT nor ET (NT). Second breast cancer events (SBCE) were captured using Chubak's high-specificity algorithm. We used Chi-square tests for descriptive statistics, multivariable multinomial logistic regression to estimate relative risks (RR) of undergoing a treatment, and multivariable, propensity-weighted competing-risks survival regression to estimate standardized hazard ratio (SHR) of SBCE. We set significance at p≤0.01. RESULTS:Most women underwent both treatments, with 44% undergoing ET+RT, 41% RT, 6.6% ET, and 8.6% NT but practice patterns varied over time: from 2007-2012, RT decreased from 49% to 30%, whereas ET and ET+RT increased (ET: 5.4% to 9.6%; ET+RT: 38% to 51%). Compared to patients 66-69 years, patients 80-85 years were more likely to receive NT (OR=8.9), RT (OR=1.9), or ET (OR=8.8) vs. ET+RT (p<0.01).3% of subjects had an SBCE (2.2% ET+RT, 3.0% RT, 3.2% ET, 7.0% NT). Relative to ET+RT, NT and ET were associated with higher SBCE (NT: SHR 3.7, p<0.001; ET: SHR 2.2, p=0.008)), whereas RT was not associated with a higher SBCE (SHR 1.21, p=0.137). Clinical factors associated with higher SBCE were HER2 positivity and pT1c (SHR 1.7, p=0.006). CONCLUSIONS:Treatment with RT alone in older women with stage I ER+ disease is decreasing. RT alone is not associated with an increased risk for SBCE. By contrast, NT and ET are both associated with higher SBCE in multivariable analysis with propensity weighting. Further study of the omission of endocrine therapy in this patient population is warranted.

OBJECTIVES/UNASSIGNED:This study investigated differences in the provision of root canal therapy and outcomes in a publicly insured cohort of children and adolescents. METHODS/UNASSIGNED:New York State Medicaid administrative claims from 2006 to 2018 were analyzed. Enrollees aged 6-18 were included in the study if they had initial non-surgical root canal therapy (NSRCT), in the permanent dentition, that allowed for at least 1 year of post-treatment follow-up. Descriptive analyses, multivariable logistic regression, and multivariable Cox proportional hazard models were used to examine the association between demographic variables (gender, age, race/ethnicity, and area-based factors) and dental treatment provision and outcomes. RESULTS/UNASSIGNED:Male gender was associated with having more than one initial NSRCT (adjusted odds ratio (aOR) = 1.06; 95% confidence interval (CI) = 1.02-1.10), as was rurality (aOR = 1.15; 95% CI = 1.06-1.24). Black/African American (AA) and Hispanic children were less likely than non-Hispanic white children to have multiple NSRCTs (aOR = 0.88; 95% CI = 0.83-0.93 and aOR = 0.78; 95% CI = 0.74-0.83). Being older or female conferred a lower hazard of an untoward event (aHR = 0.93; 95% CI = 0.92-0.94 and aHR = 0.86; 95% CI = 0.81-0.91). Compared to non-Hispanic white children, Hispanic and Black/AA children had a higher risk of untoward event (aHR = 1.31; 95% CI = 1.21-1.41 and aHR = 1.55; 95% CI = 1.43-1.67) while children of Asian descent had a lower incidence after initial NSRCT (aHR = 0.79; 95% CI = 0.71-0.88). CONCLUSION/UNASSIGNED:Race/ethnicity was the strongest demographic predictor of provision of initial non-surgical root canal therapy, subsequent placement of a permanent restoration and the occurrence of an untoward event after NSRCT in this cohort.

Background Lupus nephritis can occur as an isolated component of disease activity or be accompanied by diverse extrarenal symptoms that can adversely affect a patient's quality of life (QOL). Whether renal disease absent other activity is sufficient to decrease QOL is unknown. A lack of reported QOL impairment may place patients at risk for delayed diagnosis of nephritis or medication noncompliance yet nephritis trials have largely neglected QOL. As such, this study leveraged the multi-center multi-racial Accelerating Medicines Partnership (AMP) lupus nephritis cohort to assess QOL measured by PROMIS-29. Methods Patients (n=182) fulfilling ACR or SLICC criteria for SLE with a uPCR >= .5 and biopsy Class III, IV, V, or mixed were consecutively enrolled in AMP at the time of renal biopsy and clinical history, PROMIS-29, and disease activity as assessed by the hybrid SELENA-SLEDAI were recorded. Patients were determined to have extrarenal clinical activity if, after excluding all laboratory parameters from the SLEDAI, the score remained >= 1. Raw PROMIS-29 scores were transformed to t-scores with the mean of 50 +/- 10 representing the US population and a difference of 5 points considered clinically meaningful. PROMIS-29 physical and mental health summary scores were calculated according to published formulas. Results Forty-three percent of patients (n=78) had extrarenal clinical manifestations including vasculitis (4%), arthritis (39%), rash (45%), alopecia (42%), mucosal ulcers (13%), pleurisy (12%), pericarditis (8%), and fever (4%). Patients with isolated renal disease (n=104, 57%) did not have PROMIS-29 scores that differed clinically from the US population whereas patients with extrarenal disease reported deficits in physical functioning, fatigue, social functioning, and pain (table 1). Patients with extrarenal disease had significantly lower physical health summary scores compared to patients with isolated disease (median [IQR]: 40.31 [35.79, 47.02] p<0.001 vs. 48.6 [40.14, 57.08]) and significantly lower mental health summary scores (44.12 [38.63, 51.39], p=0.024 vs. 48.67 [40.51, 55.07]). Female and African American patients and those with nephrotic range proteinuria or undergoing first biopsy had significantly lower physical health summary scores, but mental health summary scores did not differ by these variables. Patients on greater than 20 mg of prednisone had both significantly lower physical and mental health summary scores compared to those on lower doses. PROMIS-29 scores did not differ by low complements, anti-dsDNA, or anti-Ro antibodies. Stepwise multivariable linear regression analysis demonstrated that the association between extrarenal disease and lower PROMIS-29 summary scores was primarily driven by arthritis and independent of potential confounders (tables 2 and 3). Conclusion The majority of patients had isolated renal disease and report a QOL similar to that of the general population. In contrast, those with extrarenal manifestations report significantly worse QOL outcomes. These results reinforce the critical importance of routine laboratory surveillance and medication compliance for nephritis even in patients with seemingly quiescent clinical disease since lupus nephritis is often asymptomatic

BACKGROUND:A number of studies have identified patient-, provider-, and community-level barriers to effective diabetes management among South Asian Americans, who have a high prevalence of type 2 diabetes. However, no multi-level, integrated community health worker (CHW) models leveraging health information technology (HIT) have been developed to mitigate disease among this population. This paper describes the protocol for a multi-level, community-clinical linkage intervention to improve glycemic control among South Asians with uncontrolled diabetes. METHODS:The study includes three components: 1) building the capacity of primary care practices (PCPs) to utilize electronic health record (EHR) registries to identify patients with uncontrolled diabetes; 2) delivery of a culturally- and linguistically-adapted CHW intervention to improve diabetes self-management; and 3) HIT-enabled linkage to culturally-relevant community resources. The CHW intervention component includes a randomized controlled trial consisting of group education sessions on diabetes management, physical activity, and diet/nutrition. South Asian individuals with type 2 diabetes are recruited from 20 PCPs throughout NYC and randomized at the individual level within each PCP site. A total of 886 individuals will be randomized into treatment or control groups; EHR data collection occurs at screening, 6-, 12-, and 18-month. We hypothesize that individuals receiving the multi-level diabetes management intervention will be 15% more likely than the control group to achieve ≥0.5% point reduction in hemoglobin A1c (HbA1c) at 6-months. Secondary outcomes include change in weight, body mass index, and LDL cholesterol; the increased use of community and social services; and increased health self-efficacy. Additionally, a cost-effectiveness analysis will focus on implementation and healthcare utilization costs to determine the incremental cost per person achieving an HbA1c change of ≥0.5%. DISCUSSION/CONCLUSIONS:Final outcomes will provide evidence regarding the effectiveness of a multi-level, integrated EHR-CHW intervention, implemented in small PCP settings to promote diabetes control among an underserved South Asian population. The study leverages multisectoral partnerships, including the local health department, a healthcare payer, and EHR vendors. Study findings will have important implications for the translation of integrated evidence-based strategies to other minority communities and in under-resourced primary care settings. TRIAL REGISTRATION/BACKGROUND:This study was registered with clinicaltrials.gov: NCT03333044 on November 6, 2017.