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Advancing Lifestyle Medicine in New York City's Public Health Care System

Babich, John S; McMacken, Michelle; Correa, Lilian; Polito-Moller, Krisann; Chen, Kevin; Adams, Eric; Morgenstern, Samantha; Katz, Mitchell; Long, Theodore G; Joshi, Shivam; Wallach, Andrew B; Shah, Sapana; Boas, Rebecca
Chronic diseases are the leading cause of death and disability in the United States, and much of this burden can be attributed to lifestyle and behavioral risk factors. Lifestyle medicine is an approach to preventing and treating lifestyle-related chronic disease using evidence-based lifestyle modification as a primary modality. NYC Health + Hospitals, the largest municipal public health care system in the United States, is a national pioneer in incorporating lifestyle medicine systemwide. In 2019, a pilot lifestyle medicine program was launched at NYC Health + Hospitals/Bellevue to improve cardiometabolic health in high-risk patients through intensive support for evidence-based lifestyle changes. Analyses of program data collected from January 29, 2019 to February 26, 2020 demonstrated feasibility, high demand for services, high patient satisfaction, and clinically and statistically significant improvements in cardiometabolic risk factors. This pilot is being expanded to 6 new NYC Health + Hospitals sites spanning all 5 NYC boroughs. As part of the expansion, many changes have been implemented to enhance the original pilot model, scale services effectively, and generate more interest and incentives in lifestyle medicine for staff and patients across the health care system, including a plant-based default meal program for inpatients. This narrative review describes the pilot model and outcomes, the expansion process, and lessons learned to serve as a guide for other health systems.
PMID: 38828080
ISSN: 2542-4548
CID: 5664872

Addressing social determinants of health in primary care: a quasi-experimental study using unannounced standardised patients to evaluate the impact of audit/feedback on physicians' rates of identifying and responding to social needs

Gillespie, Colleen; Wilhite, Jeffrey A; Hanley, Kathleen; Hardowar, Khemraj; Altshuler, Lisa; Fisher, Harriet; Porter, Barbara; Wallach, Andrew; Zabar, Sondra
BACKGROUND:Although efforts are underway to address social determinants of health (SDOH), little is known about physicians' SDOH practices despite evidence that failing to fully elicit and respond to social needs can compromise patient safety and undermine both the quality and effectiveness of treatment. In particular, interventions designed to enhance response to social needs have not been assessed using actual practice behaviour. In this study, we evaluate the degree to which providing primary care physicians with feedback on their SDOH practice behaviours is associated with increased rates of eliciting and responding to housing and social isolation needs. METHODS:Unannounced standardised patients (USPs), actors trained to consistently portray clinical scenarios, were sent, incognito, to all five primary care teams in an urban, safety-net healthcare system. Scenarios involved common primary care conditions and each included an underlying housing (eg, mould in the apartment, crowding) and social isolation issue and USPs assessed whether the physician fully elicited these needs and if so, whether or not they addressed them. The intervention consisted of providing physicians with audit/feedback reports of their SDOH practices, along with brief written educational material. A prepost comparison group design was used to evaluate the intervention; four teams received the intervention and one team served as a 'proxy' comparison (no intervention). Preintervention (February 2017 to December 2017) rates of screening for and response to the scripted housing and social needs were compared with intervention period (January 2018 to March 2019) rates for both intervention and comparison teams. RESULTS:108 visits were completed preintervention and 183 during the intervention period. Overall, social needs were not elicited half of the time and fully addressed even less frequently. Rates of identifying the housing issue increased for teams that received audit/feedback reports (46%-60%; p=0.045) and declined for the proxy comparison (61%-42%; p=0.174). Rates of responding to housing needs increased significantly for intervention teams (15%-41%; p=0.004) but not for the comparison team (21%-29%; p=0.663). Social isolation was identified more frequently postintervention (53%) compared with baseline (39%; p=0.041) among the intervention teams but remained unchanged for the comparison team (39% vs 32%; p=0.601). Full exploration of social isolation remained low for both intervention and comparison teams. CONCLUSIONS:Results suggest that physicians may not be consistently screening for or responding to social needs but that receiving feedback on those practices, along with brief targeted education, can improve rates of SDOH screening and response.
PMID: 35623722
ISSN: 2044-5423
CID: 5284022

Implementation and early outcomes of a telehealth visit model to deliver tecovirimat for mpox infection in New York City

Chan, Justin; DiTullio, David J; Pagan Pirallo, Patricia; Foote, Mary; Knutsen, Dorothy; Kottkamp, Angelica Cifuentes; McPherson, Tristan D; Mukherjee, Vikramjit; Pitts, Robert; Wallach, Andrew; Wong, Marcia; Mazo, Dana; Mgbako, Ofole
The 2022 mpox outbreak in New York City posed challenges to rapidly scaling up treatment capacity. We describe a telehealth treatment model launched during this outbreak that facilitated healthcare provider treatment capacity, and was able to adhere to a Centers for Disease Control and Prevention (CDC)-sponsored expanded access investigational new drug (EA-IND) protocol for tecovirimat. Sixty-nine patients were evaluated and prescribed tecovirimat for mpox through telehealth visits at NYC Health + Hospitals/Bellevue and NYU Langone Health from June to August 2022. Thirty-two (46.4%) were previously diagnosed with HIV. Forty-four (63.8%) reported full recovery, with the remainder lost to follow-up. Most patients (n = 60, 87.0%) attended at least one follow-up visit (either in person or through telehealth) after starting treatment. We observed favorable treatment outcomes, with no serious adverse events, hospitalizations, or deaths related to mpox. While equitable access to telehealth remains a limitation that needs to be addressed, this telehealth model enabled a rapid scale-up of tecovirimat prescription during the mpox outbreak, and should be considered as an important tool used to respond to future infectious disease outbreaks.
PMID: 37632124
ISSN: 1758-1109
CID: 5598892

Critical Elements of an Mpox Vaccination Model at the Largest Public Health Hospital System in the United States

Piccolo, Anthony J Lo; Chan, Justin; Cohen, Gabriel M; Mgbako, Ofole; Pitts, Robert A; Postelnicu, Radu; Wallach, Andrew; Mukherjee, Vikramjit
In the spring of 2022, mpox spread to non-endemic countries, including the United States. In New York City (NYC), vaccine demand grew as quickly as case counts. With the leadership of the Regional Emerging Special Pathogens Treatment Center (RESPTC) at NYC Health and Hospitals/Bellevue (NYC H+H)-part of the largest public hospital system in the United States-an innovative vaccination model was established that overcame challenges involving health inequities, inadequate access, and lack of vaccine uptake, to successfully administer JYNNEOS vaccines to over 12,000 patients. Transmission has slowed since its peak in August 2022, which has been attributed to successful vaccination campaigns, infection-induced immunity, and behavioral changes among those at highest risk; however, a Centers for Disease Control and Prevention (CDC) assessment released on 4 April 2023 suggests jurisdictions with low vaccination levels (<35%) remain at risk for an mpox resurgence. Here, we summarize the critical aspects of our mpox vaccination model in NYC, which include integration into routine clinical care, prioritization of health equity, and reutilization of COVID-19 vaccination systems, to provide valuable insights for healthcare institutions as we move into the next stage of this ongoing outbreak.
PMID: 37514954
ISSN: 2076-393x
CID: 5591792

Understanding the Relationship Between Antiviral Prescription Data and COVID-19 Incidence in New York City: A Retrospective Cohort Study

Kaul, Christina M; Cohen, Gabriel M; Silverstein, Matthew; Wallach, Andrew B; Diago-Navarro, Elizabeth; Holzman, Robert S; Foote, Mary K
The coronavirus disease 2019 (COVID-19) pandemic has caused more than 675 million confirmed cases and nearly 7 million deaths worldwide [1]. While testing for COVID-19 was initially centered in health care facilities, with required reporting to health departments, it is increasingly being performed in the home with rapid antigen testing [2]. Most at-home tests are self-interpreted and not reported to a provider or health department, which could lead to delayed reporting or underreporting of cases [3]. As such, there is a strong possibility that reported cases may become a less reliable indicator of transmission over time.
PMID: 37333721
ISSN: 2328-8957
CID: 5518382

Effectiveness of Goal-Directed and Outcome-Based Financial Incentives for Weight Loss in Primary Care Patients With Obesity Living in Socioeconomically Disadvantaged Neighborhoods: A Randomized Clinical Trial

Ladapo, Joseph A; Orstad, Stephanie L; Wali, Soma; Wylie-Rosett, Judith; Tseng, Chi-Hong; Chung, Un Young Rebecca; Cuevas, Miguel A; Hernandez, Christina; Parraga, Susan; Ponce, Robert; Sweat, Victoria; Wittleder, Sandra; Wallach, Andrew B; Shu, Suzanne B; Goldstein, Noah J; Jay, Melanie
IMPORTANCE/UNASSIGNED:Financial incentives for weight management may increase use of evidence-based strategies while addressing obesity-related economic disparities in low-income populations. OBJECTIVE/UNASSIGNED:To examine the effects of 2 financial incentive strategies developed using behavioral economic theory when added to provision of weight management resources. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Three-group, randomized clinical trial conducted from November 2017 to May 2021 at 3 hospital-based clinics in New York City, New York, and Los Angeles, California. A total of 1280 adults with obesity living in low-income neighborhoods were invited to participate, and 668 were enrolled. INTERVENTIONS/UNASSIGNED:Participants were randomly assigned to goal-directed incentives, outcome-based incentives, or a resources-only group. The resources-only group participants were given a 1-year commercial weight-loss program membership, self-monitoring tools (digital scale, food journal, and physical activity monitor), health education, and monthly one-on-one check-in visits. The goal-directed group included resources and linked financial incentives to evidence-based weight-loss behaviors. The outcome-based arm included resources and linked financial incentives to percentage of weight loss. Participants in the incentive groups could earn up to $750. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Proportion of patients achieving 5% or greater weight loss at 6 months. RESULTS/UNASSIGNED:The mean (SD) age of the 668 participants enrolled was 47.7 (12.4) years; 541 (81.0%) were women, 485 (72.6%) were Hispanic, and 99 (14.8%) were Black. The mean (SD) weight at enrollment was 98.96 (20.54) kg, and the mean body mass index (calculated as weight in kilograms divided by height in meters squared) was 37.95 (6.55). At 6 months, the adjusted proportion of patients who lost at least 5% of baseline weight was 22.1% in the resources-only group, 39.0% in the goal-directed group, and 49.1% in the outcome-based incentive group (difference, 10.08 percentage points [95% CI, 1.31-18.85] for outcome based vs goal directed; difference, 27.03 percentage points [95% CI, 18.20-35.86] and 16.95 percentage points [95% CI, 8.18-25.72] for outcome based or goal directed vs resources only, respectively). However, mean percentage of weight loss was similar in the incentive arms. Mean earned incentives was $440.44 in the goal-directed group and $303.56 in the outcome-based group, but incentives did not improve financial well-being. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this randomized clinical trial, outcome-based and goal-directed financial incentives were similarly effective, and both strategies were more effective than providing resources only for clinically significant weight loss in low-income populations with obesity. Future studies should evaluate cost-effectiveness and long-term outcomes. TRIAL REGISTRATION/ Identifier: NCT03157713.
PMID: 36469353
ISSN: 2168-6114
CID: 5378582

Comparison of Primary Care Patients"™ and Unannounced Standardized Patients"™ Perceptions of Care

Altshuler, Lisa; Fisher, Harriet; Wilhite, Jeffrey; Phillips, Zoe; Holmes, Isaac; Greene, Richard E.; Wallach, Andrew B.; Smith, Reina; Hanley, Kathleen; Schwartz, Mark D.; Zabar, Sondra
The objective of this study was to compare unannounced standardized patient (USP) and patient reports of care. Patient satisfaction surveys and USP checklist results collected at an urban, public hospital were compared to identify items included in both surveys. Qualitative commentary was reviewed to better understand USP and patient satisfaction survey data. Analyses included χ2 and Mann-Whitney U test. Patients provided significantly higher ratings on 10 of the 11 items when compared to USPs. USPs may provide a more objective perspective on a clinical encounter than a real patient, reinforcing the notion that real patients skew overly positive or negative.
ISSN: 2374-3735
CID: 5446962

The Role of a Tertiary Level Safety Net Hospital in New York City's 2022 Mpox Outbreak

Lo Piccolo, Anthony J; Wallach, Andrew; McPherson, Tristan D; Mgbako, Ofole; Fagan, Ian; Pitts, Robert A; Klinger, Amanda; Foote, Mary; Garcia, Elizabeth A; Zucker, Jason E; Chan, Justin; Bails, Douglas B; Cohen, Gabriel M; Tennill, Patricia Ann; Wong, Marcia; Mukherjee, Vikramjit
Similar to the early phases of the COVID-19 pandemic, New York City was the national epicenter of the ongoing 2022 mpox (formerly monkeypox) outbreak. Cases quickly began to rise in July 2022, primarily in gay, bisexual, or other men who have sex with men. Tools in the form of a reliable diagnostic test, an effective vaccine, and a viable treatment option have been available from the onset, although logistically complex to roll out. The special pathogens program at NYC Health + Hospitals/Bellevue, the flagship facility for the largest public hospital system in the United States, collaborated with multiple departments within Bellevue, the hospital system, and the NYC Department of Health and Mental Hygiene, to swiftly establish ambulatory testing, immunizations, patient-centered inpatient care, and outpatient therapeutics. With the ongoing mpox outbreak, hospitals and local health departments must prepare a systemwide response to identify and isolate patients and provide high-quality care. Findings from our experience can help guide institutions in developing a multipronged, comprehensive response to the ongoing mpox outbreak.
PMID: 36862506
ISSN: 2326-5108
CID: 5427702

Effectiveness of Goal-Directed and Outcome-Based Financial Incentives for Weight Loss in Primary Care Patients With Obesity Living in Socioeconomically Disadvantaged Neighborhoods: A Randomized Clinical Trial (vol 183, pg 61, 2023) [Correction]

Ladapo, Joseph A.; Orstad, Stephanie L.; Wali, Soma; Wylie-Rosett, Judith; Tseng, Chi-Hong; Chung, Un Young Rebecca; Cuevas, Miguel A.; Hernandez, Christina; Parraga, Susan; Ponce, Robert; Sweat, Victoria; Wittleder, Sandra; Wallach, Andrew B.; Shu, Suzanne B.; Goldstein, Noah J.; Dapkins, Isaac; Jay, Melanie
ISSN: 2168-6106
CID: 5477662

Utilizing Antiviral Prescription Data as a Predictor of Increasing COVID-19 Incidence: A Retrospective Study of Citywide Data

Kaul, Christina; Cohen, Gabriel M; Silverstein, Matthew; Wallach, Andrew B; Diago-Navarro, Elizabeth; Foote, Mary K
ISSN: 2328-8957
CID: 5375712