Faculty Bibliography

BACKGROUND/UNASSIGNED:COVID-19 has caused over 46,000 deaths in New York City, with a disproportional impact on certain communities. As part of the COVID-19 response, the city has directly administered over 6 million COVID-19 tests (in addition to millions of indirectly administered tests not covered in this analysis) at no cost to individuals, resulting in nearly half a million positive results. Given that the prevalence of testing, throughout the pandemic, has tended to be higher in more affluent areas, these tests were targeted to areas with fewer resources. OBJECTIVE/UNASSIGNED:This study aimed to evaluate the impact of New York City's COVID-19 testing program; specifically, we aimed to review its ability to provide equitable testing in economically, geographically, and demographically diverse populations. Of note, in addition to the brick-and-mortar testing sites evaluated herein, this program conducted 2.1 million tests through mobile units to further address testing inequity. METHODS/UNASSIGNED:Testing data were collected from the in-house Microsoft SQL Server Management Studio 18 Clarity database, representing 6,347,533 total tests and 449,721 positive test results. These tests were conducted at 48 hospital system locations. Per capita testing rates by zip code tabulation area (ZCTA) and COVID-19 positivity rates by ZCTA were used as dependent variables in separate regressions. Median income, median age, the percentage of English-speaking individuals, and the percentage of people of color were used as independent demographic variables to analyze testing patterns across several intersecting identities. Negative binomial regressions were run in a Jupyter Notebook using Python. RESULTS/UNASSIGNED:Per capita testing inversely correlated with median income geographically. The overall pseudo r2 value was 0.1101 when comparing hospital system tests by ZCTA against the selected variables. The number of tests significantly increased as median income fell (SE 1.00000155; P<.001). No other variables correlated at a significant level with the number of tests (all P values were >.05). When considering positive test results by ZCTA, the number of positive test results also significantly increased as median income fell (SE 1.57e-6; P<.001) and as the percentage of female residents fell (SE 0.957; P=.001). The number of positive test results by ZCTA rose at a significant level alongside the percentage of English-only speakers (SE 0.271; P=.03). CONCLUSIONS/UNASSIGNED:New York City's COVID-19 testing program was able to improve equity through the provision of no-cost testing, which focused on areas of the city that were disproportionately impacted by COVID-19 and had fewer resources. By detecting higher numbers of positive test results in resource-poor neighborhoods, New York City was able to deploy additional resources, such as those for contact tracing and isolation and quarantine support (eg, free food delivery and free hotel stays), early during the COVID-19 pandemic. Equitable deployment of testing is feasible and should be considered early in future epidemics or pandemics.

CONTEXT/BACKGROUND:Over 200 000 people seeking asylum have arrived in New York City from 2022 to 2024. PROGRAM/METHODS:As the safety net hospital system for our city, New York City (NYC) Health + Hospitals (H + H) has taken the lead in caring for newly arrived asylum seekers. We used electronic medical record data to gain early insights into utilization and needs among these patients. IMPLEMENTATION/METHODS:We developed a hybrid definition to identify patients who are asylum seekers and examined their demographics, insurance, utilization, primary billing diagnoses, and immunizations from the Epic EMR. We included data on other patients as a point of comparison and analyzed data separately for adult and pediatric patients. EVALUATION/RESULTS:In 2023, 15 233 or 1.4% of H + H patients were asylum seekers. Asylum seekers had fewer visits than other patients in 2023, and utilization was particularly driven by pregnancy and childbirth. Children seeking asylum were engaged in primary care at high rates. Documented childhood vaccinations were higher among asylum-seeking children engaged in primary care compared to those who were not. The majority of adults and children were insured. Adult primary care engagement was low, as were visits for those seeking care for behavioral health issues. DISCUSSION/CONCLUSIONS:For adult asylum seekers, pregnancy and childbirth are key needs for adults. Increasing vaccination rates among children is critical and promoting engagement in primary care is a promising way to do so. Coordinated efforts are required to meet the varied needs of migrant arrivals, and safety net hospitals can play a key role in addressing their health care needs.

During infectious disease epidemics, accurate diagnostic testing is key to rapidly identify and treat cases, and mitigate transmission. When a novel pathogen is involved, building testing capacity and scaling testing services at the local level can present major challenges to healthcare systems, public health agencies, and laboratories. This mixed methods study examined lessons learned from the scale-up of SARS-CoV-2 testing services in New York City (NYC), as a core part of NYC's Test & Trace program. Using quantitative and geospatial analyses, the authors assessed program success at maximizing reach, equity, and timeliness of SARS-CoV-2 diagnostic testing services across NYC neighborhoods. Qualitative analysis of key informant interviews elucidated key decisions, facilitators, and barriers involved in the scale-up of SARS-CoV-2 testing services. A major early facilitator was the ability to establish working relationships with private sector vendors and contractors to rapidly procure and manufacture necessary supplies locally. NYC residents were, on average, less than 25 min away from free SARS-CoV-2 diagnostic testing services by public transport, and services were successfully directed to most neighborhoods with the highest transmission rates, with only one notable exception. A key feature was to direct mobile testing vans and rapid antigen testing services to areas based on real-time neighborhood transmission data. Municipal leaders should prioritize fortifying supply chains, establish cross-sectoral partnerships to support and extend testing services, plan for continuous testing and validation of assays, ensure open communication feedback loops with CBO partners, and maintain infrastructure to support mobile services during infectious disease emergencies.

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.

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.

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.

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.

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.

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/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03157713.

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.