Faculty Bibliography

BACKGROUND & AIMS/OBJECTIVE:The septin 9 blood test is indicated for colorectal cancer screening in individuals who decline first-line tests, but participation in this context is unclear. We conducted a randomized controlled trial to compare reoffering colonoscopy and fecal immunochemical test (FIT) alone versus also offering the blood test among individuals who declined colonoscopy and FIT. METHODS:Screen-eligible Veterans aged 50-75 years who declined colonoscopy and FIT within the previous 6 months were randomized to letter and telephone outreach to reoffer screening with colonoscopy/FIT only (control), or additionally offering the blood test as a second-line option (intervention). The primary outcome was completion of any screening test within 6 months. The secondary outcome was completion of a full screening strategy within 6 months, including colonoscopy for those with a positive noninvasive test. RESULTS:Of 359 participants who completed follow-up, 9.6% in the control group and 17.1% in the intervention group completed any screening (7.5% difference; P = .035). Uptake of colonoscopy and FIT was similar in the 2 groups. The full screening strategy was completed in 9.0% and 14.9% in the control and intervention groups, respectively (5.9% difference; P = .084). CONCLUSIONS:Among individuals who previously declined colonoscopy and FIT, offering a blood test as a secondary option increased screening by 7.5% without decreasing uptake of first-line screening options. However, completion of a full screening strategy did not increase. These findings indicate that a blood test is a promising method to improve colorectal cancer screening, but obtaining a timely colonoscopy after a positive noninvasive test remains a challenge (ClincialTrials.gov number, NCT03598166).

The care continuum represents a longitudinal, patient-centered view of clinical care within an integrated health system, providing patients consistency in discrete healthcare encounters, while accounting for their medical needs and personal context. Failure of effective care coordination occurs when patient transitions between care settings are disjointed or fragmented. These failures account for a substantial portion of the waste in the United States healthcare system. In this article, we propose target areas for care coordination interventions and describe potential cost savings. We focus on maximizing the appropriate utilization of the Emergency Department by promoting urgent cares, primary care providers, community healthcare workers, targeted interventions for high utilizers, observation units, and hospital-at-home programs. We describe strategies for working across the care continuum to build multimodal post-discharge care programs and partnerships, such as nurse discharge navigators, early clinician follow-up, specialty post-acute care clinic visits, community partnerships, and collaborations with post-acute care settings. To help drive improvement across other hospital systems, we propose a tangible blueprint for interventions to address failures of care coordination across the care continuum.

Discrepancy between computed tomography (CT) and transthoracic echocardiography (TTE) regarding pericardial effusion (PEff) size is common, but there is limited data regarding the correlation between these 2 imaging methods. The aim of this study is to examine the real-world concordance of observed PEff size between CT and TTE. We performed a retrospective analysis of all imaging reports available from 2013 to 2019 and identified patients with a PEff who underwent both a chest CT and TTE within a 24-hour period. We evaluated the agreement between CT and TTE in assessing PEff size. Of 1,118 patients included in the study, mean age was 66 (±17 years) and 54% were female. The median time interval between the 2 studies was 9.4 hours (interquartile range 3.5 to 16.6). Patients within a half-grade or full-grade of agreement were 71.9% and 97.2%, respectively. The mean difference in grade of agreement (TTE minus CT) between the 2 imaging methods was -0.1 (±0.6, p <0.0001). CT was more likely to report a higher grade (i.e. larger PEff size) when compared with TTE (261 patients vs 157 patients, p <0.001). The weighted kappa was 0.73 (95% confidence interval 0.69 to 0.76). After excluding patients with trace/no effusion, 42.3% and 94.1% of patients' studies were within a half-grade or full-grade of agreement, respectively. Of the 18 patients who had large discrepancies, 9 patients had loculated effusions, 2 patients had large pleural effusions, and 6 patients had suboptimal TTEs images. In conclusion, TTE and CT showed relatively strong agreement in estimation of PEff size, with CT sizes larger than TTE, on average. Large discrepancies in size may be related to reduced image quality, large pleural effusions, and loculated PEff.

BACKGROUND/OBJECTIVES:Obesity and other predictors of type 2 diabetes disproportionally affect Hispanic and Black children in the US compared to non-Hispanic White (NHW) children. Yet, the prevalence of prediabetes in children remains unestablished, and guidelines for screening young children are lacking. This study examined the relationships between demographic factors and prediabetes in vulnerable youth in central Texas. SUBJECTS/METHODS:This is a cross-sectional analysis of baseline data from 976 3rd-5th graders (7-12 years) who participated in TX Sprouts, a school-based gardening, nutrition, and cooking trial in 16 elementary schools serving mainly children from minority backgrounds and lower-income households. Measures collected included age, sex, ethnicity, free/reduced-priced school lunch (FRL) status, parent educational attainment (questionnaires), BMI from height (stadiometer) and weight (TANITA scale), and prediabetes status from fasting plasma glucose (FPG) and HbA1c. Regressions examined cross-sectional associations between demographics and FPG, HbA1c, and prediabetes. RESULTS:Children were 47% male, 67% Hispanic, and 10% Black, with a mean age of 9.3 years; 71% received FRL, 50% had overweight/obesity, and 26% had prediabetes. Prediabetes rates were 2.8 and 4.8 times higher in Hispanic and Black children compared to NHW children, respectively (p ≤ 0.001), and 1.5 times higher in children with obesity versus normal BMI (p = 0.02). Children of parents with only an 8th-grade education, some high school education, or a high school degree had 3.1, 2.7, and 2.2 times higher odds of having prediabetes compared to children of college graduates, respectively (p ≤ 0.004). Analyses with FPG and HbA1c yielded similar results. CONCLUSION:These findings suggest a potential need for earlier screening, more comprehensive testing guidelines, and prevention programs tailored toward minority children, children with obesity, and children of parents with low educational attainment. Future research should explore this finding in a larger, nationally representative sample.

BACKGROUND:Hospital acquired anemia is common during admission and can result in increased transfusion and length of stay. Recumbent posture is known to lead to lower hemoglobin measurements. We tested to see if an initiative promoting evening lab draws would lead to higher hemoglobin measurements due to more time in upright posture during the day and evening. METHODS:We included patients hospitalized on 2 medical units, beginning March 26, 2020 and discharged prior to January 25, 2021. On one of the units, we implemented an initiative to have routine laboratory draws in the evening rather than the morning starting on August 26, 2020. There were 1217 patients on the control unit and 1265 on the intervention unit during the entire study period. First we used a linear mixed-effects model to see if timing of blood draw was associated with hemoglobin level in the pre-intervention period. We then compared levels of hemoglobin before and after the intervention using a difference-in-difference analysis. RESULTS:In the pre-intervention period, evening blood draws were associated with higher hemoglobin compared to morning (0.28; 95% CI, 0.22-0.35). Evening blood draws increased with the intervention (10.3% vs 47.9%, P > 0.001). However, the intervention floor was not associated with hemoglobin levels in difference-in-difference analysis (coefficient of -0.15; 95% CI, -0.51-0.21). CONCLUSIONS:While evening blood draws were associated with higher hemoglobin levels, an intervention that successfully changed timing of routine labs to the evening did not lead to an increase in hemoglobin levels.

OBJECTIVES:Poor medication adherence in low-income and middle-income countries is a major cause of suboptimal hypertension and diabetes control. We aimed to identify key factors associated with medication adherence in western Kenya, with a focus on cost-related and economic wealth factors. SETTING:We conducted a cross-sectional analysis of baseline data of participants enrolled in the Bridging Income Generation with Group Integrated Care study in western Kenya. PARTICIPANTS:All participants were ≥35 years old with either diabetes or hypertension who had been prescribed medications in the past 3 months. PRIMARY AND SECONDARY OUTCOME MEASURES:Baseline data included sociodemographic characteristics, wealth and economic status and medication adherence information. Predictors of medication adherence were separated into the five WHO dimensions of medication adherence: condition-related factors (comorbidities), patient-related factors (psychological factors, alcohol use), therapy-related factors (number of prescription medications), economic-related factors (monthly income, cost of transportation, monthly cost of medications) and health system-related factors (health insurance, time to travel to the health facility). A multivariable analysis, controlling for age and sex, was conducted to determine drivers of suboptimal medication adherence in each overarching category. RESULTS:The analysis included 1496 participants (73.7% women) with a mean age of 60 years (range 35-97). The majority of participants had hypertension (69.2%), 8.8% had diabetes and 22.1% had both hypertension and diabetes. Suboptimal medication adherence was reported by 71.2% of participants. Economic factors were associated with medication adherence. In multivariable analysis that investigated specific subtypes of costs, transportation costs were found to be associated with worse medication adherence. In contrast, we found no evidence of association between monthly medication costs and medication adherence. CONCLUSION:Suboptimal medication adherence is highly prevalent in Kenya, and primary-associated factors include costs, particularly indirect costs of transportation. Addressing all economic factors associated with medication adherence will be important to improve outcomes for non-communicable diseases. TRIAL REGISTRATION NUMBER:NCT02501746.

PROBLEM:Reviewing residency application narrative components is time intensive and has contributed to nearly half of applications not receiving holistic review. The authors developed a natural language processing (NLP)-based tool to automate review of applicants' narrative experience entries and predict interview invitation. APPROACH:Experience entries (n = 188,500) were extracted from 6,403 residency applications across 3 application cycles (2017-2019) at 1 internal medicine program, combined at the applicant level, and paired with the interview invitation decision (n = 1,224 invitations). NLP identified important words (or word pairs) with term frequency-inverse document frequency, which were used to predict interview invitation using logistic regression with L1 regularization. Terms remaining in the model were analyzed thematically. Logistic regression models were also built using structured application data and a combination of NLP and structured data. Model performance was evaluated on never-before-seen data using area under the receiver operating characteristic and precision-recall curves (AUROC, AUPRC). OUTCOMES:The NLP model had an AUROC of 0.80 (vs chance decision of 0.50) and AUPRC of 0.49 (vs chance decision of 0.19), showing moderate predictive strength. Phrases indicating active leadership, research, or work in social justice and health disparities were associated with interview invitation. The model's detection of these key selection factors demonstrated face validity. Adding structured data to the model significantly improved prediction (AUROC 0.92, AUPRC 0.73), as expected given reliance on such metrics for interview invitation. NEXT STEPS:This model represents a first step in using NLP-based artificial intelligence tools to promote holistic residency application review. The authors are assessing the practical utility of using this model to identify applicants screened out using traditional metrics. Generalizability must be determined through model retraining and evaluation at other programs. Work is ongoing to thwart model "gaming," improve prediction, and remove unwanted biases introduced during model training.

BACKGROUND:Language concordance between health care practitioners and patients have recently been shown to lower the risk of adverse health events. Continuity of care also been shown to have the same impact. OBJECTIVE:The purpose of this paper is to examine the relative effectiveness of both continuity of care and language concordance as alternative or complementary interventions to improve health outcomes of people with limited English proficiency. DESIGN:A multivariable logistic regression model using rehospitalization as the dependent variable was built. The variable of interest was created to compare language concordance and continuity of care. PARTICIPANTS:The final sample included 22,103 patients from the New York City area between 2010 and 2015 who were non-English-speaking and admitted to their home health site following hospital discharge. MEASURES:The odds ratio (OR) average marginal effect (AME) of each included variable was calculated for model analysis. RESULTS:When compared with low continuity of care and high language concordance, high continuity of care and high language concordance significantly decreased readmissions (OR=0.71, 95% CI: 0.62-0.80, P<0.001, AME=-4.95%), along with high continuity of care and low language concordance (OR=0.80, 95% CI: 0.74-0.86, P<0.001, AME=-3.26%). Low continuity of care and high language concordance did not significantly impact readmissions (OR=1.04, 95% CI: 0.86-1.26, P=0.672, AME=0.64%). CONCLUSION:In the US home health system, enhancing continuity of care for those with language barriers may be helpful to address disparities and reduce hospital readmission rates.

OBJECTIVES/OBJECTIVE:The US Preventive Services Task Force lowered the recommended starting age for colorectal cancer (CRC) screening in average-risk adults from 50 to 45 years. We aimed to estimate the global burden and trends of colorectal cancer in adults aged 20-49 years (early-onset CRC). METHODS:This is an analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019). The GBD 2019 estimation methods were used to describe the incidence, mortality, and disability-adjusted life years (DALYs) of early CRC from 1990 to 2019. Data from 204 countries and geographic areas were available. RESULTS:The global incidence rate of early-onset CRC increased from 4.2/100 000 to 6.7/100 000 from 1990 to 2019. Mortality and DALYs of early-onset CRC also increased. The CRC incidence rate increased faster in younger adults (1.6%) than in adults aged 50-74 years (0.6%) as measured by the annual percentage change. The increase in early-onset CRC incidence was consistently observed in all five socio-demographic index (SDI) regions and 190 out of 204 countries and territories. Middle and high-middle SDI regions had faster annual increases in early-onset CRC, which warrants further attention. CONCLUSIONS:The global incidence, mortality, and DALYs of early-onset CRC increased from 1990 to 2019. The increase in early-onset CRC incidence was prevalent worldwide. Several countries were found to have higher incidence rates than the United States or fast increase in early-onset CRC, which warrants further attention.