Faculty Bibliography

Telehealth services may improve access to care, but there are concerns around whether availability of telehealth may increase care utilization. We assessed whether usage of telehealth was associated with differential primary care utilization at a large, urban public healthcare system. Using electronic health record data from 23 primary care clinics, we categorized patients as telehealth users and non-users. Then, we compared the number of visits per patient between groups using Welch's t-tests while stratifying by comorbidity count. We used multivariable Poisson regression to test for associations between telehealth usage and visit count while controlling for other demographic factors. Compared with telehealth non-users, telehealth users had approximately 1 more primary care visit per patient over the year regardless of comorbidity count or other patient characteristics. Availability of telehealth services may be associated with increased primary care utilization in a safety-net setting, though further research on outcomes, costs of care, and patient and clinician experiences is needed to better inform decisions regarding provision and reimbursement of telehealth services.

An observational cohort study was conducted with data from the Observational Pharmaco-Epidemiology Research & Analysis (OPERA) cohort to investigate weight gain among virologically suppressed people with HIV (PWH) switching to regimens containing tenofovir alafenamide/emtricitabine/ (TAF/FTC). Virologically suppressed, ART-experienced PWH switching to TAF/FTC with either darunavir/cobicistat (DRV/c), elvitegravir (EVG)/c, dolutegravir (DTG) or bictegravir (BIC) were selected. Cox proportional hazards models were used to assess the risk of excessive weight gain (i.e. ≥5% gain within 28 weeks or ≥10% within 54 weeks), by regimen. A linear mixed effects model with random intercept and restricted cubic splines on time was used to assess continuous changes in weight. Confounding was controlled for with both inverse probability of treatment weighting and traditional covariate adjustment. Among 5,536 PWH, 18% gained ≥5% of their weight within 28 weeks, and 9% gained ≥10% within 54 weeks. There were no differences in the risk of excessive weight gain by regimen, although there was a non-statistically significant 20% increase in the risk of gaining ≥10% within 54 weeks with all regimens compared to DRV/c. Throughout follow-up, the mean predicted weight remained fairly constant, with no notable differentiation between regimens. Expected weight gains ranged from +0.2 kg to +0.3 kg at 6 months and from +0.5 kg to +0.6 kg at 24 months. In conclusion, in this study of virologically suppressed, ART-experienced PWH switching to regimens containing TAF/FTC and either DRV/c, EVG/c, DTG or BIC, up to 18% experienced excessive levels of weight gain. However, no statistically significant difference was observed across regimens.

Introduction:The known markers of insulin resistance in obese children are well studied. However, they require serial measurements and complicated calculations. The objective is to study IGFBP-1 and its relation with other known risk measures. Materials and Methods:The study included 98 New York City school students of diverse ethnic/racial backgrounds (57 males and 41 females), 11-15 years of age. Subjects were enrolled in a cross-sectional study, and anthropometric measures were collected. They underwent fasting intravenous glucose tolerance tests (IVGTT), and glucose, insulin, lipids, IGFBP-1, adiponectin and inflammatory markers were collected. Results:The subjects were stratified into 3 groups based upon the BMI Z-score. Out of all the subjects, 65.3% were in the group with a BMI Z-score <1 SDS, 16.3% subjects were in the group with a BMI Z-score of 1 to 2 SDS, and 18.4% of the subjects were in the group with a BMI Z-score of more than 2 SDS. The group with a BMI Z-score of more than 2 SDS had increased waist circumference (WC), body fat, increased fasting insulin, and triglycerides (TG). This group had decreased levels of adiponectin and HDL and low IGFBP-1 as compared to the group with BMI <1 SDS. The group with a BMI Z-score of 1 to 2 SDS had a decreased level of IGFBP-1 as compared to the group with a BMI Z-score less than 1 SDS. IGFBP-1 inversely correlated with age, WC, BMI, body fat, TG, and insulin levels. IGFBP-1 positively correlated with adiponectin and HDL levels. Conclusion:IGFBP-1 in children can identify the presence of insulin resistance in the group with BMI 1 to 2 SDS, even before the known markers of insulin resistance such as elevated triglycerides and even before decreased HDL and adiponectin levels are identified.

The COVID-19 pandemic drove a rapid transition to virtual care experiences for graduate medical trainees. Core training competencies have expanded to incorporate virtual contexts, however there is limited knowledge of the optimal design of virtual care training tools for learners. In this study, we describe the application of a Design Thinking approach to the identification and co-design of novel training tools to support residents and precepting attending physicians in virtual ambulatory care practice. We applied the model of "Empathize, Define, Ideate, Prototype, and Test" via a mixed methods approach to (1) explore the needs, preferences, and concerns of Internal Medicine residents and outpatient precepting attendings regarding virtual ambulatory care training environments, and (2) evaluate, prototype, and test potential training tools. Eleven residents and eight attending physicians participated. Identified learner needs and problem areas included: improving virtual visit technical skills; acquiring virtual communication skills; adapting to the loss of shared in-person learning space and optimizing virtual learning environments; remediating non-virtual procedural competencies; and educating on new documentation requirements. Key solution areas included: virtual precepting support tools; digital information and education dissemination tools; and strategies for management of technical issues. Several prototypes were proposed, with a single tool (a virtual preceptor tip sheet) deployed in clinical practice. Residents found the workshop program improved their understanding of Design Thinking and its relevance to healthcare. Ultimately, Design Thinking can be deployed to engage medical trainees and precepting attendings in the effective development of novel educational tools for the virtual care learning environment.

BACKGROUND:The need to engage adults, age 65 and older, in clinical trials of conditions typical in older populations, (e.g. hypertension, diabetes mellitus, Alzheimer's disease and related dementia) is exponentially increasing. Older adults have been markedly underrepresented in clinical trials, often exacerbated by exclusionary study criteria as well as functional dependencies that preclude participation. Such dependencies may further exacerbate communication challenges. Consequently, the evidence of what works in subject recruitment is less generalizable to older populations, even more so for those from racial and ethnic minority and low-income communities. METHODS:To support capacity of research staff, we developed a virtual, three station simulation (Group Objective Structured Clinical Experience-GOSCE) to teach research staff communication skills. This 2-h course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs) and faculty observer who provided immediate feedback; and debrief to highlight best practices. Each learner had opportunities for active learning and observational learning. Learners completed a retrospective pre-post survey about the experience. SP completed an 11-item communication checklist evaluating the learner on a series of established behaviorally anchored communication skills (29). RESULTS:In the research staff survey, 92% reported the overall activity taught them something new; 98% reported it provided valuable feedback; 100% said they would like to participate again. In the SP evaluation there was significant variation: the percent well-done of items by case ranged from 25-85%. CONCLUSIONS:Results from this pilot suggest that GOSCEs are a (1) acceptable; (2) low cost; and (3) differentiating mechanism for training and assessing research staff in communication skills and structural competency necessary for participant research recruitment.

BACKGROUND:Hospitalization can be hazardous for older people, but most hospitals in Europe are not prepared to meet the unique needs of older adult inpatients. Adaptations of the physical environment, care processes, and staff knowledge and skills in geriatric care are essential to improve the quality of care for older people. An assessment of baseline organizational approaches to older adult care is an important first step toward recognizing the challenges organizations face when delivering acute care services to older adults and attempting to improve them. The Geriatric Institutional Assessment Profile could be a promising tool for this endeavor. OBJECTIVES/OBJECTIVE:To describe a systematic process implemented across seven countries and languages that sought to develop valid and culturally-appropriate translations of the Geriatric Institutional Assessment Profile. DESIGN/METHODS:Cross-cultural instrument translation and content validation study. SETTING AND PARTICIPANTS/METHODS:Expert review panels comprised of 68 practicing nurses from seven European or EU associated countries (Austria (German), Belgium (Dutch), Denmark (Danish), Israel (Hebrew), Poland (Polish), Switzerland (German, French), and Turkey (Turkish)) evaluated cross-cultural relevance, including translation, of the Geriatric Institutional Assessment Profile. METHOD/METHODS:A systematic approach to translating and validating a cross-cultural survey instrument, including back-to-back translation, adaptation, and evaluation of content validity using content validity indexing (CVI) techniques for each country and language, assessing translation and relevance content validity separately. The item, subscale and domain content validity index scores were calculated and adjusted for chance agreement among raters for all parts of the Geriatric Institutional Assessment Profile: the four subscales of geriatric care environment, the general knowledge about older adults subscale, and the clinical geriatric knowledge subscale. Consensus discussions among the raters then finalized translations. RESULTS:CVI scores for relevance and translation were all in the "good" to "excellent" range. The geriatric care environment scale's CVI scores were 0.84 to 0.94 for relevance and 0.82 to 0.98 for translation. The clinical geriatric knowledge subscale's CVI scores were 0.83 to 0.97 for relevance and 0.94 to 0.98 for translation. The general knowledge about older adults subscale received high translation agreement (0.93 to 0.99) but slightly lower scores for relevance, ranging from 0.46 to 0.94. CONCLUSION/CONCLUSIONS:Study results provided preliminary evidence of the applicability and validity of a multi-factor measure of age-friendly care in diverse health care systems, in German, Dutch, Danish, Hebrew, Polish, French, and Turkish languages.