Faculty Bibliography

IMPORTANCE/UNASSIGNED:Syringe services programs (SSPs) are evidence-based interventions that reduce bloodborne infections and injection-related harms among people who inject drugs, yet access remains limited and geographically uneven across the US. OBJECTIVE/UNASSIGNED:To quantify the travel time, distance, and cost required to reach the nearest SSP from population-weighted census tracts nationwide and to examine differences by urbanicity, state, and SSP legality. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional geospatial study linked all known SSP locations as of August 2024 to the population-weighted centroids of census tracts in the 50 US states and the District of Columbia. Analyses were conducted between December 2024 and February 2026. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Population-weighted mean and median driving time, distance, and cost to access the nearest SSP, stratified by National Center for Health Statistics urban-rural county category and SSP legal status. Costs were estimated using 2024 Internal Revenue Service (IRS) medical mileage deduction rates and 2022 state-specific gasoline prices. RESULTS/UNASSIGNED:In 1338 SSPs across 83 780 census tracts, the population-weighted mean 1-way driving time to the nearest SSP was 46.1 minutes (95% CI, 45.7-46.5 minutes) and the median was 23.3 minutes (IQR, 12.2-58.5 minutes). Altogether, 23.1% of the population lived more than 60 minutes from an SSP and 12.6% lived over 120 minutes away. The mean 1-way driving distance was 41.8 miles (95% CI, 41.3-42.2 miles). The mean 1-way driving cost was $8.77 (95% CI, $8.68-$8.86) using the 2024 IRS mileage rate and $6.91 (95% CI, $6.84-$6.98) using state mean gasoline prices in 2022. In states where SSPs were legal, mean driving time was 30.1 minutes (95% CI, 29.8-30.4 minutes) and mean cost by IRS mileage rates was $4.94 (IQR, $4.88-$5.00), compared with 110.7 minutes (95% CI, 109.6-111.8 minutes) and $24.19 (IQR, $23.92-$24.46) in states where SSPs were illegal. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This cross-sectional study of travel burden to SSPs found substantial geographic and financial barriers to accessing SSPs across the US, particularly in nonmetropolitan areas. Targeting new SSPs to areas with the greatest travel burden could improve utilization and reduce drug-related morbidity.

BACKGROUND:The need for evidence to inform interventions to prevent mass shootings (MS) in the USA has never been greater. METHODS:Data were abstracted from the Gun Violence Archive, an independent online database of US gun violence incidents. Descriptive analyses consisted of individual-level epidemiology of victims, suspected shooters and weapons involved, trends and county-level choropleths of population-level incident and fatality rates. Counties with and without state-level assault weapons bans (AWB) were compared, and we conducted a multivariable negative binomial model controlling for county-level social fragmentation, median age and number of gun-related homicides for the association of state-level AWB with aggregate county MS fatalities. RESULTS:73.3% (95% CI 72.1 to 74.5) of victims and 97.2% (95% CI 96.3 to 98.3) of shooters were males. When compared with incidents involving weapons labelled 'handguns', those involving a weapon labelled AR-15 or AK-47 were six times more likely to be associated with case-fatality rates greater than the median (OR=6.1, 95% CI 2.3 to 15.8, p<0.00001). MS incidents were significantly more likely to occur on weekends and during summer months. US counties in states without AWB had consistently higher MS rates throughout the study period (p<0.0001), and the slope for increase over time was significantly lower in counties with AWB (beta=-0.11, p=0.01). In a multivariable negative binomial model, counties in states with AWB were associated with a 41% lower incidence of MS fatalities (OR=0.58, 95% CI 0.37 to 0.97, p=0.02). CONCLUSIONS:Counties located in states with AWB were associated with fewer MS fatalities between 2014 and 2022.

OBJECTIVE:Health systems have finite capacity. During crises, policymakers may explicitly reallocate health system resources, or capacity limitations may necessitate implicit resource reallocation. This study modelled timing and intensity of pre-vaccination health system resource reallocation policies to predict excess mortality during the COVID-19 pandemic. METHODS:This longitudinal panel analysis included 85 countries (752 country-months, January 2020-January 2021). The predictor was resource reallocation scope, scale (summarized as intensity, 0-100), and timing. The outcome was all-cause excess mortality (percentage deaths greater than historical average/month). Covariates included COVID-19 incidence and health system parameters. RESULTS:= -0.58, 95%CI -0.93-0.23: e.g., 42,010 fewer deaths per unit increased resource reallocation, March 2020, all study countries). Effects were magnified in older populations. Health system capacity and preparedness were associated with lower mortality. CONCLUSIONS:In the pre-vaccination COVID-19 pandemic, preemptive health system resource reallocation was associated with lower mortality, whereas simultaneous resource reallocation was associated with greater mortality. This longitudinal multinational study indicates that readiness, capacity building, and proactive resource reallocation improve crisis response.

INTRODUCTION/BACKGROUND:To help address the continuing epidemic of firearm-related trauma in the United States (US), we conducted a detailed analysis of recent trauma center discharge data and compared firearm-related injuries to mechanisms such as falls, pedestrian injuries, and motor vehicle crashes. METHODS:We combined Trauma Quality Improvement Program (TQIP) data for 2011 to 2022 and analyzed variables for patient demographics, injury mechanisms, disposition, and hospital characteristics over time. Analyses consisted of descriptive statistics, bar plots, time series plots, and comparative tables. RESULTS:There were 3,597,688 US trauma hospital discharges in the TQIP data set for 2011 to 2022 of which 307,062 (8.4%) involved firearms-a higher proportion than those involving pedestrian injuries (3.8%), pedal cycles (2.0%), or motorcycles (6.2%). The case-fatality rate of inpatient hospital deaths for firearm injuries was 8.8%, surpassed only by that of pedestrian injuries (9.9%). Firearms accounted for the youngest patient population over the 12-year study period for the six injury mechanisms analyzed. Over time, firearm-related assaults increased from 75.7% of all firearm injuries in 2011 to 88.6% in 2020. Most, if not all, of this increase appeared to occur in the post-2014 time period. CONCLUSIONS:Better defining national injury trends allows for targeted injury prevention efforts, prioritized research endeavors, and optimized resource allocation.

OBJECTIVES/OBJECTIVE:We aimed to describe pediatric firearm incidents treated at 6 New York City public trauma hospitals over a 5-year period. METHODS:We conducted a retrospective, multi-institutional, descriptive study of firearm-related incidents among patients below 18 years treated at 6 municipal trauma centers in New York City from July 1, 2016, to June 30, 2021. We used trauma registries, electronic health records (EHR), and geospatial analysis, supplemented with Gun Violence Archive (GVA) and New York Police Department data to characterize and map incidents, excluding missing data. RESULTS:Of n=176 patients, data on injury intent and circumstances were unavailable for 13% (n=22) and 22% (n=38), respectively. Most were male (n=161, 91%), Black (n=133, 76%), and adolescents (median 16 y, IQR: 15, 17) who sustained nonfatal (n=166, 94%) assaults (n=151, 98%). Limited available data suggests that identified assailants were unknown to the unintentional victims of community violence. Incidents largely occurred on weekdays (n=133, 76%); between 15:00 and 20:59 (n=72, 42%); and outside a residential home (n=149, 93%), including sidewalk/street (n=85, 53%) and playground/park/basketball court (n=25, 16%). The most common circumstances were running/jogging/walking outside (n=54, 39%), altercation involvement (n=32, 23%), and drive-by (n=27, 20%). Fifty-four percent (n=72) of incidents occurred within 0.2 miles of public housing in 3 primary geospatial clusters. GVA and New York Police Department databases suggest between 39% and 46% capture of relevant incidents. CONCLUSIONS:Regional gun violence data suffers from a lack of standardization and missingness across sources. Nonetheless, triangulating available data from trauma registries, EHR, GVA, and geospatial analysis, we found that most pediatric patients were Black, adolescent, unintended victims who sustained assaults on weekdays, outside a home, and within 0.2 miles of public housing in 3 primary clusters. These results may inform hospital data surveillance and ongoing evidence-based prevention strategies.

IMPORTANCE/UNASSIGNED:Hurricanes are associated with increased cardiovascular disease (CVD) risk, yet little is known about whether these risks extend into the long term and for how long. OBJECTIVE/UNASSIGNED:To examine the association between hurricane-related flooding and CVD risk up to 5 years after landfall. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cohort study included a 20% national sample of continuously enrolled Medicare fee-for-service beneficiaries from New Jersey, New York City, and Connecticut from January 1, 2010, to December 31, 2017. Data were analyzed from December 14, 2023, to June 20, 2025. EXPOSURE/UNASSIGNED:Residence in zip code tabulation areas (ZCTAs) impacted by flooding from Hurricane Sandy throughout the study period. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the rate of ZCTA-level adjusted CVD events (including myocardial infarction [MI], heart failure [HF], and stroke), defined per 1000 beneficiary-years, with associated 95% bayesian credible intervals (bCrIs). Secondary outcomes included the rate of events for each CVD subtype (MI, HF, and stroke). RESULTS/UNASSIGNED:In the matched cohort, 121 395 beneficiaries resided in 690 ZCTAs, of which 441 (63.9%) flooded. In nonflooded vs flooded ZCTAs, mean (SD) age (74.2 [1.4] vs 74.1 [1.2] years; P = .16), proportion of female beneficiaries (61.4% [8.4%] vs 61.3% [6.6%]; P = .89), and proportion of White beneficiaries (74.3% [28.7%] vs 76.7% [26.8%]; P = .27) were similar, but ZCTA-level median income ($81 168 [$33 410] vs $69 650 [$27 594]; P < .001) and median National Area Deprivation Index rank (17.1 [IQR, 10.2-27.6] vs 21.0 [IQR, 10.9-32.5]; P = .02) differed; prevalence of CVD and CVD subtypes was similar at baseline. Flooding was associated with an increase in adjusted 5-year CVD risk post landfall (relative risk, 1.05; 95% bCrI, 1.01-1.08) and HF rates overall (relative risk, 1.03; 95% bCrI, 1.00-1.08). No significant difference was found in rates of MI or stroke in adjusted analyses. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cohort study of Medicare fee-for-service beneficiaries, hurricane-related flooding was associated with increases in CVD event rates as long as 5 years after landfall and increased HF rates in New Jersey. These findings highlight the importance of place-based vulnerability from hurricane exposure to mitigate longer-term CVD risk and the need to consider long-term outcomes in hurricane mitigation efforts.

INTRODUCTION/BACKGROUND:Delayed Emergency Medical Services (EMS) response and transport (time from injury occurrence to hospital arrival) are associated with increased injury mortality. Inequities in accessing EMS care for injured patients are not well characterized. We sought to evaluate the association between the area deprivation index (ADI), a measure of geographic socioeconomic disadvantage, and timely access to EMS care within the United States. METHODS:The Homeland Infrastructure Foundation Level Data open-source database from the National Geospatial Intelligence Agency was used to evaluate the location of EMS stations across the United States using longitude and latitude coordinates. The ADI was obtained from Neighborhood Atlas at the census block group level. An ambulance desert (AD) was defined as populated census block groups with a geographic center outside of a 25-minute ambulance service area. The total population (urban and rural) located within an AD and outside an AD (non-ambulance desert [NAD]) and the ADI index distribution within those areas were calculated with their statistical significance derived from χ2 testing. Spearman correlations between the number of EMS stations available within 25-minutes service areas and ADI were calculated, and statistical significance was derived after accounting for spatial autocorrelation. RESULTS:A total of 42,472 ground EMS stations were identified. Of the 333,036,755 people (current US population), 2.6% are located within an AD. When stratified by type of population, 0.3% of people within urban populations and 8.9% of people within rural populations were located within an AD (p < 0.01). When compared with NADs, ADs were more likely to have a higher ADI (ADIAD, 53.13; ADINAD, 50.41; p < 0.01). The number of EMS stations available per capita was negatively correlated with ADI (rs = -0.25, p < 0.01), indicating that people living in more disadvantaged neighborhoods are likely to have fewer EMS stations available. CONCLUSION/CONCLUSIONS:Ambulance deserts are more likely to affect rural versus urban populations and are associated with higher ADIs. The impact of inequities in access to EMS care on outcomes deserves further study. LEVEL OF EVIDENCE/METHODS:Prognostic and Epidemiological; Level III.

BACKGROUND:Unmet structural and social needs create barriers to breast cancer screening and treatment. The impact of the intersection of these barriers on screening participation and timeliness of breast cancer care remains poorly understood. METHODS:People identifying as women participating in a breast cancer navigation program for screening or treatment were included. Patient navigators administered survey questions that addressed potential barriers to care access using the Health Leads Screening Toolkit. Odds ratios were calculated for unadjusted bivariate associations, and Cox proportional hazards were used to examine the relationship between barriers and time to treatment. RESULTS:A total of 2804 women (mean age, 53 years) enrolled in navigation for screening or cancer treatment participated in the survey about barriers to care. Of those, 435 (16%) reported unstable housing, 610 (23%) reported poor health literacy, and 164 (6%) reported feeling depressed. Limited transportation was significantly associated with unstable housing (odds ratio [OR] = 26.5, 95% confidence interval [CI] 19.9-35.4, p < 0.00001), poor health literacy (OR = 11.5, 95% CI 9.3-14.2, p < 0.0001), and depression (OR = 2.9, 95% CI 2.1-4.0, p < 0.00001). Individual barriers were not associated with a longer time to treatment, but an increasing number of barriers was associated with a longer time to treatment (Coef = 0.9, p < 0.05). CONCLUSIONS:Compounding structural and social barriers limit participation in breast cancer screening, and women with increasing unmet social needs face delays in treatment for breast cancer. Navigation programs may help women overcome barriers to care; however, understanding and targeting the intersectionality of unmet needs is essential for targeted interventions through breast cancer care navigation programs to be effective.

OBJECTIVE:The objective of this study was to examine the effect of corona virus 2019 (COVID-19) vaccination on perioperative outcomes after major vascular surgery. BACKGROUND DATA/BACKGROUND:COVID-19 vaccination is associated with decreased mortality in patients undergoing various surgical procedures. However, the effect of vaccination on perioperative mortality after major vascular surgery is unknown. METHODS:This is a multicenter retrospective study of patients who underwent major vascular surgery between December 2021 through August 2023. The primary outcome was all-cause mortality within 30 days of index operation or prior to hospital discharge. Multivariable models were used to examine the association between vaccination status and the primary outcome. RESULTS:Of the total 85,424 patients included, 19161 (22.4%) were unvaccinated. Unvaccinated patients were younger compared to vaccinated patients (mean age 68.44 +/- 10.37 y vs 72.11 +/- 9.20 y, P <0.001) and less likely to have comorbid conditions, including hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dialysis. After risk factor adjustment, vaccination was associated with decreased mortality (OR 0.7, 95% CI 0.62 - 0.81, P <0.0001). Stratification by procedure type demonstrated that vaccinated patients had decreased odds of mortality after open AAA (OR 0.6, 95% CI 0.42-0.97, P =0.03), EVAR (OR 0.6, 95% CI 0.43-0.83, p 0.002), CAS (OR 0.7, 95% CI 0.51-0.88, P =0.004) and infra-inguinal lower extremity bypass (OR 0.7, 95% CI 0.48-0.96, P =0.03). CONCLUSIONS:COVID-19 vaccination is associated with reduced perioperative mortality in patients undergoing vascular surgery. This association is most pronounced for patients undergoing aortic aneurysm repair, carotid stenting and infrainguinal bypass.

IMPORTANCE/UNASSIGNED:Inequities in rapid access to emergency medical services (EMS) represent a critical gap in prehospital care and the first system-level milestone for critically injured patients. As delays in EMS response are associated with increased mortality and known disparities within historically redlined areas are prevalent, this study sought to examine disparities in rapid access to EMS across the United States. OBJECTIVE/UNASSIGNED:To assess the association between historically redlined areas and rapid EMS access (defined as ≤5-minute response time) across the United States. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This retrospective, cross-sectional study analyzed the geographic distribution of EMS centers in relation to 2020 US Census block groups and Home Owners' Loan Corporation (HOLC) residential security maps, classified by grades (A-D). Populations of 236 US cities with publicly available redlining data were included. Travel distance radius (5-minute drive times) was centered on population-weighted block group centroids. Redlining grades include A ("most desirable," green), B ("still desirable," blue), C ("declining," yellow), and D ("hazardous," red). EXPOSURE/UNASSIGNED:HOLC grade classification (A-D). MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the proportion of the population with rapid EMS access. Secondary outcomes included the socioeconomic and demographic profiles of populations without rapid access. RESULTS/UNASSIGNED:Of the total US population (N = 333 036 755), 41 367 025 (12.42%) lived in cities with redlining data. Among these, 2 208 269 (5.34%) lacked rapid access to 42 472 EMS stations. Grade D areas had a higher proportion of residents without rapid EMS access compared with grade A areas (7.06% vs 4.36%; P < .001). The odds of having no rapid access to EMS in grade D areas were 1.67 (95% CI, 1.66-1.68) times higher than in grade A areas. Compared with grade A, grade D areas had a lower percentage of non-Hispanic White residents (65.21% [95% CI, 59.43%-70.99%] vs 39.36% [95% CI, 36.99%-41.73%]; P < .001), a higher percentage of non-Hispanic Black residents (10.38% [95% CI, 7.14%-13.62%] vs 27.85% [95% CI, 25.4%-30.3%]; P < .001), and greater population density (7500.72 [95% CI, 4341.26-10 660.18] persons/km2 vs 15 277.87 [95% CI, 13 281.7-17 274.04] persons/km2; P < .001). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study, structural disparities in rapid EMS access were associated with historically redlined areas. Strategic resource allocation and system redesign are warranted to address these inequities in prehospital emergency care.