Faculty Bibliography

OBJECTIVE/UNASSIGNED:To perform a geospatial analysis of food insecurity in a rural county known to have poor health outcomes and assess the effect of the COVID-19 pandemic. METHODS/UNASSIGNED:In 2020, we mailed a comprehensive cross-sectional survey to all households in Sullivan County, a rural county with the second-worst health outcomes among all counties in New York State. Surveys of households included validated food insecurity screening questions. Questions were asked in reference to 2019, prior to the pandemic, and for 2020, in the first year of the pandemic. Respondents also responded to demographic questions. Raking adjustments were performed using age, sex, race/ethnicity, and health insurance strata to mitigate non-response bias. To identify significant hotspots of food insecurity within the county, we also performed geospatial analysis. FINDINGS/UNASSIGNED:From the 28,284 households surveyed, 20% of households responded. Of 4725 survey respondents, 26% of households reported experiencing food insecurity in 2019, and in 2020, this proportion increased to 35%. In 2020, 58% of Black and Hispanic households reported experiencing food insecurity. Food insecurity in 2020 was also present in 58% of unmarried households with children and in 64% of households insured by Medicaid. The geospatial analyses revealed that hotspots of food insecurity were primarily located in or near more urban areas of the rural county. CONCLUSIONS/UNASSIGNED:Our countywide health survey in a high-risk rural county identified significant increases of food insecurity in the first year of the COVID-19 pandemic, despite national statistics reporting a stable rate. Responses to future crises should include targeted interventions to bolster food security among vulnerable rural populations.

BACKGROUND:Up to 50% of antibiotic prescriptions for upper respiratory infections (URIs) are inappropriate. Clinical decision support (CDS) systems to mitigate unnecessary antibiotic prescriptions have been implemented into electronic health records, but their use by providers has been limited. OBJECTIVE:As a delegation protocol, we adapted a validated electronic health record-integrated clinical prediction rule (iCPR) CDS-based intervention for registered nurses (RNs), consisting of triage to identify patients with low-acuity URI followed by CDS-guided RN visits. It was implemented in February 2022 as a randomized controlled stepped-wedge trial in 43 primary and urgent care practices within 4 academic health systems in New York, Wisconsin, and Utah. While issues were pragmatically addressed as they arose, a systematic assessment of the barriers to implementation is needed to better understand and address these barriers. METHODS:We performed a retrospective case study, collecting quantitative and qualitative data regarding clinical workflows and triage-template use from expert interviews, study surveys, routine check-ins with practice personnel, and chart reviews over the first year of implementation of the iCPR intervention. Guided by the updated CFIR (Consolidated Framework for Implementation Research), we characterized the initial barriers to implementing a URI iCPR intervention for RNs in ambulatory care. CFIR constructs were coded as missing, neutral, weak, or strong implementation factors. RESULTS:Barriers were identified within all implementation domains. The strongest barriers were found in the outer setting, with those factors trickling down to impact the inner setting. Local conditions driven by COVID-19 served as one of the strongest barriers, impacting attitudes among practice staff and ultimately contributing to a work infrastructure characterized by staff changes, RN shortages and turnover, and competing responsibilities. Policies and laws regarding scope of practice of RNs varied by state and institutional application of those laws, with some allowing more clinical autonomy for RNs. This necessitated different study procedures at each study site to meet practice requirements, increasing innovation complexity. Similarly, institutional policies led to varying levels of compatibility with existing triage, rooming, and documentation workflows. These workflow conflicts were compounded by limited available resources, as well as an implementation climate of optional participation, few participation incentives, and thus low relative priority compared to other clinical duties. CONCLUSIONS:Both between and within health care systems, significant variability existed in workflows for patient intake and triage. Even in a relatively straightforward clinical workflow, workflow and cultural differences appreciably impacted intervention adoption. Takeaways from this study can be applied to other RN delegation protocol implementations of new and innovative CDS tools within existing workflows to support integration and improve uptake. When implementing a system-wide clinical care intervention, considerations must be made for variability in culture and workflows at the state, health system, practice, and individual levels. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT04255303; https://clinicaltrials.gov/ct2/show/NCT04255303.

To assess the effectiveness of culturally and linguistically tailored, peer-delivered obstructive sleep apnea education and of social support to increase adherence to physician-recommended obstructive sleep apnea evaluation among blacks. In a two-arm randomised controlled trial, we ascertained the effectiveness of peer-delivered obstructive sleep apnea education in increasing obstructive sleep apnea evaluation among 319 blacks at risk of obstructive sleep apnea (intervention = 159 and control = 160); their average age was 47 ± 12.9 years, and 41% were male. Obstructive sleep apnea risk was assessed with the Apnea Risk Evaluation System questionnaire, administered in community venues. Participants in the intervention arm received tailored obstructive sleep apnea education during a 6 month period; those in the control arm received standard sleep and healthy lifestyle information. Analysis focussed on the effectiveness of peer-delivered obstructive sleep apnea education on adherence to obstructive sleep apnea evaluation, but also considered the role of psychosocial factors. The results showed no significant differences in baseline demographic and clinical measures when contrasting participants in the study arms. The adherence rates for home-based obstructive sleep apnea evaluation in the intervention and control arms were 45.9% and 45.6%, respectively. Overall, participants in both study arms (adherers) who underwent obstructive sleep apnea evaluations were likely to experience a greater level of social support (8.2 ± 2.4 vs. 7.3 ± 2.4; p = 0.06). Moreover, adherers showed greater psychosocial scores (i.e., Dysfunctional Beliefs and Attitudes about Sleep scale, Apnea Beliefs Scale (ABS) (and Apnea Knowledge) compared with non-adherers (6.0 ± 1.8 vs. 4.9 ± 2.2; p = 0.02; 77.0 ± 7.1 vs. 73.2 ± 7.4; p = 0.04, and 6.4 ± 3.1 vs. 7.6 ± 2.4; p = 0.06, respectively). The results of the present randomised controlled trial favoured a potential role of peer-based social support and psychosocial factors, associated with obstructive sleep apnea adherence behaviour.

BACKGROUND:Poverty can be a robust barrier to HIV care engagement. We assessed the extent to which delivering care for HIV, diabetes and hypertension within community-based microfinance groups increased savings and reduced loan defaults among microfinance members living with HIV. METHODS:We analyzed cluster randomized trial data ascertained during November 2020-May 2023 from 57 self-formed microfinance groups in western Kenya. Groups were randomized 1:1 to receive care for HIV and non-communicable diseases in the community during regular microfinance meetings (intervention) or at a health facility during routine appointments (standard care). Community and facility care provided clinical evaluations, medications, and point-of-care testing. The trial enrolled 900 microfinance members, with data collected quarterly for 18-months. We used a two-part model to estimate intervention effects on microfinance shares purchased, and a negative binomial regression model to estimate differences in loan default rates between trial arms. We estimated effects overall and by participant characteristics. RESULTS:Participants' median age and distance from a health facility was 52 years and 5.6 km, respectively, and 50% reported earning less than $50 per month. The probability of saving any amount (>$0) through purchasing microfinance shares was 2.7 percentage points higher among microfinance group members receiving community vs. facility care. Community care recipients and facility care patients saved $44.90 and $25.24 over 18-months, respectively, and the additional amount saved by community care recipients was statistically significant (p = 0.036). Overall and in stratified analyses, loan defaults rates were not statistically significantly different between community and facility care patients. CONCLUSIONS:Receiving integrated care in the community was significantly associated with modest increases in savings. We did not find any significant association between community-delivered care and reductions in loan defaults among HIV-positive microfinance group members. Longer follow up examination and formal mediation analyses are warranted.

Black sexually minoritized men (BSMM) are the most likely to acquire HIV in Chicago- a racially segregated city where their daily travel may confer different HIV-related risks. From survey and GPS data among participants of the Neighbourhoods and Networks Cohort Study, we examined spatial (proportion of total activity space away from home), temporal (proportion of total GPS points away from home), and motivation-specific (discordance between residential and frequented sex or socializing neighbourhoods) dimensions of mobility. To identify potential drivers of BSMM's risk, we then examined associations between mobility and sexual behaviours known to cause HIV transmission: condomless anal sex, condomless anal sex with a casual partner, transactional sex, group sex, and sex-drug use. Multivariable logistic regression models assessed associations. Of 269 cisgender BSMM, most were 20-29 years old, identified as gay, and lowincome. On average, 96.9% (Standard Deviation: 3.7%) of participants' activity space and 53.9% (Standard Deviation: 38.1%) of participants' GPS points occurred outside their 800m home network buffer. After covariate adjustment, those who reported sex away from home were twice as likely to report condomless sex (Odds Ratio: 2.02, [95% Confidence Interval (CI): 1.08, 3.78]). Those who reported socializing away from home were four times more likely to have condomless sex with a casual partner (Odds Ratio: 4.16 [CI: 0.99, 29.0]). BSMM are on the move in Chicago, but only motivation-specific mobility may increase HIV transmission risk. Multidimensional investigations of mobility can inform place-based strategies for HIV service delivery.

PURPOSE/OBJECTIVE:Examine associations between whether participants' were matched to their preferred financial incentive design and behavioral goal adherence in a weight management intervention. DESIGN/METHODS:Secondary quantitative analysis incorporating qualitative survey data. SETTING/METHODS:Primary care clinics in socioeconomically disadvantaged communities in New York City and Los Angeles. SUBJECTS/METHODS:668 participants (mean age 47.7 years, 81.0% female, 72.6% Hispanic) with obesity were enrolled in the Financial Incentives foR Weight Reduction (FIReWoRk) intervention. MEASURES/METHODS:We explored qualitatively participant's reasons for hypothetically choosing a behavioral goal-directed vs a weight loss outcome-based financial incentive program. Additionally, behavioral adherence to different goals was collected at the 6-month timepoint, categorized by match to preferred financial incentive design. ANALYSIS/METHODS:Logistic regression was used to examine if participants with certain demographic and higher psychosocial factors were more likely to choose goal-directed over outcome-based incentives. Additionally, logistic regression was used to test for associations between preference and behavioral adherence, using incentive type as an interaction term. RESULTS:= .025). Moderation analysis revealed that participants who preferred goal-directed and were matched to goal-directed had greater rates of behavioral adherence for program attendance and self-weighing, but not dietary tracking and physical activity tracking, compared to those who preferred outcome-based and were matched to outcome-based. CONCLUSION/CONCLUSIONS:Receiving one's preferred incentive design may not play a strong role in behavioral goal adherence during financially incentivized weight loss interventions.

Hepatitis C virus (HCV) elimination is an important global public health goal. However, the United States (US) is not on track to meet the World Health Organization's 2030 targets for HCV elimination. Recently, the White House proposed an HCV elimination plan that includes point-of-care (POC) HCV RNA testing, which is currently in use in many countries, but is not approved in the US. POC HCV RNA testing is crucial for implementing community-based testing, and for enabling test-and-treat programs, assessing cure, and monitoring for reinfection.. In this commentary, we review the status of POC HCV RNA testing in the US, discuss factors that are needed for successful implementation, and issue specific public health and policy recommendations that would allow for the use of POC HCV RNA testing to support HCV elimination.

BACKGROUND:Particulate matter exposure (PM) is a cause of aerodigestive disease globally. The destruction of the World Trade Center (WTC) exposed first responders and inhabitants of New York City to WTC-PM and caused obstructive airways disease (OAD), gastroesophageal reflux disease (GERD) and Barrett's Esophagus (BE). GERD not only diminishes health-related quality of life but also gives rise to complications that extend beyond the scope of BE. GERD can incite or exacerbate allergies, sinusitis, bronchitis, and asthma. Disease features of the aerodigestive axis can overlap, often necessitating more invasive diagnostic testing and treatment modalities. This presents a need to develop novel non-invasive biomarkers of GERD, BE, airway hyperreactivity (AHR), treatment efficacy, and severity of symptoms. METHODS:No GERD or AHR, from the sub-cohort control group. We will then phenotype and examine non-invasive biomarkers of these subgroups to identify under-diagnosis and/or treatment efficacy. The findings may further contribute to the development of future biologically plausible therapies, ultimately enhance patient care and quality of life. DISCUSSION/CONCLUSIONS:Although many studies have suggested interdependence between airway and digestive diseases, the causative factors and specific mechanisms remain unclear. The detection of the disease is further complicated by the invasiveness of conventional GERD diagnosis procedures and the limited availability of disease-specific biomarkers. The management of reflux is important, as it directly increases risk of cancer and negatively impacts quality of life. Therefore, it is vital to develop novel noninvasive disease markers that can effectively phenotype, facilitate early diagnosis of premalignant disease and identify potential therapeutic targets to improve patient care. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT05216133; January 18, 2022.

Environmental toxicants and pollutants are causes of adverse health consequences, including well-established associations between environmental exposures and cardiovascular diseases. Environmental degradation is widely prevalent and has a long latency period between exposure and health outcome, potentially placing a large number of individuals at risk of these health consequences. Emerging evidence suggests that environmental exposures in early life may be key risk factors for cardiovascular conditions across the life span. Children are a particularly sensitive population for the detrimental effects of environmental toxicants and pollutants given the long-term cumulative effects of early-life exposures on health outcomes, including congenital heart disease, acquired cardiac diseases, and accumulation of cardiovascular disease risk factors. This scientific statement highlights representative examples for each of these cardiovascular disease subtypes and their determinants, focusing specifically on the associations between climate change and congenital heart disease, airborne particulate matter and Kawasaki disease, blood lead levels and blood pressure, and endocrine-disrupting chemicals with cardiometabolic risk factors. Because children are particularly dependent on their caregivers to address their health concerns, this scientific statement highlights the need for clinicians, research scientists, and policymakers to focus more on the linkages of environmental exposures with cardiovascular conditions in children and adolescents.

BACKGROUND:Telemedicine expanded during the COVID-19 pandemic, though use differed by age, sex, race or ethnicity, educational attainment, income, and location. It is unclear if high telehealth use or inequities persisted late into the pandemic. OBJECTIVE:This study aims to evaluate the prevalence of, inequities in, and primary reasons for telehealth visits a year after telemedicine expansion. METHODS:We used cross-sectional data from the 2022 Health Information National Trends Survey (HINTS 6), the first cycle with data on telemedicine. In total, 4830 English- and Spanish-speaking US adults (aged ≥18 years) were included in this study. The primary outcomes were telehealth visit attendance in the 12 months before March 7, 2022, to November 8, 2022, and the primary reason for the most recent telehealth visit. We evaluated sociodemographic and clinical predictors of telehealth visit attendance and the primary reason for the most recent telehealth visit through Poisson regression. Analyses were weighted according to HINTS 6 standards. RESULTS:We included 4830 participants (mean age 48.3, SD 17.5 years; 50.28% women; 65.21% White). Among US adults, 38.78% reported having a telehealth visit in the previous year. Telehealth visit attendance rates were similar across age, race or ethnicity, income, and urban versus rural location. However, individuals with a telehealth visit were less likely to live in the Midwest (adjusted prevalence ratio [aPR] 0.65, 95% CI 0.54-0.77), and more likely to be women (aPR 1.21, 95% CI 1.06-1.38), college graduates or postgraduates (aPR 1.24, 95% CI 1.05-1.46), covered by health insurance (aPR 1.56, 95% CI 1.08-2.26), and married or cohabitating (aPR 1.17, 95% CI 1.03-1.32), adjusting for sociodemographic characteristics, frequency of health care visits, and comorbidities. Among participants with a telehealth visit in the past year, the primary reasons for their most recent visit were minor or acute illness (32.15%), chronic disease management (21%), mental health or substance abuse (16.94%), and an annual exam (16.22%). Older adults were more likely to report that the primary reason for their most recent telehealth visit was for chronic disease management (aPR 2.08, 95% CI 1.33-3.23), but less likely to report that it was for a mental health or substance abuse issue (aPR 0.19, 95% CI 0.10-0.35), adjusting for sociodemographic characteristics and frequency of health care visits. CONCLUSIONS:Among US adults, telehealth visit attendance was high more than a year after telemedicine expansion and did not differ by age, race or ethnicity, income, or urban versus rural location. Telehealth could continue to be leveraged following COVID-19 to improve access to care and health equity.