Faculty Bibliography

BACKGROUND:Nursing documentation burden is a growing point of concern in the United States healthcare system. Documentation in the electronic health record (EHR) is a contributor to perceptions of burden. Efficiency tools like flowsheet macros are one development intended to ease the burden of documentation. OBJECTIVE:Evaluate if flowsheet macros, a documentation efficiency tool in the EHR that consolidates documentation into a single click, reduces the time spent in documentation activities and the EHR overall. METHODS:Nurses in the health system were encouraged to create and utilize flowsheet macros for their documentation. Flowsheet documentation and time in system data for nurses' first and last shift in the evaluation period was extracted from the EHR. Linear regression with control variables was utilized to understand if utilization of flowsheet macros for documentation reduced the time spent in flowsheets or the EHR. RESULTS:The results of linear regression showed a significant, negative relationship between flowsheet macros use and time in flowsheets (AOR = -0.291, CI = -0.342 - -0.240, p < 0.001). Flowsheet macros use and time in system also had a significant, negative relationship (AOR = -0.269, CI = -0.390 - -0.147, p = <0.001). Subgroups for department specialties showed time savings in flowsheet activities for medical surgical, critical care, and obstetrics units, however a significant relationship was not found in emergency and rehabilitation units. CONCLUSION/CONCLUSIONS:Utilization of flowsheet macros was associated with a decrease in the amount of time a nurse spends in both flowsheets and the EHR. Adoption and time savings varied by the department setting, suggesting flowsheet macros may not be applicable to all patient types or conditions. Future research should investigate if the time savings from this tool yield benefits in perceptions of nurse documentation burden.

OBJECTIVE:To examine the associations between patient out-of-pocket (OOP) costs and nonadherence to glucagon-like peptide 1 receptor agonists (GLP-1a), and the consequent impact on adverse outcomes, including hospitalizations and emergency department (ED) visits. RESEARCH DESIGN AND METHODS/METHODS:This retrospective cohort study used MarketScan Commercial data (2016-2021). The cohort included nonpregnant adults aged 18-64 years with type 2 diabetes who initiated GLP-1a therapy. Participants were continuously enrolled in the same private insurance plan for 6 months before the prescription date and 1 year thereafter. Exposures included average first 30-day OOP costs for GLP-1a, categorized into quartiles (lowest [Q1] to highest [Q4]). Primary outcomes were the annual proportion of days covered (PDC) for GLP-1a and nonadherence, defined as PDC <0.8. Secondary outcomes included diabetes-related and all-cause hospitalizations and ED visits 1 year post-GLP-1a initiation. RESULTS:Among 61,907 adults who initiated GLP-1a, higher 30-day OOP costs were associated with decreased adherence. Patients in the highest OOP cost quartile (Q4: $80-$3,375) had significantly higher odds of nonadherence (odds ratio [OR]1.25; 95% CI 1.19-1.31) compared with those in Q1 ($0-$21). Nonadherence was linked to increased incidence rates of diabetes-related hospitalizations or ED visits (incidence rate ratio [IRR] 1.86; 95% CI 1.43-2.42), cumulative length of hospitalization (IRR 1.56; 95% CI 1.41-1.72), all-cause ED visits (IRR 1.38; 95% CI 1.32-1.45), and increased ED-related costs ($69.81, 95% CI $53.54-$86.08). CONCLUSIONS:Higher OOP costs for GLP-1a were associated with reduced adherence and increased rates of adverse outcomes among type 2 diabetes patients.

INTRODUCTION/BACKGROUND:Expanding access to medication for opioid use disorder (MOUD) to people involved in the carceral system is a priority for the New Hampshire Department of Corrections (NHDOC), where more than 40% of residents have an opioid use disorder (OUD). NHDOC participated in the multi-site Justice Community Opioid Innovation Network (JCOIN) clinical trial, "Long-acting buprenorphine vs. naltrexone opioid treatments in criminal justice system-involved adults (EXIT-CJS)". We examine the contributing factors to the expansion of the NHDOC MOUD program from 2021 to 2023, including participation in EXIT-CJS, which occurred from 2019 to 2024. METHODS:Data on quarterly MOUD prescribing and EXIT-CJS enrollments were abstracted from the NHDOC medical records from July 1, 2021- December 31, 2023 as part of a quality improvement initiative. To examine factors influencing expansion of the program, conversations were conducted with NHDOC leadership team and clinical staff. RESULTS:From 2021 to 2023, the quarterly number of patients treated with MOUD at the NHDOC increased by more than 400% from a total of 165 patients in July-September 2021, to 685 patients in October-December 2023. At the policy level, elimination of the federal DATA-Waiver (X-Waiver) Program allowed additional providers to prescribe MOUD. At the organizational level, support from NHDOC leadership, including Medical and Forensics and the Commissioner's Office, encouraged broader engagement in MOUD from providers, multidisciplinary staff, and security. This work was augmented through receipt of State Opioid Response (SOR) dollars with a requirement to continue to advance education for NHDOC staff on the efficacy of MOUD. Resulting discussions between medical providers, experts on addiction treatment, staff and residents supported a culture change in attitudes about MOUD. During this same time window, the NHDOC made significant adjustments in the distribution of MOUD by adjusting the nursing administration process thus reducing the stigma associated with being a patient on MOUD and treating MOUD medication administration like all other medical conditions. DISCUSSION/CONCLUSIONS:Policy-related, organizational, and individual factors contributed to the expansion of the MOUD program at the NHDOC. EXIT-CJS recruitment occurred synergistically with the expansion of the MOUD program. As NHDOC was engaged as a site in EXIT-CJS, study recruitment increased awareness of extended-release treatment options among residents and staff.

BACKGROUND:Sustaining evidence-based interventions in resource-limited settings is critical to optimizing gains in health outcomes. In 2015, we published a review of the sustainability of health interventions in African countries, highlighting gaps in the measurement and conceptualization of sustainability in the region. This review updates and expands upon the original review to account for developments in the past decade and recommendations for promoting sustainability. METHODS:First, we searched five databases (PubMed, SCOPUS, Web of Science, Global Health, and Cumulated Index to Nursing and Allied Health Literature (CINAHL)) for studies published between 2015 and 2022. We repeated the search in 2023 and 2024. The review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies were included if they reported on the sustainability of health interventions implemented in African countries. Study findings were summarized using descriptive statistics and narrative synthesis, and sustainability strategies were categorized based on the Expert Recommendations for Implementing Change (ERIC) strategies. RESULTS:Thirty-four publications with 22 distinct interventions were included in the review. Twelve African countries were represented in this review, with Nigeria (n = 6) having the most representation of available studies examining sustainability. Compared to the 2016 review, a similar proportion of studies clearly defined sustainability (52% in the current review versus 51% in the 2015 review). Eight unique strategies to foster sustainability emerged, namely: a) multi-sectorial partnership and developing stakeholder relationships, b) tailoring strategies to enhance program fit and integration, c) active stakeholder engagement and collaboration, d) capacity building through training, e) accessing new funding, f) adaptation, g) co-creation of intervention and implementation strategies and h) providing infrastructural support. The most prevalent facilitators of sustainability were related to micro-level factors (e.g., intervention fit and community engagement). In contrast, salient barriers were related to structural-level factors (e.g., limited financial resources). CONCLUSIONS:This review highlights some progress in the published reports on the sustainability of evidence-based intervention in Africa. The review emphasizes the importance of innovation in strategies to foster funding determinants for sustainable interventions. In addition, it underscores the need for developing contextually relevant sustainability frameworks that emphasize these salient determinants of sustainability in the region.

INTRODUCTION/BACKGROUND:Effective July 2018, the U.S. Department of Housing and Urban Development issued a rule requiring all public housing authorities to implement smoke-free housing (SFH) policies in their developments. We examined the differential impacts of SFH policy on hospitalizations for myocardial infarction (MI) and stroke among adults aged ≥50 years old living in New York City (NYC) Housing Authority (NYCHA) versus a matched-comparison population in NYC. AIMS AND METHODS/OBJECTIVE:We identified census block groups (CBGs) comprised solely of 100% NYCHA units (N = 160) and compared NYCHA CBGs to a selected subset of CBGs from all CBGs with no NYCHA units (N = 5646). We employed propensity score matching on distributions of key CBG-level sociodemographic and housing covariates. We constructed incident rates per 1000 persons by aggregating 3-month "quarterly" counts of New York State all-payer hospitalization data from October 2015 to December 2022 and dividing by the population aged ≥50 in selected CBGs, ascertained from 2016 American Community Survey 5-year estimates. We selected a difference-in-differences (DID) analytic approach to examine pre- and post-policy differences in incident hospitalizations between the intervention and matched-comparison groups. RESULTS:Matching results indicated a balanced match for all covariates, with standardized mean differences <0.10. In DID analyses, we observed small declines in both MI (DID = -0.26, p = .02) and stroke (DID = -0.28, p = .06) hospitalization rates for NYCHA CBGs compared to non-NYCHA CBGs from pre-to post-54 months' policy. CONCLUSIONS:SFH policies in NYC were associated with small reductions in CVD-related hospitalizations among older adults living in housing subject to the policy. IMPLICATIONS/CONCLUSIONS:Housing remains a key focal setting for interventions to reduce SHS exposure and associated morbidities. Ongoing monitoring is warranted to understand the long-term impacts of SFH policies in public housing developments.

OBJECTIVE:Little is known about how parenting interventions might influence families' access to related healthcare services during early childhood. This study describes the effects of a parenting intervention, Smart Beginnings (SB), on referrals to early intervention (EI) or early childhood special education (ECSE) after evaluation within a predominantly Black/Latine sample with low incomes. SB is a tiered intervention integrating a universal parenting program delivered in primary care clinics (PlayReadVIP) with a targeted home visiting program (Family Check-Up). METHODS:Data were drawn from a randomized controlled trial of SB, with sites in NYC and Pittsburgh, PA. The 280 families (132 treatment; 148 control) were 43% Black, 47% Latine, 37% Spanish-speaking, and 100% Medicaid-eligible. Hierarchical logistic regressions examined associations between expressive vocabulary and problem behaviors (internalizing and externalizing symptoms) at 2 years, and the impact of the SB intervention on the likelihood of EI/ECSE evaluation and service referrals based on evaluation results by 4 years. RESULTS:Across sites, children's lower expressive vocabulary and higher problem behaviors at 2 years predicted receiving EI/ECSE evaluation and service referrals by age 4. Assignment to the SB intervention reduced the likelihood of evaluations leading to referrals for EI/ECSE service. CONCLUSIONS:Results from this RCT showed that children with early behavior and language challenges were more likely to receive EI/ECSE evaluation and services by preschool-age. Children assigned to SB were less likely to be referred for services. Studying factors that predict EI/ECSE involvement for children from historically marginalized populations can help promote equity in early care systems.

BACKGROUND:Childhood environmental factors back to the prenatal environment can contribute to MS risk. Childhood adversity, which causes biological, behavioral, and epigenetic changes that can be passed down through families, has been understudied in MS. Here, we emphasize the need to understand the role that intergenerational adversity may play among families affected by MS. OBJECTIVE:To evaluate the frequency and types of adverse childhood experiences among parents of children with MS. METHODS:Individuals with pediatric MS (n = 68) were enrolled in a longitudinal study of cognition. At enrollment, the patient and one caregiver or parent completed questionnaires. As the pediatric participants were under age 18 at time of enrollment, one parent completed the Adverse Childhood Experiences (ACEs, a 10-item self-report measure) about the parents' own childhood. Results from the ACE questionnaire among parents of pediatric healthy controls (n = 96) and adults in a national cohort are also reported for comparison. RESULTS:Over half of pediatric MS parents reported at least one ACE exposure. Of parents that did have ACE exposures, the exposures were broad in terms of abuse, neglect, and household dysfunction. Over 10 % of parents reported total ACE scores of 7 or above. CONCLUSION/CONCLUSIONS:Over half of pediatric MS parents experienced some degree of childhood adversity. The impact of intergenerational adversity on the development of pediatric onset MS warrants further study.

BackgroundBreast conserving surgery represents the preferred surgical treatment option for patients with early-stage breast cancer. Reexcision rates are generally higher for patients undergoing lumpectomies for ductal carcinoma in situ (DCIS) compared to invasive breast cancer, as the microscopic extent of disease is difficult to assess during excision. This study investigated the clinicopathological characteristics of patients undergoing BCS for pure DCIS and reexcision rates over time, including the effect of the MarginProbe™ device.MethodsWe queried our prospectively maintained Institutional Breast Cancer Database for patients diagnosed with DCIS and treated with BCS as their primary procedure from 2010-2021. The primary endpoint was the rate of reexcision. Variables of interest included age at diagnosis, race/ethnicity, mode of diagnostic imaging, mammographic breast density, method of core biopsy, nuclear grade, size of DCIS, multifocality, DCIS subtype, and MarginProbe™ use.ResultsPapillary DCIS (P < 0.004) and larger size (P < 0.001) was associated with an increased reexcision rate. There were also differences in the method of core biopsy (P < 0.001), with stereotactic core biopsy predominating among patients who did not require reexcision (71.3% vs 49.5%). In an unadjusted estimate for the odds ratio for association, patients who had MarginProbe™ used were 81% less likely to require reexcision (OR = 0.19, 95% CI = 0.12, 0.31, P < 0.0001).ConclusionYounger age, papillary DCIS, larger DCIS size, and non-stereotactic core biopsy method were found to be associated with higher reexcision rates. Additionally, patients whose primary procedures included intraoperative margin assessment with the MarginProbe™ were significantly less likely to require reexcision.

INTRODUCTION/BACKGROUND:The number of assays on proteomic platforms has grown rapidly. The leading platforms, SomaScan and Olink, have strengths and limitations. Comparisons of precision on the latest platforms-SomaScan 11k and Olink Explore HT-have not yet been established. METHODS:Among 102 participants in the Atherosclerosis Risk in Communities Study (mean age 74 years, 53% women, 47% Black), we used split plasma samples to measure platform precision. CV and Spearman correlations were calculated for each assay. Cross-platform agreement was assessed for overlapping proteins. RESULTS:SomaScan 11k demonstrated a median correlation of 0.85 for the 10 778 assays and a median CV of 6.8%, similar precision to earlier versions. The 5420 assays on Olink Explore HT exhibited a median correlation of 0.65 and median CV of 35.7%, which was higher than observed in its predecessors (e.g., 19.8% for Olink Explore 3072). Precision of Olink assays was inversely correlated with the percentage of samples above the limit of detection (LOD) (r = -0.77). Upon replacing Olink values below the LOD with values half the LOD, the median correlation for Olink assays measured in duplicate increased to 0.79; the median CV decreased to 13.3%. The distribution of between-platform correlations for the 4443 overlapping proteins had peaks at r approximately 0 and at r approximately 0.8. One-tenth of the protein pairs had cross-platform correlations r ≥ 0.8. CONCLUSIONS:Precision of these 2 proteomics platforms in human plasma has diverged as the coverage has increased. These results highlight the need for careful consideration in platform selection based on specific research requirements.

INTRODUCTION/BACKGROUND:Foundational preacademic skills are crucial for academic success and serve as predictors of socioeconomic status, income and access to healthcare. However, there is a gap in our understanding of neurodevelopmental patterns underlying preacademic skills in children across low-income and middle-income countries (LMICs). It is essential to identify primary global and regional factors that drive children's neurodevelopment in LMICs. This study aims to characterise the typical development of healthy children and factors that influence child development in Bahir Dar, Ethiopia. METHODS AND ANALYSIS/METHODS:The Bahir Dar Child Development Study is a cross-sectional study implemented in two health centres, Shimbit and Abaymado and in Felege Hiwot Comprehensive Specialized Hospital (FHCSH) in Bahir Dar, Amhara, Ethiopia. Healthy children between 6 and 60 months of age will be recruited from the health centres during vaccination visits or via community outreach. Young children aged 6-36 months will complete the Global Scale for Early Development. A battery of paper and tablet-based assessments of neurocognitive outcomes including visual and verbal reasoning, executive functions and school readiness will be completed for children aged 48-60 months. Caregivers will respond to surveys covering sociodemographic information, the child's medical history and nutrition, and psychosocial experiences including parental stress and mental health. During a second visit, participants will undergo a low-field MRI scan using the ultra-low-field point-of-care Hyperfine MRI machine at FHCSH. Analyses will examine relationships between risk and protective factors, brain volumes and neurocognitive/developmental outcomes. ETHICS AND DISSEMINATION/BACKGROUND:The study is approved by the Institutional Review Boards of Addis Continental Institute of Public Health (ACIPH/lRERC/004/2023/Al/05-2024), Mass General Brigham Hospital (2022P002539) and Brown University (STUDY00000474). Findings will be disseminated via local dissemination events, international conferences and publications. TRIAL REGISTERATION NUMBER/BACKGROUND:NCT06648863.