Faculty Bibliography

We present a comprehensive Framework for Digital Health Equity, detailing key digital determinants of health (DDoH), to support the work of digital health tool creators in industry, health systems operations, and academia. The rapid digitization of healthcare may widen health disparities if solutions are not developed with these determinants in mind. Our framework builds on the leading health disparities framework, incorporating a digital environment domain. We examine DDoHs at the individual, interpersonal, community, and societal levels, discuss the importance of a root cause, multi-level approach, and offer a pragmatic case study that applies our framework.

BACKGROUND:Although a few studies reported an association between varicose veins and physical function, this potentially bidirectional association has not been systematically evaluated in the general population. METHOD:In 5 580 participants (aged 71-90 years) from the Atherosclerosis Risk in Communities study, varicose veins were identified in outpatient and inpatient administrative data prior to (prevalent cases) and after (incident cases) visit 5 (2011-2013). Physical function was evaluated by the Short Physical Performance Battery (SPPB, score ranging from 0 to 12). We evaluated (i) cross-sectional association between prevalent varicose veins and physical function, (ii) association of prevalent varicose veins with subsequent changes in physical function from visit 5 to visits 6 (2016-2017) and 7 (2018-2019), and (iii) association of physical function at visit 5 with incident varicose veins during a median follow-up of 3.6 years (105 incident varicose veins among 5 350 participants without prevalent cases at baseline). RESULTS:At baseline, varicose veins were recognized in 230 (4.1%) participants and cross-sectionally associated with reduced physical function. Longitudinally, prevalent varicose veins were not significantly associated with a decline in SPPB over time. In contrast, a low SPPB ≤6 was associated with a greater incidence of varicose veins compared to SPPB ≥10 (adjusted hazard ratio 2.13 [95% confidence interval = 1.19, 3.81]). CONCLUSION:In community-dwelling older adults, varicose veins and low physical function were associated cross-sectionally. Longitudinally, low physical function was a risk factor for incident varicose veins, but not vice versa. Our findings suggest an etiological contribution of low physical function to incident varicose veins.

STUDY OBJECTIVES/OBJECTIVE:Characteristics of neighborhood social environments, such as safety and social cohesion, have been examined as determinants of poor sleep. The current study investigates associations between neighborhood social characteristics and sleep health, as well as the mediating role of psychological distress on these possible associations. METHODS:Three waves of PHRESH Zzz (n=2,699), a longitudinal study conducted in two low-income, predominately Black neighborhoods, were utilized for this analysis. Characteristics of neighborhood social environments were measured using crime rates, a neighborhood social disorder index, and self-reported social cohesion. Sleep health was measured via 7 days of wrist-worn actigraphy as insufficient sleep, sleep duration, wake after sleep onset (WASO), and sleep efficiency. G-estimations based on structural nested mean models and mediation analyses were performed to estimate effects of neighborhood social environments on sleep as well as direct/indirect effects through psychological distress. RESULTS:Crime rate around residential addresses was associated with increased risk of insufficient sleep (risk ratio: 1.05 [1.02, 1.12]), increased WASO (β: 3.73 [0.26, 6.04]), and decreased sleep efficiency (β: -0.54 [-0.91, -0.09]). Perceived social cohesion was associated with decreased risk of insufficient sleep (OR: 0.93 [0.88, 0.97]). Psychological distress mediated part of the associations of crime and social cohesion with insufficient sleep. CONCLUSIONS:Neighborhood social environments may contribute to poor sleep health in low-income, predominantly Black neighborhoods, and psychological distress can be a salient pathway linking these neighborhood characteristics and sleep health.

OBJECTIVE/UNASSIGNED:Despite intending to eat healthy foods, people often yield to temptation. In environments rife with unhealthy food options, a positive implicit evaluation of unhealthy foods may inadvertently influence unhealthy choices. This study investigates if and under which conditions implicit evaluations of unhealthy and healthy foods can be influenced by a computer-based Go/No-Go (GNG) training. DESIGN/UNASSIGNED: MAIN OUTCOME MEASURE/UNASSIGNED:Implicit evaluations of chips and grapes were assessed using the Extrinsic Affective Simon Task. RESULTS/UNASSIGNED:This GNG training impacted implicit evaluations of chips, but not grapes. GNG training effects were stronger for participants with lower sensitivity for behavioural inhibition measured with the Behavioural Inhibition System scale. CONCLUSION/UNASSIGNED:GNG training might help people change implicit food evaluations. More research is needed to understand how individual and training characteristics affect outcomes with the goal of tailoring and optimising the GNG training to produce the strongest effect.

INTRODUCTION/BACKGROUND:Homebound individuals with advanced Parkinson's disease (PD) are underrepresented in research and care. We tested the impact of interdisciplinary, telehealth-enhanced home visits (IN-HOME-PD) on patient quality of life (QoL) compared with usual care. METHODS:Nonrandomized controlled trial of quarterly, structured, telehealth-enhanced interdisciplinary home visits focused on symptom management, home safety, medication reconciliation, and psychosocial needs (ClinicalTrials.gov NCT03189459). We enrolled homebound participants with advanced PD (Hoehn & Yahr (HY) stage ≥3). Usual care participants had ≥2 visits in the Parkinson's Outcomes Project (POP) registry. We compared within- and between-group one-year change in QoL using the Parkinson's Disease Questionnaire. RESULTS:Sixty-five individuals enrolled in IN-HOME-PD (32.3% women; mean age 78.9 (SD 7.6) years; 74.6% white; 78.5% HY ≥ 4) compared with 319 POP controls, with differences in age, race, and PD severity (37.9% women; mean age 70.1 (7.8) years; 96.2% white; 15.1% HY ≥ 4). Longitudinally, the intervention group's QoL remained unchanged (within-group p = 0.74, Cohen's d = 0.05) while QoL decreased over time in POP controls (p < 0.001, Cohen's d = 0.27). The difference favored the intervention (between-group p = 0.04). POP participants declined in 7/8 dimensions while IN-HOME-PD participants' bodily discomfort improved and hospice use and death at home-markers of goal-concordant care-far exceeded national data. CONCLUSIONS:Telehealth-enhanced home visits can stabilize and may improve the predicted QoL decline in advanced PD via continuity of care and facilitating goal-concordant care, particularly among diverse populations. Extrapolating features of this model may improve continuity of care and outcomes in advanced PD.

INTRODUCTION/BACKGROUND:Although prevalence of smoking in the USA has been decreasing for decades, smoking rates among low-income individuals remain elevated. Theories from behavioral economics and prior research suggest that financial stress may contribute to the difficulty that low-income smokers face in quitting. The present work is a secondary analysis of a randomized controlled trial that incorporated financial coaching and social services referrals into smoking cessation treatment. Primary analyses showed that participants randomized to the intervention (N = 208) were significantly more likely not to smoke, to have lower financial stress, and to be able to afford leisure activities (p < .05) than were control participants (N = 202). METHODS:This paper investigates subgroup discrepancies in attendance of intervention sessions and in uptake of various components of this intervention through exploratory analysis. RESULTS:Analysis using logistic regression indicated that decreased age, not having received higher education, and having income less than $1000 per month were predictive of decreased counseling attendance (p < .05). Few demographic factors were predictive of uptake of counseling components among those who attended counseling. CONCLUSIONS:These results can guide future efforts to increase participant engagement in the intervention. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03187730.

School nutrition programs (SNP) provide much needed access to fruits, vegetables, and other healthy foods at low or no cost. Yet, the infrastructure of school kitchens and cafeteria vary across schools, potentially contributing to systematic barriers for SNP operation and equity. The purpose of this paper is to examine the association between school infrastructure and outcomes including meal participation, untraditional lunch periods, and having an open campus. Regression analyses were conducted using administrative data for 1804 schools and school nutrition manager survey data (n = 821) in New York City (NYC). Co-location was significantly associated with open campus status (OR = 2.84, CI: 1.11, 7.26) and high school breakfast participation (β = -0.056, p = 0.003). Overcrowding was associated with breakfast (elementary: β = -0.046, p = 0.03; middle: β = 0.051, p = 0.04; high: β = 0.042, p = 0.04) and lunch participation (elementary: β = -0.031, p = 0.01) and untraditional lunchtimes (elementary: OR = 2.47, CI: 1.05, 5.83). Higher enrollment to cafeteria capacity ratios was associated with breakfast (elementary: β = -0.025, p = 0.02) and lunch (elementary: β = -0.015, p = 0.001; high: β = 0.014, p = 0.02) participation and untraditional lunchtimes (middle: OR = 1.66, CI: 1.03, 2.68). Infrastructure characteristics are an important source of variation across NYC schools that may hinder the equity of school nutrition programs across the city.

Background As the number of adults with congenital heart disease increases because of therapeutic advances, cardiac rehabilitation (CR) is increasingly being used in this population after cardiac procedures or for reduced exercise tolerance. We aim to describe the adherence and exercise capacity improvements of patients with adult congenital heart disease (ACHD) in CR. Methods and Results This retrospective study included patients with ACHD in CR at New York University Langone Rusk Rehabilitation from 2013 to 2020. We collected data on patient characteristics, number of sessions attended, and functional testing results. Pre-CR and post-CR metabolic equivalent task, exercise time, and maximal oxygen uptake were assessed. In total, 89 patients with ACHD (mean age, 39.0 years; 54.0% women) participated in CR. Referral indications were reduced exercise tolerance for 42.7% and post-cardiac procedure (transcatheter or surgical) for the remainder. Mean number of sessions attended was 24.2, and 42 participants (47.2%) completed all 36 CR sessions. Among participants who completed the program as well as pre-CR and post-CR functional testing, metabolic equivalent task increased by 1.3 (95% CI, 0.7-1.9; baseline mean, 8.1), exercise time increased by 66.4 seconds (95% CI, 21.4-111.4 seconds; baseline mean, 536.1 seconds), and maximal oxygen uptake increased by 2.5 mL/kg per minute (95% CI, 0.7-4.2 mL/kg per minute; baseline mean, 20.2 mL/kg per minute). Conclusions On average, patients with ACHD who completed CR experienced improvements in exercise capacity. Efforts to increase adherence would allow more patients with ACHD to benefit.

BACKGROUND:The growing population of patients over the age of 65 faces particular vulnerability following discharge after hospitalization or an emergency room visit. Specific areas of concern include a high risk for falls and poor comprehension of discharge instructions. Emergency medical technicians (EMTs), who frequently transport these patients home from the hospital, are uniquely positioned to aid in mitigating transition of care risks and are both trained and utilized to do so using the Transport PLUS intervention. METHODS:Existing literature and focus groups of various stakeholders were utilized to develop two checklists: the fall safety assessment (FSA) and the discharge comprehension assessment (DCA). EMTs were trained to administer the intervention to eligible patients in the geriatric population. Using data from the checklists, follow-up phone calls, and electronic health records, we measured the presence of hazards, removal of hazards, the presence of discharge comprehension issues, and correction or reinforcement of comprehension. These results were validated during home visits by community health workers (CHWs). Feasibility outcomes included patient acceptance of the Transport PLUS intervention and accuracy of the EMT assessment. Qualitative feedback via focus groups was also obtained. Clinical outcomes measured included 3-day and 30-day readmission or ED revisit. RESULTS:One-hundred three EMTs were trained to administer the intervention and participated in 439 patient encounters. The intervention was determined to be feasible, and patients were highly amenable to the intervention, as evidenced by a 92% and 74% acceptance rate of the DCA and FSA, respectively. The majority of patients also reported that they found the intervention helpful (90%) and self-reported removing 40% of fall hazards; 85% of such changes were validated by CHWs. Readmission/revisit rates are also reported. CONCLUSIONS:The Transport PLUS intervention is a feasible, easily implemented tool in preventative community paramedicine with high levels of patient acceptance. Further study is merited to determine the effectiveness of the intervention in reducing rates of readmission or revisit. A randomized control trial has since begun utilizing the knowledge gained within this study.

In response to rapidly changing societal conditions stemming from the COVID-19 pandemic, we summarize data sources with potential to produce timely and spatially granular measures of physical, economic, and social conditions relevant to public health surveillance, and we briefly describe emerging analytic methods to improve small-area estimation. To inform this article, we reviewed published systematic review articles set in the United States from 2015 to 2020 and conducted unstructured interviews with senior content experts in public heath practice, academia, and industry. We identified a modest number of data sources with high potential for generating timely and spatially granular measures of physical, economic, and social determinants of health. We also summarized modeling and machine-learning techniques useful to support development of time-sensitive surveillance measures that may be critical for responding to future major events such as the COVID-19 pandemic. (Am J Public Health. Published online ahead of print August 4, 2022:e1-e10. https://doi.org/10.2105/AJPH.2022.306917).