Faculty Bibliography

OBJECTIVES/OBJECTIVE:The purpose of this study was to assess the feasibility and clinical impact of telemedicine-based opioid treatment with buprenorphine-naloxone following the Coronavirus disease 2019 pandemic. METHODS:Participants included in this retrospective analysis consisted of adult New York City residents with opioid use disorder eligible for enrollment in the NYC Health+Hospitals Virtual Buprenorphine Clinic between March and May 2020 (n = 78). Follow-up data were comprised of rates of retention in treatment at 2 months, referrals to community treatment, and induction-related events. RESULTS:During the initial 9 weeks of clinic operations, the clinic inducted 78 patients on to buprenorphine-naloxone and completed 252 visits. Patient referrals included non-NYC Health + Hospitals (n = 22, 28.2%) and NYC Health + Hospitals healthcare providers (n = 17, 21.8%), homeless shelter staff (n = 13, 16.7%), and the NYC Health + Hospitals jail reentry program in Rikers Island (n = 11, 14.1%). At 8 weeks, 42 patients remained in care (53.8%), 21 were referred to a community treatment program (26.9%), and 15 were lost to follow-up (19.2%). No patients were terminated from care due to disruptive behavior or suspicions of diversion or misuse of Buprenorphine. Adverse clinical outcomes were uncommon and included persistent withdrawal symptoms (n = 8, 4.3%) and one nonfatal opioid overdose (0.5%). CONCLUSIONS:Telemedicine-based opioid treatment and unobserved home induction on buprenorphine-naloxone offers a safe and feasible approach to expand the reach of opioid use disorder treatment, primary care, and behavioral health for a highly vulnerable urban population during an unprecedented natural disaster.

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

OBJECTIVES/OBJECTIVE:The number of older adults on methadone maintenance treatment (MMT) for opioid use disorder is increasing, but little is known about the characteristics and healthcare needs of this aging treatment population. This population may experience accelerated aging due to comorbidities and health behaviors. The aim of this study was to compare the prevalence of geriatric conditions among adults age ≥50 on MMT to a nationally representative sample of community-dwelling older adults. METHODS:We performed a geriatric assessment on 47 adults age ≥50 currently on MMT enrolled in 2 opioid treatment programs, in New York City and in East Providence, Rhode Island. We collected data on self-reported geriatric conditions, healthcare utilization, chronic medical conditions, physical function, and substance use. The results were compared to 470 age, sex, and race/ethnicity-matched adults in the national Health and Retirement Study. RESULTS:The mean age of the study sample was 58.8 years and 23.4% were female. The most common chronic diseases were hypertension (59.6%) and arthritis (55.3%) with 66% reporting ≥2 diseases. For geriatric conditions, adults on MMT had a significantly higher prevalence of mobility, hearing, and visual impairments as well as falls, urinary incontinence, chronic pain, and insomnia than the Health and Retirement Study sample. CONCLUSIONS:Older adults on MMT in 2 large opioid treatment programs have a high prevalence of geriatric conditions. An interdisciplinary, geriatric-based approach to care that focuses on function and addresses geriatric conditions is needed to improve the health of this growing population.

To mitigate the negative impact of resource needs on child health, practices serving low-income immigrant families have implemented screening programs to connect families to community resources. Little is known about how duration of US residence relates to patterns of resource needs and indicators of acculturation such as community resource knowledge/experience or self-efficacy. We conducted a cross-sectional analysis of a convenience sample of immigrant families with young children at an urban primary care clinic. These families were seen 5/2018-1/2020 for well child care, screening positive for ≥1 social need using a tool derived from Health Leads. Analysis of 114 families found that newly arrived families with a shorter duration of US residence (≤5 years) were more likely to report immediate material hardships like food insecurity and need for essential child supplies. Newly arrived families were also less likely to have access to technology resources such as a computer or smartphone. Long-term families with a longer duration of US residence (≥15 years) were more likely to report chronic needs like poor housing conditions, but also reported increased community resource knowledge/experience and increased self-efficacy. Primary care pediatric practices should assess immigration contextual factors to identify subgroups such as newly arrived families with young children to target resources (e.g., increase screening frequency) or enhance services (e.g., patient navigators) to relieve resource needs.

INTRODUCTION: The pulmonary embolism severity index (PESI) score is a well-known and validated clinical tool, utilized to predict 30-day mortality in patients with pulmonary embolism (PE). It is used to identify low-risk individuals (PESI < =85) who can be safely started on novel oral anticoagulation agents (NOAC) and discharged from the Emergency Department (ED). After calculating the PESI score in all patients admitted for PE within a 3-year period at a community hospital, this study first estimated the fraction of low-risk patients who ended up getting admitted. Additionally, this study compared the prevalence of right heart strain (RHS), incidence of bleeding events, and mortality rates between the low-risk and high-risk (PESI >85) cohorts.
METHOD(S): This study is a retrospective chart review of patients admitted with a primary diagnosis of PE to Mercy Fitzgerald Hospital from January 2018 to March 2021. The Fisher test was used to compare odds ratios (OR) of RHS on initial CT angiogram of the chest, bleeding events after initiation of the anticoagulation (drop in hemoglobin > 2 g/dL, positive hemoccult status, episodes of overt bleeding), and death rates between low-risk and high-risk groups. PRISM statistical software was used for statistical analysis.
RESULT(S): 211 patients were included in this study. 102 (48.3%) patients were categorized as low-risk and 109 (51.7%) as high-risk. RHS was present in 16 patients of the low-risk group (2 of which had saddle PE) versus 41 in the high-risk group (OR 0.39, CI [0.2-0.76], p 0.005). Bleeding after initiation of anticoagulation was observed in 2 patients in the low-risk versus 5 patients in the high-risk group (OR 0.42, CI [0.08-2], p 0.45). None of the patients in the low-risk group died during the admission compared to 6 patients from the high-risk group (OR non reported, CI [0-0.74], p 0.03).
CONCLUSION(S): When factoring in patients with RHS on initial imaging, 40.7% of the patients hospitalized for PE potentially could have been discharged safely for outpatient management based on this study. The patients who were identified as high risk had a higher occurrence of RHS and had significantly higher mortality compared to the low-risk group. The rate of bleeding events after initiation of anticoagulation among both groups was not statistically different

BACKGROUND:National guidelines recommend different pharmacologic management of hypertension (HTN) without comorbidities for Black/African Americans (BAA) compared with non-BAA. We sought to 1) identify if these recommendations have influenced prescription patterns in BAA and 2) identify the differences in uncontrolled HTN in BAA on different antihypertensive medications. METHODS:We constructed a linked retrospective observational cohort using 2 years of electronic health records data, comprising of patients aged 18 to 85 with HTN on 1- or 2-drug regimens, including angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), thiazide diuretics, or calcium channel blockers (CCB). We examined prescribing differences and HTN control in BAA versus non-BAA. RESULTS:< .001). For each drug regimen, there was more variation in HTN control within each group than between BAA and non-BAA. CONCLUSIONS:Providers seem to be following race-based guidelines for HTN, yet HTN control for BAA remains worse than non-BAA. An individualized approach to HTN therapy for all patients may be more important than race-based guidelines.

Background/UNASSIGNED:Health providers' perceived sense of knowledge, competency, and self-efficacy to support the needs of their patients contributes to optimal patient health outcomes. With regards to mental health service delivery in Kenya, this area needs further exploration. Guided by the e-health technology acceptance mode, the needs and preferences of health care providers around mental health training for clinical management and their ability to intervene in peripartum adolescent mental health care are explored. We probed how well-equipped service providers are, their engagement with technology to learn and offer services. The health care provider's technology use preferences were also explored. Method/UNASSIGNED:Guided by a human-centered design-focused qualitative inquiry we interviewed 20 specialists around their needs, perspectives, and preferences for digitized mental health screening and intervention. Mean age was 44.2 years, (range of 32-58 years), 25% (5) males and 75% (15) females. After a written consenting process, the online interviews (30-45 min) were conducted in April 2021, once personal information was de-identified interviews were transcribed and coded. Thematic analysis was used and we combined rapid appraisal of Google Jamboard online storyboards to do individual human-centered design personas alongside. Results/UNASSIGNED:Our participants were well-exposed to digital technologies. Prohibitive costs of data bundles, lack of funds for consistent online engagement, high workload, and instability of access to appropriate gadgets were found to be barriers to e-health training. Emerging opportunities were well-identified adolescent mental health service and intervention needs, willingness to take online courses offered on learning platforms, and wish for these to be disseminated through diverse social media. Other recommendations were the need to have a user-friendly interface such as data-light engaging and practical materials including animations, short, group-based learning. Conclusion/UNASSIGNED:Understanding contextual factors that influence perceived usefulness and ease of use of the remote/digital components would be critical for e-training development and its uptake.