Faculty Bibliography

BACKGROUND/UNASSIGNED:This paper provides an overview of adapting a micro-savings program originally developed in the United States to a resource-limited setting in Uganda, highlighting this specific case of adapting a program from one country to another. The program involved opening Child Development Accounts (CDAs) to support saving among adolescents girls and their families. Guided by the asset theory and institutional theory, the paper discusses the challenges and opportunities faced during the adaptation and implementation process. The findings offer insights that can inform efforts to expand similar micro-savings programs in other resource-limited communities. METHODS/UNASSIGNED:This paper utilizes data from the Suubi4Her study (2017-2022), a longitudinal intervention involving 1,260 adolescent girls in Southern Uganda. The analysis focused on saving behaviors among the entire sample and a subsample of 690 participants who opened CDAs. We examined self-reported and administrative savings outcomes over 30 months, encompassing bank savings behavior and savings beyond the initial deposit. Analyses also addressed key sociodemographic and psychosocial factors. A mixed-effect and adjusted logistic regression model were applied. RESULTS/UNASSIGNED:At enrollment, the participant's mean age was 15.37 years. The intervention improved bank saving behavior, evidenced by significant intervention-by-time interaction effects [χ2(2) = 43.38, p < 0.01], demonstrating a substantial increase in the odds of bank saving behavior in the intervention group at Wave 2 (OR = 78.85, 95% CI: 18.76, 331.51, p < 0.01) and Wave 3 (OR = 80.95, 95% CI: 19.31, 339.26, p < 0.01) compared to baseline within the control group. In the analysis of additional saving beyond the initial deposit, participants whose schools were located within 2 km of their home had significantly higher odds of saving (OR = 2.74, 95% CI: 1.72-4.37, p < 0.01), while older participants had lower odds (OR = 0.83, 95% CI: 0.68-0.99, p = 0.04). Living nearer to a bank was associated with increased odds of additional saving (OR = 1.74, 95% CI: 0.84-3.62, p = 0.13), though this association did not reach statistical significance. CONCLUSIONS AND IMPLICATIONS/UNASSIGNED:These findings suggest that, overall, CDA-based micro-saving programs implementation is possible even in resource limited communities like Uganda, and when given the opportunity, families living in low-income households can utilize the CDA "infrastructure" to save. Overall, for the saving intervention to yield its intended benefits, institutional barriers need to be addressed, including bringing the bank services to the people and providing financial literacy training to instill the culture of saving from a young age.

Introduction Cordon-based congestion policies have demonstrated air quality and health benefits in cities outside the United States (U.S.), yet selecting comparison areas to evaluate these policies remains a methodological challenge. Using two pre-policy administrative health datasets, we examined the feasibility of constructing local, state, and regional counterfactual populations to inform an evaluation of child health impacts of the recently implemented New York City (NYC) congestion pricing policy, focusing on pediatric asthma emergency department visits. Methods Our study population included children aged 0-17 years. Using a difference-in-differences approach for repeated measures, we evaluated crude pre-policy pediatric asthma trends between the congestion relief zone (CRZ) and three comparison areas: (1) NYC neighborhoods outside the CRZ, (2) nine major New York State cities, and (3) dense, heavily trafficked Northeast regional U.S. cities. We compared this approach with a generalized synthetic control method (G-SCM). Results Crude pre-policy pediatric asthma trends were most parallel between the CRZ and the local NYC comparison zone. Socioeconomic, built environment, and environmental exposure covariates varied across comparison areas at baseline. G-SCM improved visual pre-policy trend alignment across all three comparison areas; however, placebo tests revealed statistically significant parallel trend violations persisted for non-local comparison areas. Conclusions Local comparison populations may offer the most representative counterfactual for evaluating NYC congestion pricing child health impacts. Residual parallel trend violations in non-local areas underscore the methodological challenges of counterfactual selection for geographically concentrated urban policies, highlighting the value of triangulating findings across comparison areas and analytic approaches in future post-implementation evaluations.

IMPORTANCE/UNASSIGNED:Lower estimated glomerular filtration rate (eGFR) is associated with increased rates of death and kidney and cardiovascular events. Associations of measured GFR (mGFR) with outcomes remain unclear. OBJECTIVE/UNASSIGNED:To quantify associations between mGFR and adverse clinical outcomes and to compare these with eGFR-based associations. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:Retrospective observational cohort study of 6174 adults from Stockholm, Sweden, between January 1, 2011, and December 31, 2021. EXPOSURE/UNASSIGNED:Measured GFR was obtained based on plasma clearance of intravenously administered iohexol (primary independent variable of interest). Estimated GFR was calculated with plasma creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys), using the Chronic Kidney Disease Epidemiology Collaboration 2021 and 2012 equations. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Primary outcomes were all-cause mortality and kidney failure with replacement therapy. Associations of each GFR measure with outcomes were evaluated using hazard ratios adjusted for age, sex, body mass index (calculated as weight in kilograms divided by height in meters squared), medical history, medications, and urine albumin to creatinine ratio. RESULTS/UNASSIGNED:Of 6174 participants (median age, 59 years [IQR, 43-69]; 3686 [60%] were male and 2488 [40%] were female), 1977 (32%) died and 426 (6.9%) developed kidney failure with replacement therapy during a median follow-up of 5.9 years (IQR, 3.0-8.8 years). Compared with a baseline mGFR of 90 mL/min/1.73 m2, an mGFR of 60 mL/min/1.73 m2 was associated with higher rates of all-cause mortality (27.6 vs 22.4 per 1000 person-years; hazard ratio [HR], 1.21; 95% CI, 1.14-1.28) and kidney failure with replacement therapy (1.2 vs 0.4 per 1000 person-years; HR, 2.85; 95% CI, 2.06-3.94). For all-cause mortality, associations for eGFRcr-cys did not significantly differ from those for mGFR (ratio of HRs [RHRs] at 60 mL/min/1.73 m2, 1.03; 95% CI, 0.96-1.10), whereas eGFRcr underestimated the mGFR-based association (RHR, 0.87; 95% CI, 0.79-0.95) and eGFRcys overestimated it (RHR, 1.17; 95% CI, 1.08-1.27). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Among adults in Sweden, mGFR values of 60 mL/min/1.73 m2 were associated with higher rates of all-cause mortality and kidney failure compared with mGFR values of 90 mL/min/1.73 m2, supporting the current GFR threshold of 60 mL/min/1.73 m2 to define chronic kidney disease. Associations of mGFR with mortality were most closely represented by the association of eGFRcr-cys with mortality, whereas eGFRcr underestimated and eGFRcys overestimated mortality risk.

BackgroundFew studies have examined which patients with migraine might be responders for mind-body interventions. Thus, we examined whether certain baseline mindfulness traits and interest in physical exercise might predict response to treatment.MethodsThis is a planned exploratory analysis of a phase 2 randomized controlled study (N  =  50; 25 per arm) comparing a 6-week physical therapist (PT)-delivered biofeedback-assisted relaxation (BAR) program vs. an Enhanced Usual Care (EUC) migraine self-management program (diary tracking and emailed migraine-related educational materials). We conducted moderation analyses to determine whether the Multidimensional Assessment of Interoceptive Awareness (MAIA), Difficulties in Emotion Regulation Scale (DERS) and Physical Activity Enjoyment Scale (PACES) at baseline influenced the effect of BAR on migraine-related outcomes (Migraine-Specific Quality of Life Role Function Restrictive (MSQv2.1-RFR) and Migraine-Related Disability (MIDAS)) at 6 months.ResultsAmong the n = 40 participants (BAR = 19; EUC = 21), the majority were female (95%), non-Hispanic (77.5%) and white (67.5%). Mean (SD) age was 45.6 (11.2) years. For the MAIA Not-Worrying subscale, BAR produced the greatest improvement in 6-month MSQv2.1-RFR scores among participants with low baseline Not-Worrying scores (those who tended to worry about bodily sensations/discomfort more) (BAR = 77.1 ± 6.6 vs. EUC = 48.9 ± 5.0; p = 0.002, g = 4.75). The benefit diminished at average levels (p = 0.060, g = 2.72) and was absent at high baseline Not-Worrying (p = 0.528, g =  -0.91). For the MAIA Self-Regulation subscale, BAR was most effective among those low in baseline self-regulation (BAR = 71.7 ± 5.3 vs. EUC = 44.3 ± 7.2; p = 0.004, g = 4.27). The DERS total score showed that BAR demonstrated little benefit among participants with better baseline emotion regulation (i.e. lower DERS score; p = 0.907, g = 0.17) but was more effective as baseline emotion regulation difficulties increased, showing a moderate benefit at average levels (BAR = 69.2 ± 4.2 vs. EUC = 55.8 ± 4.0, p = 0.027, g = 3.25) and a large, significant difference at high levels (BAR = 70.6 ± 6.3 vs. EUC = 44.7 ± 5.7; p = 0.004, g = 4.22). The PACES total score indicated that BAR benefits were strongest among those with low (BAR = 76.1 ± 7.0 vs. EUC = 47.1 ± 5.3, p = 0.002, g = 4.60) to average (BAR = 71.2 ± 4.2 vs. EUC = 58.6 ± 4.0, p = 0.035, g = 3.07) enjoyment of physical activity.ConclusionsWe found subgroups of individuals with migraine who may be better responders to PT-delivered BAR, specifically those who tend to worry more about bodily sensations (lower MAIA Not-Worrying score), those with low self-regulation (lower MAIA Self-Regulation score), those with worse emotion regulation (higher DERS score) and those with lower levels of physical activity enjoyment (lower PACES score) at baseline. This may help us determine who may benefit most from BAR.Trial RegistrationClinicalTrials.gov Identifier: NCT06077812.

BACKGROUND:Remote patient monitoring (RPM) and telehealth improve hypertension management but remain underutilized in resource-constrained settings. The Advancing Long-term Improvements in Hypertension Outcomes through a Team-based Care Approach (ALTA) intervention integrates RPM and virtual health coaching into routine care across a large urban FQHC network and has improved blood pressure outcomes. OBJECTIVE:Explore contextual and mechanistic factors shaping ALTA's implementation outcomes from the perspective of intervention deliverers. DESIGN/METHODS:Following 1 year of ALTA implementation, we conducted a realist-informed qualitative evaluation to examine factors influencing intervention uptake using semi-structured interviews and focus groups conducted from September to November 2023. PARTICIPANTS/METHODS:Practice leadership, clinicians, and staff. APPROACH/METHODS:Participants were recruited through convenience sampling. Transcripts were analyzed using a stepwise deductive and inductive coding approach. Deductive codes were drawn from Proctor's taxonomy of implementation outcomes. Themes were developed using context-mechanism-outcome (C-M-O) configurations. KEY RESULTS/RESULTS:Analysis of 32 semi-structured interviews and four focus groups with a total of 46 intervention deliverers revealed five primary C-M-O-oriented themes: (1) Appropriateness, determined by perceptions of fit, drives acceptability. (2) Demanding workflows raise concerns around ALTA's additional burden, influencing perceptions of appropriateness. (3) Intervention challenges are mitigated by practice facilitation and team-based problem-solving, enhancing acceptability, feasibility, and fidelity. (4) Repeated exposure promotes workflow optimizations, fostering intervention penetration over time. (5) Staff desire insight into ALTA's impact, and communication about intervention progress increases motivation and buy-in. Five of Proctor's implementation outcomes emerged most prominently: appropriateness, acceptability, feasibility, fidelity, and penetration. Notably, these outcomes were interdependent, with one acting as an important contextual factor or mechanistic element for another. CONCLUSIONS:This evaluation highlights important contextual factors, mechanisms, and interconnected outcomes underlying implementation of ALTA. Shared understanding and peer learning, workflow optimization, and communication of outcomes with frontline staff improve reach, equity, and sustainability of RPM-enabled interventions for hypertension management in FQHCs. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT03713515, date of registration: October 19, 2018, https://classic. CLINICALTRIALS/RESULTS:gov/ct2/show/NCT03713515.

BACKGROUND:Timely emergency medical services (EMS) response is critical to improving survival after trauma. However, concordance between EMS dispatch level and on-scene patient acuity remains poorly understood. This study evaluated the association between racial and ethnic residential segregation and concordance between EMS response level and on-scene acuity among critically injured trauma patients. METHODS:Using 2018-2022 National EMS Information System data, we analyzed trauma patient entries meeting CDC field triage criteria for transport to a trauma center. Concordance was defined as alignment between dispatch classification of response (emergent vs. nonemergent) and EMS providers' subsequent on-scene clinical assessment of acuity (critical/emergent vs. noncritical/low acuity). Racial and ethnic residential segregation at the ZIP Code level was measured using a multigroup dissimilarity index comparing neighborhood composition to county distribution. χ2 tests and multivariable logistic regression were used to assess the associations between segregation and under-triage, adjusting for region (Northeast, Midwest, South, West). RESULTS:Among 34.7 million critically injured patients over 5 years, 69% had concordant EMS responses, 6% were under-triaged, and 26% over-triaged. Concordance was highest in the Midwest (74%) and lowest in the Northeast (62%). Under-triage was most frequent in the West (10%) and least in the South (4%). Neighborhoods with medium and high segregation had twice the under-triage rates than low-segregation areas (8% and 7% vs. 4%, p<0.001). In adjusted analyses, medium and high segregation were 60% more likely to be associated with increased odds of under-triage (odds ratio: 1.61, 95% confidence: 1.60-1.61). CONCLUSIONS:This is the largest study to date demonstrating that racial and ethnic residential segregation was significantly associated with meaningfully and significantly increased risk of under-triage among critically injured trauma patients. Furthermore, structural inequities in neighborhood segregation may delay access to definitive trauma care. Equity-driven EMS policy reform, standardized dispatch protocols, and targeted training are needed to mitigate disparities in prehospital trauma response. (J Trauma Acute Care Surg 2026;00:000-000. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE/METHODS:Prognostic and Epidemiological; Level IV.

Comparing outcomes across treatments is essential in medicine and public policy. To do so, researchers typically estimate a set of parameters, possibly counterfactual, each targeting adifferent treatment. Treatment-specific means are commonly used, but their identification requires a positivity assumption: every subject has a nonzero probability of receiving each treatment. This assumption is often implausible, especially when treatment can take many values. Causal parameters based on dynamic stochastic interventions offer robustness to positivity violations. However, comparing these parameters may fail to reflect the effects of the underlying target treatments because the parameters can depend on outcomes under nontarget treatments. To clarify when two parameters targeting different treatments yield a useful comparison of treatment efficacy, we propose a comparability criterion: if the conditional treatment-specific mean for one treatment is greater than that for another, then the corresponding causal parameter should also be greater. Many standard parameters fail to satisfy this criterion, but we show that only a mild positivity assumption is needed to identify parameters that yield useful comparisons. We then provide two simple examples that satisfy this criterion and are identifiable under the milder positivity assumption: trimmed and smooth-trimmed treatment-specific means with multivalued treatments. For smooth-trimmed treatment-specific means, we develop doubly robust-style estimators that attain parametric convergence rates under nonparametric conditions. We illustrate our methods with an analysis of dialysis providers in New York State.

BACKGROUND:Given established relationships between social class and mortality, the growing concentration of income, wealth, and power among business owners in the U.S. may have increased mortality inequities across classes. To investigate this hypothesis, we analyzed temporal changes in mortality inequities between owners and non-owners. METHODS:Our sample included respondents ages 25-64 in the 1984, 1989, 1994, and 1999-2013 Panel Study of Income Dynamics with mortality follow-up through 2022 (respondents: 22,103; observations: 103,965). Business owners were individuals with personal or family ownership of, or direct financial interest in, a business in the prior year. Using g-computation, we estimated how inequities between owners and non-owners in 10-year age-adjusted mortality risks changed from 1984-2013. Next, we analyzed whether any changes were attributable to shifting social stratification. Finally, we analyzed whether growing income and wealth disparities between owners and non-owners exacerbated inequities. RESULTS:In 1984, non-owners had 1.4 times (95% CI: 1.1, 1.8) greater 10-year age-adjusted mortality risks than owners. In 2013, the figure was 2.3 (95% CI: 1.8, 3.0), yielding a ratio of risk ratios (RRR) of 1.7 (95% CI: 1.1, 2.5). After social-stratification-adjustment, within-year inequities lessened; however, increases across years attenuated only somewhat (2013 vs 1984 RRR: 1.5 [95% CI: 0.99, 2.2]). Finally, we did not find that increases in inequities across years would have lessened if income and wealth distributions had remained at 1984 levels. CONCLUSIONS:Mortality inequities between owners and non-owners have increased and cannot be fully explained by social stratification and individual-level income and wealth distributions.

IMPORTANCE/UNASSIGNED:Current pregnancy surveillance efforts in the US face substantial challenges in providing timely and accurate data on prenatal care use. Electronic health record (EHR) networks have the potential to enhance existing surveillance systems by providing near real-time, clinically documented data. OBJECTIVE/UNASSIGNED:To assess whether EHR network data could be used to define valid and reliable surveillance metrics of prenatal care use. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This longitudinal cohort study included US adults (age ≥18 years) who received prenatal care and delivered a live birth from January 1, 2023, to December 31, 2024, at a facility that used the Epic Cosmos EHR network. EXPOSURE/UNASSIGNED:Live birth at a facility that used the selected EHR network. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Prenatal care use was calculated as the proportions of patients who initiated care by the 13th week of pregnancy (early care) and who received adequate or better prenatal care (adequate care). Raking weights were applied to adjust the EHR sample to match the marginal distributions for US residents with live births by age, race and ethnicity, insurance, pregnancy risk factors, and geographic region. Electronic health records-based metrics were externally validated against published natality data estimates from National Center for Health Statistics (NCHS) using the two 1-sided test of equivalence. Patterns by demographics, state, and year were examined. RESULTS/UNASSIGNED:In total, 1 963 496 patients (mean [SD] age, 29.5 [5.7] years; 100% women) had a live birth and evidence of prenatal care at a facility using the selected EHR network during the study period. Compared with all US birthing people (n = 7 224 951), patients who gave birth at a facility using the selected EHR network had lower Medicaid coverage (40.5% vs 21.1%) and a higher prevalence of pregnancy risk factors (eg, prior preterm birth: 4.0% vs 8.8%). After weighting to the national population, EHR-based estimates of early care were consistently lower than those from NCHS data (68.0% [95% CI, 67.9%-68.2%] vs 76.1% [95% CI, 76.1%-76.1%]). However, adequacy estimates were equivalent to NCHS-based estimates (76.0% [95% CI, 75.9%-76.2%] vs 75.2% [95% CI, 75.1%-75.2%]; P < .001 at 0.01 equivalence bound), aligned with expected demographic patterns, and were stable across place and time. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cohort study, EHR network data reliably informed surveillance of prenatal care adequacy after adjusting for nonrepresentativeness of the patient population. These findings suggest that near real-time availability of EHR data has the potential to improve the timeliness of population-level pregnancy surveillance to better inform policy, public health, and clinical efforts aimed at enhancing prenatal care access and use among individuals receiving inadequate care.