Faculty Bibliography

STUDY OBJECTIVE/OBJECTIVE:Input from adolescents and healthcare providers is needed to develop electronic tools that can support patient-centered sexual and reproductive (SRH) care. This study explores facilitators and barriers to patient-centered communication in the context of developing an electronic appointment planning tool to promote SRH communication in clinic settings. DESIGN/METHODS:In-depth interviews were conducted to explore what constitutes adolescent-friendly SRH care and communication, as well as on the design of the appointment planning tool. Interviews were coded iteratively, and analyzed using the software Atlas.TI v8. SETTING/METHODS:An adolescent primary care clinic, and a pediatric and adolescent gynecology clinic. PARTICIPANTS/METHODS:Adolescent girls (N=32; ages 14-18) and providers who care for adolescent girls (N=10). MAIN OUTCOME MEASURES/METHODS:Thematic analyses explored facilitators/barriers to SRH communication and care and preferences for the tool. RESULTS:Facilitators identified by adolescents and providers included: direct patient/provider communication; adolescent-driven decision-making regarding care and contraceptive choice; supplementing clinic visits with electronic resources; and holistic care addressing physical, mental, and social needs. Barriers identified by participants included: limited time for appointments; limited adolescent autonomy in appointments; and poor continuity of care when adolescents cannot see the same provider. Given the complexity of issues raised, adolescents and providers were interested in developing an appointment planning tool to guide communication during appointments, and contributed input on its design. The resulting Appointment Planning Tool app pilot is in progress. CONCLUSIONS:Qualitative interviews with adolescents and providers offer critical insights for the development and implementation of mobile health (mHealth) tools that can foster patient-centered care.

Maintaining influenza vaccination at high coverage has the potential to prevent a proportion of COVID-19 morbidity and mortality. We examined whether flu-vaccination is associated with severe corona virus disease 2019 (COVID-19) disease, as measured by intensive care unit (ICU)-admission, ventilator-use, and mortality. Other outcome measures included hospital length of stay and total ICU days. Our findings showed that flu-vaccination was associated with a significantly reduced likelihood of an ICU admission especially among aged <65 and non-obese patients. Public health promotion of flu-vaccination may help mitigate the overwhelming demand for critical COVID-19 care pending the large-scale availability of COVID-19 vaccines.

Federally Qualified Health Centers (FQHCs) provide primary care services in underserved areas and are governed by patient-majority boards. A phenomenological approach was used to explore the lived experiences of board members as they addressed the need for fundamental change to meet the demands of a rapidly changing, highly competitive health care market (2010-2020). Findings were that board members rely upon personal experience and monthly board meetings to be alerted to change that affects health care delivery. They may need additional training to adjust governance and organizational performance to address the new patient consumerism, market conditions, and competition from other providers.

BACKGROUND:While specific interventions have previously demonstrated benefit in patients with the Acute Respiratory Distress Syndrome (ARDS), use of these interventions is inconsistent, and patient mortality remains high. The impact of variability in center management practices on ARDS mortality rates remains unknown. RESEARCH QUESTION/OBJECTIVE:What is the impact of treatment variability on mortality in patients with moderate-to-severe ARDS in the United States (US)? STUDY DESIGN AND METHODS/METHODS:O, who were admitted to 29 US centers between October 1, 2016 and April 30, 2017. The primary outcome was 28-day in-hospital mortality. Center variation in ventilator management, adjunctive therapy use, and mortality were also assessed. RESULTS:O) was 31.4% and varied between centers (0%-65%), as did rates of adjunctive therapy use (27.1%-96.4%), types of modalities used (neuromuscular blockade, prone positioning, systemic steroids, pulmonary vasodilators, and extracorporeal support), and mortality (16.7-73.3%). Center standardized mortality ratios (SMRs), calculated using baseline patient-level characteristics to derive expected mortality rate, ranged from 0.33 to 1.98. Of the treatment-level factors explored, only center adherence to early lung protective ventilation (LPV) was correlated with SMR. INTERPRETATION/CONCLUSIONS:Substantial center-to-center variability exists in ARDS management, suggesting that further opportunities for improving ARDS outcomes exist. Early adherence to LPV was associated with lower center mortality and may be a surrogate for overall quality of care processes. Future collaboration is needed to identify additional treatment-level factors influencing center-level outcomes. CLINICAL TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03021824.

OBJECTIVE:To describe factors associated with Quality improvement and patient safety (QIPS) participation using 2018 American Urological Association Census data. QIPS have become increasingly important in medicine. However, studies about QIPS in urology suggest low levels of participation, with little known about factors predicting non-participation. METHODS:Results from 2339 census respondents were weighted to estimate 12,660 practicing urologists in the United States. Our primary outcome was participation in QIPS. Predictor variables included demographics, practice setting, rurality, fellowship training, QIPS domains in practice, years in practice, and non-clinical/clinical workload. RESULTS:QIPS participants and non-participants significantly differed in distributions of age (P = .0299), gender (P = .0013), practice setting (P <.0001), employment (employee vs partner vs owner vs combination; P <.0001), and fellowship training (P <.0001). QIPS participants reported fewer years in practice (21.3 vs 25.9, P = .018) and higher clinical (45.2 vs 39.2, P = .022) and non-clinical (8.76 vs 5.28, P = .002) work hours per week. Non-participation was associated with male gender (OR = 2.68, 95% CI 1.03-6.95) and Asian race (OR = 2.59, 95% CI 1.27-5.29) for quality programs and private practice settings (ORs = 8.72-27.8) for patient safety initiatives. CONCLUSION/CONCLUSIONS:QIPS was associated with academic settings. Interventions to increase rates of quality and safety participation should target individual and system-level factors, respectively. Future work should discern barriers to QIPS engagement and its clinical benefits.

OBJECTIVES/OBJECTIVE:Understanding barriers to care for transgender people with cancer is necessary to increase oncologic care access. Little has been published regarding the experiences of transgender people with cancer. We sought to explore these experiences, assess barriers to oncologic care, and elucidate potential solutions. METHODS:Using an interpretive descriptive approach, we conducted two group interviews with transgender people who had been diagnosed with cancer and one with physicians who treat patients with cancer. Two investigators independently analyzed verbatim transcripts and, together, refined themes, resolving disagreements with consensus. Member checking and peer debriefing were used to confirm and elaborate on findings. RESULTS:Seven people who had been diagnosed with cancer and five physicians who treat people with cancer participated in group interviews. Themes included: (a) experiences with cancer may uniquely impact transgender people; (b) enforcement of clinician and systemic gender expectations creates barriers to cancer care; and (c) resistance to gender expectations may facilitate care. CONCLUSIONS:Gender expectations create barriers to oncologic care, which can be resisted by patients, clinicians, and institutions. IMPLICATIONS FOR PRACTICE/CONCLUSIONS:Clinicians and institutions should create gender-inclusive oncologic spaces, demonstrate allyship, and support patient autonomy to decrease barriers to care for transgender people with cancer.

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More stringent blood pressure (BP) goals have led to greater prevalence of apparent resistant hypertension (ARH), yet the long-term prognostic impact of ARH diagnosed according to these goals in the general population remains unknown. We assessed the prognostic impact of ARH according to contemporary BP goals in 9612 participants of the Atherosclerosis Risk in Communities (ARIC) study without previous cardiovascular disease. ARH, defined as BP above goal (traditional goal <140/90 mmHg, more stringent goal <130/80 mmHg) despite the use of ≥3 antihypertensive drug classes or any BP with ≥4 antihypertensive drug classes (one of which was required to be a diuretic) was compared with controlled hypertension (BP at goal with 1-3 antihypertensive drug classes). Cox regression models were adjusted for age, sex, race, study center, BMI, heart rate, smoking, eGFR, LDL, HDL, triglycerides, and diabetes. Using the traditional BP goal, 133 participants (3.8% of the treated) had ARH. If the more stringent BP goal was instead applied, 785 participants (22.6% of the treated) were reclassified from controlled hypertension to uncontrolled hypertension (n = 725) or to ARH (n = 60). Over a median follow-up time of 19 years, ARH was associated with increased risk for a composite end point (all-cause mortality, hospitalization for myocardial infarction, stroke, or heart failure) regardless of whether traditional (adjusted HR 1.50, 95% CI: 1.23-1.82) or more stringent (adjusted HR 1.43, 95% CI: 1.20-1.70) blood pressure goals were applied. We conclude that in patients free from cardiovascular disease, ARH predicted long-term risk regardless of whether traditional or more stringent BP criteria were applied.

INTRODUCTION/BACKGROUND:Cardiovascular disease is the leading cause of death worldwide, and cardiovascular disease burden is increasing in low-resource settings and for lower socioeconomic groups. Machine learning algorithms are being developed rapidly and incorporated into clinical practice for cardiovascular disease prediction and treatment decisions. Significant opportunities for reducing death and disability from cardiovascular disease worldwide lie with accounting for the social determinants of cardiovascular outcomes. This study reviews how social determinants of health are being included in machine learning algorithms to inform best practices for the development of algorithms that account for social determinants. METHODS:A systematic review using 5 databases was conducted in 2020. English language articles from any location published from inception to April 10, 2020, which reported on the use of machine learning for cardiovascular disease prediction that incorporated social determinants of health, were included. RESULTS:Most studies that compared machine learning algorithms and regression showed increased performance of machine learning, and most studies that compared performance with or without social determinants of health showed increased performance with them. The most frequently included social determinants of health variables were gender, race/ethnicity, marital status, occupation, and income. Studies were largely from North America, Europe, and China, limiting the diversity of the included populations and variance in social determinants of health. DISCUSSION/CONCLUSIONS:Given their flexibility, machine learning approaches may provide an opportunity to incorporate the complex nature of social determinants of health. The limited variety of sources and data in the reviewed studies emphasize that there is an opportunity to include more social determinants of health variables, especially environmental ones, that are known to impact cardiovascular disease risk and that recording such data in electronic databases will enable their use.

INTRODUCTION/BACKGROUND:The aim of this review article is to compare the outcomes of newer non-thermal endovenous ablation techniques to thermal ablation techniques for the treatment of symptomatic venous insufficiency. EVIDENCE ACQUISITION/METHODS:Three independent reviewers screened PubMed® and EMBASE® databases to identify relevant studies. A total of 1173 articles were identified from database search that met our inclusion criteria. Two articles were identified through reference search. Removal of duplicates from our original search yielded 695 articles. We then screened these articles and assessed 173 full-text articles for eligibility. Subsequent to exclusion, 11 full-text articles were selected for final inclusion. EVIDENCE SYNTHESIS/RESULTS:The non-thermal techniques are similar to thermal techniques in terms of a high technical success rate, closure rate at 12 months, change in Venous Clinical Severity Score and change in quality of life after procedure. However, the length of procedure is shorter for non-thermal modalities and patient comfort is improved with lower pain scores. Return to work may also be earlier after non-thermal ablation. The rates of bruising, phlebitis and paresthesia are higher after thermal ablation. CONCLUSIONS:The non-thermal modalities are safe and effective in treating venous reflux and have shown improved patient comfort and shorter length of procedure which may make them favorable for use compared to the thermal modalities.