Faculty Bibliography

IMPORTANCE/UNASSIGNED:Hearing loss treatment delays cognitive decline in high-risk older adults. The preventive potential of addressing hearing loss on incident dementia in a community-based population of older adults, and whether it varies by method of hearing loss measurement, is unknown. OBJECTIVE/UNASSIGNED:To calculate the population attributable fraction of incident dementia associated with hearing loss in older adults and to investigate differences by age, sex, self-reported race, and method of hearing loss measurement. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This prospective cohort study was part of the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS) and had up to 8 years of follow-up (2011-2019). The 4 ARIC field centers in the study included Jackson, Mississippi; Forsyth County, North Carolina; the Minneapolis suburbs, Minnesota; and Washington County, Maryland. Community-dwelling older adults aged 66 to 90 years without dementia at baseline who underwent a hearing assessment at ARIC-NCS visit 6 (2016-2017) were included in the analysis. Data analysis took place between June 2022 and July 2024. EXPOSURES/UNASSIGNED:Hearing loss measured objectively (audiometric) and subjectively (self-reported). MAIN OUTCOMES AND MEASURES/UNASSIGNED:The main outcome was incident dementia (standardized algorithmic diagnosis with expert panel review). The population attributable fractions of dementia from both audiometric and self-reported hearing loss were calculated in the same participants, which quantified the maximum proportion of dementia risk in the population that can be attributed to hearing loss. RESULTS/UNASSIGNED:Among 2946 participants (mean [SD] age, 74.9 [4.6] years; 1751 [59.4] female; 637 Black [21.6%] and 2309 White [78.4%] individuals), 1947 participants (66.1%) had audiometric hearing loss, and 1097 (37.2%) had self-reported hearing loss. The population attributable fraction of dementia from any audiometric hearing loss was 32.0% (95% CI, 11.0%-46.5%). Population attributable fractions were similar by hearing loss severity (mild HL: 16.2% [95% CI, 4.2%-24.2%]; moderate or greater HL: 16.6% [95% CI, 3.9%-24.3%]). Self-reported hearing loss was not associated with an increased risk for dementia, so the population attributable fraction was not quantifiable. Population attributable fractions from audiometric hearing loss were larger among those who were 75 years and older (30.5% [95% CI, -5.8% to 53.1%]), female (30.8% [95% CI, 5.9%-47.1%]), and White (27.8% [95% CI, -6.0% to 49.8%]), relative to those who were younger than 75 years, male, and Black. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This cohort study suggests that treating hearing loss might delay dementia for a large number of older adults. Public health interventions targeting clinically significant audiometric hearing loss might have broad benefits for dementia prevention. Future research quantifying population attributable fractions should carefully consider which measures are used to define hearing loss, as self-reporting may underestimate hearing-associated dementia risk.

OBJECTIVE:Anogenital distance (AGD) is a postnatal marker of in utero exposure to androgens and anti-androgens, and a predictor of reproductive health. We examined the association between gestational exposure to phthalates and AGD in male and female infants. METHODS:In 506 mother-infant pairs (276 males, 230 females), we measured urinary concentrations of phthalate metabolites at < 18 and 18-25 weeks of gestation and AGD at child age 12.9 months (95 % range 11.4-21.1). Phthalate metabolite concentrations were adjusted for urinary dilution, averaged, and natural log-transformed. We measured anus-clitoris distance (AGDac) and anus-fourchette distance (AGDaf) in females, and anus-scrotum distance, anus-penis distance, and penile width in males. We used linear regression and partial-linear single-index (PLSI) models to examine associations between phthalates and AGD as single pollutants and in mixture. RESULTS:Fifty-eight percent of mothers were Hispanic, followed by 27 % non-Hispanic White. Higher exposures to ∑di-isononyl(phthalate) (∑DiNP) was associated with longer AGDaf [1.28 mm (95 % confidence interval [CI]: 0.52, 2.03) and 0.97 mm (95 %CI: 0.25, 1.69), respectively]. Higher exposures to ∑di(2-ethylhexyl)phthalate (∑DEHP) was associated with longer AGDac [2.80 mm (95 %CI: 1.17, 4.44), and 1.90 mm (95 %CI: 0.76, 3.04), respectively]. No association was observed between phthalate metabolites and AGD in males after multiple testing correction. In mixture analyses, ∑DiNP and ∑DEHP were the main contributors to longer AGD in females. We also detected an interaction between ∑DiNP and ∑DEHP in association with AGD in females. CONCLUSION/CONCLUSIONS:Early pregnancy phthalate exposure was associated with longer AGD in female infants. Biological mechanisms underlying these associations should be further investigated.

PURPOSE/OBJECTIVE:The Veterans Affairs Health Administration (VA) has experience using telehealth (TH) to deliver care to 10 million enrolled Veterans for many clinical care needs. The VA National TeleOncology Service (NTO) was established in 2020 to provide specialized cancer services regardless of geography. We sought to compare quality in TH-delivered cancer services with traditional (TR) in-person VA care. METHODS:Using electronic health record data, we identified patients with an International Classification of Diseases-10 diagnostic code for an incident malignancy from December 2016 to March 2021 at early adopting sites providing both TR and TH care. We classified patients as TH users if they received TH services at least once for their cancer care. We gathered demographic, clinical, and treatment characteristics to calculate 25 Quality Oncology Practice Initiative (QOPI) measures in the symptoms and toxicity management (two), end of life and palliative care (10), and core measure domains (13). We report disease-specific measures, QOPI measures descriptively, and performed chi-square tests to compare TH and TR. RESULTS:= .002). TH and TR rates were similar for the other QOPI measures. CONCLUSION/CONCLUSIONS:VA is a leader in TH cancer care because of both its volume and quality. VA-provided TH cancer care quality is similar to or better than that of TR in-person care. NTO specifically, and VA teleoncology broadly, provides another option to Veterans for cancer care.

BACKGROUND:Plant-based diets are associated with a lower risk of cardiovascular disease (CVD). Proteomics may improve our understanding of the biological pathways underlying these associations. OBJECTIVES/OBJECTIVE:Using large-scale proteomics, we aimed to examine if plant-based diet-related proteins, which have been previously identified, are associated with incident CVD and subtypes of CVD in the Atherosclerosis Risk in Communities (ARIC) Study and Framingham Heart Study (FHS) Offspring cohort. METHODS:Discovery analyses were based on 9,078 participants free of CVD at ARIC visit 3 (1993-1995). Cox proportional hazards regression was used to evaluate the associations between plant-based diet-related proteins and incident CVD, coronary heart disease, heart failure, and stroke. Replication analyses were based on 1,279 participants without CVD in FHS Offspring cohort. RESULTS:In the ARIC Study, over a median follow-up of 21 years, there were 3,167 CVD events. At a false discovery rate (FDR) <0.05, 26 out of 73 plant-based diet-related proteins were significantly associated with incident CVD, after adjusting for important confounders. 18, 1, and 0 proteins were associated with heart failure, stroke, and coronary heart disease, respectively. Three, and 2 additional proteins were associated with CVD, and heart failure risk in FHS Offspring cohort at the nominal threshold (p value <0.05). Soluble advanced glycosylation end product-specific receptor (AGER) was inversely associated with incident CVD whereas thrombospondin-2 (THBS2) and N-terminal pro-BNP (NT-proBNP) was positively associated with incident CVD. THBS2 was positively associated with incident heart failure, whereas neuronal growth factor regulator 1 (NEGR1) and insulin-like growth factor-binding protein 1 (IGFBP1) was inversely associated. CONCLUSION/CONCLUSIONS:These proteins highlight several pathways that could explain plant-based diets-CVD associations.

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.