Faculty Bibliography
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school:SOM
Department/Unit:Population Health
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12207
Discharge practices in skilled nursing facilities affected by COVID-19 [Meeting Abstract]
BACKGROUND: Many patients require post-acute care at skilled nursing facilities (SNF) after hospital discharge. While returning from SNF to home is often the ultimate goal for these patients, a safe discharge from SNF often requires additional support from home health care agencies or from patients' families. However, the COVID-19 pandemic affected all aspects of the healthcare industry, complicating transition home. To understand how post-acute SNF throughput was affected by the COVID-19 pandemic, we conducted a study of discharge processes of patients with COVID-19 at a skilled nursing facility.
METHOD(S): This was a retrospective study of all residents at our SNF with a positive COVID-19 PCR test between 3/1/20-6/1/20. We defined post-acute patients as those who were admitted to the nursing home 100 days or less before the positive test. Using the facility's electronic medical record, we reviewed all medical, nursing, social work and other notes to identify discharge planning processes. Specifically, we identified if discharge planning was initiated, whether the patient was successfully discharged, and whether there was evidence that the discharge was complicated by COVID-19 related challenges.
RESULT(S): Of 350 residents with a positive COVID-19 PCR, 121 were postacute patients who were admitted to our facility within 30 days of positive PCR or symptom onset. Median age was 79 (interquartile range [IQR], 69-86), 59 (49%) were female, 16 (13%) were Black, 8 (7%) were White, 8 (7%) were Hispanic and 84 (70%) did not report race. Over an average follow-up time of 185 days, 98 (81%) post-acute patients had discharge planning initiated, of which 81 were discharged to the community. Median length of stay for those discharged was 38 days (IQR 23-98). Discharge sites included home (66 [81%]), assisted living facilities (9 [7%]), and hotels (2 [2%]). Discharge planning was affected by COVID-19 for 49 (41%) patients. These included symptom development that precluded discharge; logistical issues related to establishing home oxygen; unwillingness for assisted living facilities, home care services, or families to receive COVID-19 positive patients; challenges establishing home care services due to staffing shortages; and family members sick with COVID-19 themselves.
CONCLUSION(S): The COVID-19 pandemic had a multi-layered effect on the ability of nursing home residents to be discharged safely home. LEARNING OBJECTIVE #1: Practice-Based Learning and Improvement: A diagnosis of COVID-19 has a substantial impact on the ability to safely discharge patients from SNF due to concerns from assisted living facilities, home care services, and families about directly caring for someone with COVID-19. LEARNING OBJECTIVE #2: Systems-Based Practice: Delayed discharge from SNF may impact their ability to accept new patients, which may have further upsteam effects on other aspects of the healthcare continuum such as hospital length of stay
METHOD(S): This was a retrospective study of all residents at our SNF with a positive COVID-19 PCR test between 3/1/20-6/1/20. We defined post-acute patients as those who were admitted to the nursing home 100 days or less before the positive test. Using the facility's electronic medical record, we reviewed all medical, nursing, social work and other notes to identify discharge planning processes. Specifically, we identified if discharge planning was initiated, whether the patient was successfully discharged, and whether there was evidence that the discharge was complicated by COVID-19 related challenges.
RESULT(S): Of 350 residents with a positive COVID-19 PCR, 121 were postacute patients who were admitted to our facility within 30 days of positive PCR or symptom onset. Median age was 79 (interquartile range [IQR], 69-86), 59 (49%) were female, 16 (13%) were Black, 8 (7%) were White, 8 (7%) were Hispanic and 84 (70%) did not report race. Over an average follow-up time of 185 days, 98 (81%) post-acute patients had discharge planning initiated, of which 81 were discharged to the community. Median length of stay for those discharged was 38 days (IQR 23-98). Discharge sites included home (66 [81%]), assisted living facilities (9 [7%]), and hotels (2 [2%]). Discharge planning was affected by COVID-19 for 49 (41%) patients. These included symptom development that precluded discharge; logistical issues related to establishing home oxygen; unwillingness for assisted living facilities, home care services, or families to receive COVID-19 positive patients; challenges establishing home care services due to staffing shortages; and family members sick with COVID-19 themselves.
CONCLUSION(S): The COVID-19 pandemic had a multi-layered effect on the ability of nursing home residents to be discharged safely home. LEARNING OBJECTIVE #1: Practice-Based Learning and Improvement: A diagnosis of COVID-19 has a substantial impact on the ability to safely discharge patients from SNF due to concerns from assisted living facilities, home care services, and families about directly caring for someone with COVID-19. LEARNING OBJECTIVE #2: Systems-Based Practice: Delayed discharge from SNF may impact their ability to accept new patients, which may have further upsteam effects on other aspects of the healthcare continuum such as hospital length of stay
EMBASE:635796784
ISSN: 1525-1497
CID: 4984922
Androgen deprivation therapy and excess mortality in men with prostate cancer during the initial phase of the COVID-19 pandemic
BACKGROUND:Men have a higher risk of death from COVID-19 than women and androgens facilitate entrance of the SARS-CoV-2 virus into respiratory epithelial cells. Thus, androgen deprivation therapy may reduce infection rates and improve outcomes for COVID-19. In the spring of 2020, Sweden was highly affected by COVID-19. The aim was to estimate the impact of androgen deprivation therapy on mortality from COVID-19 in men with prevalent prostate cancer by comparing all-cause mortality in the spring of 2020 to that in previous years. PATIENTS AND METHODS:Using the Prostate Cancer data Base Sweden all men with prostate cancer on March 1 each year in 2015-2020 were followed until June 30 the same year. Exposure to androgen deprivation therapy was ascertained from filled prescriptions for bicalutamide monotherapy, gonadotropin-releasing hormone agonists (GnRH), or bilateral orchidectomy. RESULTS:A total of 9,822 men died in March-June in the years 2015-2020, of whom 5,034 men were on androgen deprivation therapy. There was an excess mortality in 2020 vs previous years in all men. The crude relative mortality rate ratio for 2020 vs 2015-2019 was 0.93 (95% confidence interval (CI) 0.83 to 1.04) in men on GnRH, and 0.90 (95% CI 0.78 to 1.05) in men on bicalutamide monotherapy. After multivariable adjustment these ratios were attenuated to 1.00 (95% CI 0.89 to 1.12) and 0.97 (95% CI 0.84 to 1.12), respectively. When restricting the analysis to the regions with the highest incidence of COVID-19 or to the time period between 2 April to 10 June when mortality in 2020 was increased >30% compared to previous years, the results were similar to the main analysis. CONCLUSIONS:In this large national population-based cohort of men with prevalent prostate cancer, there was no clear evidence in support for an effect of androgen deprivation therapy on COVID-19 mortality.
PMCID:8496782
PMID: 34618806
ISSN: 1932-6203
CID: 5125312
Training Medical Students in Diet Assessment and Brief Counseling
Poor dietary choices are a leading cause of chronic disease, but nutrition is rarely discussed in clinical practice. Nutrition is taught in less than a third of medical schools and physicians in practice empirically report low levels of comfort and self-efficacy in discussing nutrition with patients. A two-part presentation was created and shared with second-year medical students at a college of medicine. Students were given pre-work that included a brief (15 minutes) pre-recorded presentation and an e-resource entitled "Practical Nutrition for the Primary Care Provider" and then engaged in a live virtual session with a brief lecture and question and answer period (45 minutes). A survey was administered following the live presentation to evaluate the extent to which the presentation met the stated objectives and could impact participants' future practice. One-hundred and six students participated in the live lecture. Eighty-eight students (83%) provided survey feedback. Over two-thirds of respondents indicated that the presentation completely met the objectives, 57% indicated that they would definitely talk to patients with chronic disease about nutrition, and 52% indicated they would incorporate diet assessment in visits with patients with chronic disease. Nutrition is integral to disease prevention and management. Many students provided comments on the importance of the topic and benefit of the information. Further research is necessary to determine the optimal time and place for nutrition education in medical training. This presentation and e-resource are evidence-based, brief, and provided tools for participants to access once in practice.
PMCID:8608407
PMID: 34819760
ISSN: 1179-7258
CID: 5063742
Racial and geographic variation in effects of maternal education and neighborhood-level measures of socioeconomic status on gestational age at birth: Findings from the ECHO cohorts
Preterm birth occurs at excessively high and disparate rates in the United States. In 2016, the National Institutes of Health (NIH) launched the Environmental influences on Child Health Outcomes (ECHO) program to investigate the influence of early life exposures on child health. Extant data from the ECHO cohorts provides the opportunity to examine racial and geographic variation in effects of individual- and neighborhood-level markers of socioeconomic status (SES) on gestational age at birth. The objective of this study was to examine the association between individual-level (maternal education) and neighborhood-level markers of SES and gestational age at birth, stratifying by maternal race/ethnicity, and whether any such associations are modified by US geographic region. Twenty-six ECHO cohorts representing 25,526 mother-infant pairs contributed to this disseminated meta-analysis that investigated the effect of maternal prenatal level of education (high school diploma, GED, or less; some college, associate's degree, vocational or technical training [reference category]; bachelor's degree, graduate school, or professional degree) and neighborhood-level markers of SES (census tract [CT] urbanicity, percentage of black population in CT, percentage of population below the federal poverty level in CT) on gestational age at birth (categorized as preterm, early term, full term [the reference category], late, and post term) according to maternal race/ethnicity and US region. Multinomial logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CIs). Cohort-specific results were meta-analyzed using a random effects model. For women overall, a bachelor's degree or above, compared with some college, was associated with a significantly decreased odds of preterm birth (aOR 0.72; 95% CI: 0.61-0.86), whereas a high school education or less was associated with an increased odds of early term birth (aOR 1.10, 95% CI: 1.00-1.21). When stratifying by maternal race/ethnicity, there were no significant associations between maternal education and gestational age at birth among women of racial/ethnic groups other than non-Hispanic white. Among non-Hispanic white women, a bachelor's degree or above was likewise associated with a significantly decreased odds of preterm birth (aOR 0.74 (95% CI: 0.58, 0.94) as well as a decreased odds of early term birth (aOR 0.84 (95% CI: 0.74, 0.95). The association between maternal education and gestational age at birth varied according to US region, with higher levels of maternal education associated with a significantly decreased odds of preterm birth in the Midwest and South but not in the Northeast and West. Non-Hispanic white women residing in rural compared to urban CTs had an increased odds of preterm birth; the ability to detect associations between neighborhood-level measures of SES and gestational age for other race/ethnic groups was limited due to small sample sizes within select strata. Interventions that promote higher educational attainment among women of reproductive age could contribute to a reduction in preterm birth, particularly in the US South and Midwest. Further individual-level analyses engaging a diverse set of cohorts are needed to disentangle the complex interrelationships among maternal education, neighborhood-level factors, exposures across the life course, and gestational age at birth outcomes by maternal race/ethnicity and US geography.
PMCID:7794036
PMID: 33418560
ISSN: 1932-6203
CID: 4771082
Racial and ethnic disparities in "stop-and-frisk" experience among young sexual minority men in New York City
Although racial/ethnic disparities in police contact are well documented, less is known about other dimensions of inequity in policing. Sexual minority groups may face disproportionate police contact. We used data from the P18 Cohort Study (Version 2), a study conducted to measure determinants of inequity in STI/HIV risk among young sexual minority men (YSMM) in New York City, to measure across-time trends, racial/ethnic disparities, and correlates of self-reported stop-and-frisk experience over the cohort follow-up (2014-2019). Over the study period, 43% reported stop-and-frisk with higher levels reported among Black (47%) and Hispanic/Latinx (45%) than White (38%) participants. Stop-and-frisk levels declined over follow-up for each racial/ethnic group. The per capita rates among P18 participants calculated based on self-reported stop-and-frisk were much higher than rates calculated based on New York City Police Department official counts. We stratified respondents' ZIP codes of residence into tertiles of per capita stop rates and observed pronounced disparities in Black versus White stop-and-frisk rates, particularly in neighborhoods with low or moderate levels of stop-and-frisk activity. YSMM facing the greatest economic vulnerability and mental disorder symptoms were most likely to report stop-and-frisk. Among White respondents levels of past year stop-and-frisk were markedly higher among those who reported past 30 day marijuana use (41%) versus those reporting no use (17%) while among Black and Hispanic/Latinx respondents stop-and-frisk levels were comparable among those reporting marijuana use (38%) versus those reporting no use (31%). These findings suggest inequity in policing is observed not only among racial/ethnic but also sexual minority groups and that racial/ethnic YSMM, who are at the intersection of multiple minority statuses, face disproportionate risk. Because the most socially vulnerable experience disproportionate stop-and-frisk risk, we need to reach YSMM with community resources to promote health and wellbeing as an alternative to targeting this group with stressful and stigmatizing police exposure.
PMCID:8389488
PMID: 34437565
ISSN: 1932-6203
CID: 5011172
Linking bacterial enterotoxins and alpha defensin 5 expansion in the Crohn's colitis: A new insight into the etiopathogenetic and differentiation triggers driving colonic inflammatory bowel disease
Evidence link bacterial enterotoxins to apparent crypt-cell like cells (CCLCs), and Alpha Defensin 5 (DEFA5) expansion in the colonic mucosa of Crohn's colitis disease (CC) patients. These areas of ectopic ileal metaplasia, positive for Paneth cell (PC) markers are consistent with diagnosis of CC. Retrospectively, we: 1. Identified 21 patients with indeterminate colitis (IC) between 2000-2007 and were reevaluation their final clinical diagnosis in 2014 after a followed-up for mean 8.7±3.7 (range, 4-14) years. Their initial biopsies were analyzed by DEFA5 bioassay. 2. Differentiated ulcer-associated cell lineage (UACL) analysis by immunohistochemistry (IHC) of the CC patients, stained for Mucin 6 (MUC6) and DEFA5. 3. Treated human immortalized colonic epithelial cells (NCM460) and colonoids with pure DEFA5 on the secretion of signatures after 24hr. The control colonoids were not treated. 4. Treated colonoids with/without enterotoxins for 14 days and the spent medium were collected and determined by quantitative expression of DEFA5, CCLCs and other biologic signatures. The experiments were repeated twice. Three statistical methods were used: (i) Univariate analysis; (ii) LASSO; and (iii) Elastic net. DEFA5 bioassay discriminated CC and ulcerative colitis (UC) in a cohort of IC patients with accuracy. A fit logistic model with group CC and UC as the outcome and the DEFA5 as independent variable differentiator with a positive predictive value of 96 percent. IHC staining of CC for MUC6 and DEFA5 stained in different locations indicating that DEFA5 is not co-expressed in UACL and is therefore NOT the genesis of CC, rather a secretagogue for specific signature(s) that underlie the distinct crypt pathobiology of CC. Notably, we observed expansion of signatures after DEFA5 treatment on NCM460 and colonoids cells expressed at different times, intervals, and intensity. These factors are key stem cell niche regulators leading to DEFA5 secreting CCLCs differentiation 'the colonic ectopy ileal metaplasia formation' conspicuously of pathogenic importance in CC.
PMCID:7942995
PMID: 33690604
ISSN: 1932-6203
CID: 5161992
Patient and provider perception of appropriateness, acceptability, and feasibility of behavioral health home (BHH) core components based on program implementation in an urban, safety-net health system
BACKGROUND/UNASSIGNED:This manuscript evaluates patient and provider perspectives on the core components of a Behavioral Health Home (BHH) implemented in an urban, safety-net health system. The BHH integrated primary care and wellness services (e.g., on-site Nurse Practitioner and Care Manager, wellness groups and tools, population health management) into an existing outpatient clinic for people with serious mental illness (SMI). METHODS/UNASSIGNED:As the qualitative component of a Hybrid Type I effectiveness-implementation study, semi-structured interviews were conducted with providers and patients 6 months after program implementation, and responses were analyzed using thematic analysis. Valence coding (i.e., positive vs. negative acceptability) was also used to rate interviewees' transcriptions with respect to their feedback of the appropriateness, acceptability, and feasibility/sustainability of 9 well-described and desirable Integrated Behavioral Health Core components (seven from prior literature and two additional components developed for this intervention). Themes from the thematic analysis were then mapped and organized by each of the 9 components and the degree to which these themes explain valence ratings by component. RESULTS/UNASSIGNED:Responses about the team-based approach and universal screening for health conditions had the most positive valence across appropriateness, acceptability, and feasibility/sustainability by both providers and patients. Areas of especially high mismatch between perceived provider appropriateness and measures of acceptability and feasibility/sustainability included population health management and use of evidence-based clinical models to improve physical wellness where patient engagement in specific activities and tools varied. Social and peer support was highly valued by patients while incorporating patient voice was also found to be challenging. CONCLUSIONS/UNASSIGNED:Findings reveal component-specific challenges regarding the acceptability, feasibility, and sustainability of specific components. These findings may partly explain mixed results from BHH models studied thus far in the peer-reviewed literature and may help provide concrete data for providers to improve BHH program implementation in clinical settings. PLAIN LANGUAGE ABSTRACT/UNASSIGNED:Many people with serious mental illness also have medical problems, which are made worse by lack of access to primary care. The Behavioral Health Home (BHH) model seeks to address this by adding primary care access into existing interdisciplinary mental health clinics. As these models are implemented with increasing frequency nationwide and a growing body of research continues to assess their health impacts, it is crucial to examine patient and provider experiences of BHH implementation to understand how implementation factors may contribute to clinical effectiveness. This study examines provider and patient perspectives of acceptability, appropriateness, and feasibility/sustainability of BHH model components at 6-7 months after program implementation at an urban, safety-net health system. The team-based approach of the BHH was perceived to be highly acceptable and appropriate. Although providers found certain BHH components to be highly appropriate in theory (e.g., population-level health management), their acceptability of these approaches as implemented in practice was not as high, and their feedback provides suggestions for model improvements at this and other health systems. Similarly, social and peer support was found to be highly appropriate by both providers and patients, but in practice, at months 6-7, the BHH studied had not yet developed a process of engaging patients in ongoing program operations that was highly acceptable by providers and patients alike. We provide these data on each specific BHH model component, which will be useful to improving implementation in clinical settings of BHH programs that share some or all of these program components.
PMCID:9978621
PMID: 37089996
ISSN: 2633-4895
CID: 5724192
Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019
ISI:000713316000024
ISSN: 0140-6736
CID: 5071782
Association between Circulating Protein C Levels and Incident Dementia: The Atherosclerosis Risk in Communities Study
INTRODUCTION:Hemostasis depends on the delicate balance between coagulants and anticoagulants. Higher levels of circulating coagulants have been associated with higher risk of cerebral infarctions and dementia. In contrast, higher levels of circulating protein C, an endogenous anticoagulant, have been associated with lower risk of cerebral infarctions, and the association between protein C levels and the risk of dementia is unknown. The goal of this study was to evaluate the association of circulating protein C levels in midlife and late life with incident dementia. METHODS:Circulating protein C levels were measured using blood samples collected at the midlife baseline (1987-1989) and the late-life baseline (2011-2013) among 14,462 and 3,614 participants, respectively, in the Atherosclerosis Risk in Communities study. Protein C levels were measured using enzyme-linked immunosorbent assay at midlife and a modified aptamer-based assay at late life. Participants were followed up to 2013 from midlife and up to 2017 from late life. Incident dementia was ascertained during the follow-up periods using in-person cognitive and functional assessment, informant interviews, and International Classification of Diseases codes at hospitalization discharge and on death certificates. Cause-specific Cox regression models were used to evaluate the association between quintiles of circulating protein C and incident dementia. RESULTS:From midlife (mean age of 54), 1,389 incident dementia events were observed over a median follow-up of 23 years. From late life (mean age of 75), 353 incident dementia events were observed over a median follow-up of 4.9 years. At both midlife and late life, circulating protein C had an inverse association with incident dementia after adjusting for demographic, vascular, and hemostatic risk factors, incident stroke as time-dependent covariate, and incorporating stabilized weights based on propensity scores (quintile 5 vs. quintile 1 as the reference, midlife hazard ratio 0.80, 95% confidence interval 0.66-0.96, p value for trend 0.04; late-life hazard ratio 0.84, 95% confidence interval: 0.55-1.28, p value for trend 0.04). DISCUSSION/CONCLUSION:Circulating protein C has an inverse association with incident dementia independent of established risk factors, including stroke. Our results suggest studying anticoagulants in addition to coagulants can increase our understanding on the relationship between hemostasis and dementia.
PMCID:8292178
PMID: 34077937
ISSN: 1423-0208
CID: 5585902
A Population-Level Assessment of Smoking Cessation following a Diagnosis of Tobacco- or Nontobacco-Related Cancer among United States Adults
Introduction/UNASSIGNED:Smoking cessation after a cancer diagnosis can significantly improve treatment outcomes and reduce the risk of cancer recurrence and all-cause mortality. Aim/UNASSIGNED:We sought to measure the association between cancer diagnosis and subsequent smoking cessation. Methods/UNASSIGNED:. Our sample was composed of 7,286 adult smokers at the baseline representing an estimated 40.9 million persons. Smoking cessation rates after a diagnosis differed after a tobacco-related cancer (25.9%), a nontobacco-related cancer (8.9%), and no cancer diagnosis (17.9%). After adjustment, diagnosis with a tobacco-related cancer was associated with a higher odds of smoking cessation (OR 1.83, 95% CI 1.00-3.33) compared to no cancer diagnosis. Diagnosis with a nontobacco-related cancer was not significantly linked to smoking cessation (OR 0.52, 95% CI 0.48-1.45). Conclusion/UNASSIGNED:Diagnosis with a tobacco-related cancer is associated with greater odds of subsequent smoking cessation compared to no cancer diagnosis, suggesting that significant behavioral change may occur in this setting.
PMCID:8279190
PMID: 34306234
ISSN: 1834-2612
CID: 4949002
