Faculty Bibliography
Searched for:
school:SOM
Department/Unit:Population Health
Total Results:
12150
Primary care medical staff attitudes toward substance use: Results of the substance abuse attitudes survey (SAAS) [Meeting Abstract]
BACKGROUND: Under-treatment of drug and alcohol use in primary care settings has been attributed, in part, to medical providers' negative attitudes toward substance use. As a part of an implementation study of electronic health record-integrated substance use screening in primary care clinics, conducted in the NIDA Clinical Trials Network, we assessed baseline attitudes among medical staff.
METHOD(S): Eligible participants were primary care providers and medical assistants in 4 urban academic primary care clinics. Prior to implementation of a substance use screening program, participants completed the Substance Abuse Attitudes Survey (SAAS), a validated 50-item self-administered survey that measures attitudes to substance use in 5 domains: permissiveness, non-moralism, nonstereotyping, treatment intervention, and treatment optimism. Participants were asked to rate their level of agreement with each item on a five-point Likert scale.
RESULT(S): In total, 131/191 (69% response rate) eligible staff completed the survey. Participants had mean age 42; 76% were female; 11% Hispanic/Latino, 6% Black, 25% Asian. The majority of the sample was physicians (78%), while 11% were nurse practitioners, and 11% were medical assistants. Participants had an overall average of 13.2 years in practice. Approximately onethird reported moderate to high satisfaction treating patients with drug problems (35.1%) and alcohol problems (33.6%). The proportion of participants having positive attitudes in each of the following domains were: non-moralism (64.1%); non-stereotyping (55.7%); treatment intervention (47.3%); treatment optimism (48.9%); and permissiveness (44.3%). Negative attitudes toward permissiveness reflect responses to items addressing health effects of substance use, especially among teens.
CONCLUSION(S): While most primary care staff did not endorse moralistic or stereotyping statements about alcohol and drug use, attitudes toward addiction treatment were mixed, with less than half endorsing positive attitudes toward treatment effectiveness. These results suggest a need to improve attitudes, particularly toward addiction treatment. This could be accomplished through education and increased exposure to effective interventions that can be delivered by primary care providers, including officebased treatment for alcohol and opioid use disorder
METHOD(S): Eligible participants were primary care providers and medical assistants in 4 urban academic primary care clinics. Prior to implementation of a substance use screening program, participants completed the Substance Abuse Attitudes Survey (SAAS), a validated 50-item self-administered survey that measures attitudes to substance use in 5 domains: permissiveness, non-moralism, nonstereotyping, treatment intervention, and treatment optimism. Participants were asked to rate their level of agreement with each item on a five-point Likert scale.
RESULT(S): In total, 131/191 (69% response rate) eligible staff completed the survey. Participants had mean age 42; 76% were female; 11% Hispanic/Latino, 6% Black, 25% Asian. The majority of the sample was physicians (78%), while 11% were nurse practitioners, and 11% were medical assistants. Participants had an overall average of 13.2 years in practice. Approximately onethird reported moderate to high satisfaction treating patients with drug problems (35.1%) and alcohol problems (33.6%). The proportion of participants having positive attitudes in each of the following domains were: non-moralism (64.1%); non-stereotyping (55.7%); treatment intervention (47.3%); treatment optimism (48.9%); and permissiveness (44.3%). Negative attitudes toward permissiveness reflect responses to items addressing health effects of substance use, especially among teens.
CONCLUSION(S): While most primary care staff did not endorse moralistic or stereotyping statements about alcohol and drug use, attitudes toward addiction treatment were mixed, with less than half endorsing positive attitudes toward treatment effectiveness. These results suggest a need to improve attitudes, particularly toward addiction treatment. This could be accomplished through education and increased exposure to effective interventions that can be delivered by primary care providers, including officebased treatment for alcohol and opioid use disorder
EMBASE:633957585
ISSN: 1525-1497
CID: 4803222
Are Low-Income, Diverse Mothers Able to Meet Breastfeeding Intentions After 2 Months of Breastfeeding?
PMID: 32357088
ISSN: 1556-8342
CID: 4437042
Diagnostic test accuracy of ADC values for identification of clear cell renal cell carcinoma: systematic review and meta-analysis
OBJECTIVES/OBJECTIVE:To perform a systematic review on apparent diffusion coefficient (ADC) values of renal tumor subtypes and meta-analysis on the diagnostic performance of ADC for differentiation of localized clear cell renal cell carcinoma (ccRCC) from other renal tumor types. METHODS:Medline, Embase, and the Cochrane Library databases were searched for studies published until May 1, 2019, that reported ADC values of renal tumors. Methodological quality was evaluated. For the meta-analysis on diagnostic test accuracy of ADC for differentiation of ccRCC from other renal lesions, we applied a bivariate random-effects model and compared two subgroups of ADC measurement with vs. without cystic and necrotic areas. RESULTS:We included 48 studies (2588 lesions) in the systematic review and 13 studies (1126 lesions) in the meta-analysis. There was no significant difference in ADC of renal parenchyma using b values of 0-800 vs. 0-1000 (p = 0.08). ADC measured on selected portions (sADC) excluding cystic and necrotic areas differed significantly from whole-lesion ADC (wADC) (p = 0.002). Compared to ccRCC, minimal-fat angiomyolipoma, papillary RCC, and chromophobe RCC showed significantly lower sADC while oncocytoma exhibited higher sADC. Summary estimates of sensitivity and specificity to differentiate ccRCC from other tumors were 80% (95% CI, 0.76-0.88) and 78% (95% CI, 0.64-0.89), respectively, for sADC and 77% (95% CI, 0.59-0.90) and 77% (95% CI, 0.69-0.86) for wADC. sADC offered a higher area under the receiver operating characteristic curve than wADC (0.852 vs. 0.785, p = 0.02). CONCLUSIONS:ADC values of kidney tumors that exclude cystic or necrotic areas more accurately differentiate ccRCC from other renal tumor types than whole-lesion ADC values. KEY POINTS/CONCLUSIONS:• Selective ADC of renal tumors, excluding cystic and necrotic areas, provides better discriminatory ability than whole-lesion ADC to differentiate clear cell RCC from other renal lesions, with area under the receiver operating characteristic curve (AUC) of 0.852 vs. 0.785, respectively (p = 0.02). • Selective ADC of renal masses provides moderate sensitivity and specificity of 80% and 78%, respectively, for differentiation of clear cell renal cell carcinoma (RCC) from papillary RCC, chromophobe RCC, oncocytoma, and minimal-fat angiomyolipoma. • Selective ADC excluding cystic and necrotic areas are preferable to whole-lesion ADC as an additional tool to multiphasic MRI to differentiate clear cell RCC from other renal lesions whether the highest b value is 800 or 1000.
PMID: 32144458
ISSN: 1432-1084
CID: 4340972
Social Needs Screening and Referral Program at a Large US Public Hospital System, 2017
Many health care providers and systems are developing and implementing processes to screen patients for social determinants of health and to refer patients to appropriate nonclinical and community-based resources. The largest public health care system in the United States, New York City Health + Hospitals, piloted such a program in 2017. A qualitative evaluation yielded insights into the implementation and feasibility of such screening and referral programs in health care systems serving low-income, minority, immigrant, and underserved populations.
PMCID:7362691
PMID: 32663088
ISSN: 1541-0048
CID: 4546032
Racial/ethnic differences in supplemental imaging for breast cancer screening in women with dense breasts
BACKGROUND:Mammography is limited when analyzing dense breasts for 2 reasons: (1) breast density masks underlying cancers and (2) breast density is an independent risk factor for cancer. We undertook this study to assess whether there is a racial/ethnic difference in supplemental image ordering for women with dense breasts. METHODS:We conducted a retrospective, observational cohort study of women aged 50-75 from an academic medical center who had completed a screening mammogram between 2014 and 2016 that was read as BI-RADS 1 with heterogeneously or extremely dense breasts or BI-RADS 2 with extremely dense breasts. Data were abstracted on type, timing and frequency of supplemental imaging tests ordered within two years of an initial screening mammogram. Patient characteristics (age, race/ethnicity, insurance, and comorbidities) were also abstracted. We used bivariate and multivariate logistic regression to assess for differences in supplemental imaging ordered by race/ethnicity. RESULTS:Three hundred twenty-six women met inclusion criteria. Mean age was 58 years: 25% were non-Hispanic white, 30% were non-Hispanic black, 27% were Hispanic, 6% were Asian and 14% unknown. Seventy-nine (24%) women were ordered a supplemental breast ultrasound after the initial screening mammogram. Non-Hispanic black and Hispanic women were less likely to have supplemental imaging ordered compared to non-Hispanic white women (15% and 10%, respectively, vs. 45%, p < 0.0001). After controlling for patient age, ordering physician specialty, insurance, BI-RADS score, breast density, and family history of breast cancer, non-Hispanic black and Hispanic women remained less likely to be ordered supplemental imaging (OR 0.38 [95% CI 0.17-0.85] and OR 0.24 [95% CI 0.10-0.61], respectively, p < 0.0001). CONCLUSION/CONCLUSIONS:Minority women with dense breasts are less likely to be ordered supplemental breast imaging. Further research should investigate physician and patient behaviors to determine barriers in supplemental imaging. Understanding these differences may help reduce disparities in breast cancer care and mortality.
PMCID:7392160
PMID: 32394349
ISSN: 1573-7217
CID: 5403852
Moral distress among physician trainees: Drivers, contexts, and adaptive strategies [Meeting Abstract]
BACKGROUND: Moral distress is defined as a situation in which an individual believes they know the ethically appropriate action to take but are unable to take that action. The concept of moral distress is increasingly recognized as an important mediator of occupational stress and burnout in medicine, particularly in the nursing profession. However, there is a dearth of literature on moral distress among physician trainees, with the majority focused on dilemmas in end-of-life care. This study explores the phenomenon of moral distress among internal medicine trainees, with particular focus on drivers, situational contexts, and adaptive strategies such as coping mechanisms.
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants, and was identified across four major domains: personal values and morals, professional competency and training challenges, interpersonal relationships and conflicts, and systems/structural issues. Participants identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, as well as between private, public, and government- run hospital facilities. Participants described a number of adaptive mechanisms for managing moral distress, including social support and connectivity, humor, and disassociation.
CONCLUSION(S): Physician trainees experience considerable moral distress across multiple domains during the course of their training. They also develop unique adaptive strategies and copingmechanisms tomanage and learn from distressing experiences. This improved understanding ofmoral distress among physician trainees, particularly drivers and protective factors, has important implications for the training of physicians, and may have a role in promoting wellness and resilience among physicians across the training and professional pipeline
METHOD(S): We report qualitative data from a mixed methods prospective observational cohort study of internal medicine (IM) residents and associated faculty at a large, urban, academic medical institution. Five focus groups were conducted with 15 internal medicine residents (PGY1- 3), between January and October 2019. In each focus group trained facilitators conducted semi-structured interviews using prompts which focused on definitions of, experiences with, and consequences of moral distress. Transcripts were independently coded by investigators, and analyzed by major themes and sub-themes. Discrepant themes and codes were reviewed by the full research team to establish clarity and consensus. Data were analyzed using Dedoose software.
RESULT(S): Focus group participants were equally distributed by gender (7 women, 8 men) and across training year (30% PGY1, 20% PGY2 40% PGY3). Experience with moral distress was universal among participants, and was identified across four major domains: personal values and morals, professional competency and training challenges, interpersonal relationships and conflicts, and systems/structural issues. Participants identified unique, place-based moral distress across different clinical environments, including intensive care units, wards, and outpatient environments, as well as between private, public, and government- run hospital facilities. Participants described a number of adaptive mechanisms for managing moral distress, including social support and connectivity, humor, and disassociation.
CONCLUSION(S): Physician trainees experience considerable moral distress across multiple domains during the course of their training. They also develop unique adaptive strategies and copingmechanisms tomanage and learn from distressing experiences. This improved understanding ofmoral distress among physician trainees, particularly drivers and protective factors, has important implications for the training of physicians, and may have a role in promoting wellness and resilience among physicians across the training and professional pipeline
EMBASE:633957241
ISSN: 1525-1497
CID: 4803322
Responding to the Needs of Early Career Physicians and Fellows in Headache Medicine: Career Planning, Getting Involved, and Considerations in Building a Headache Center
PMID: 32476142
ISSN: 1526-4610
CID: 4482092
A Cross-Cutting Workforce Solution for Implementing Community-Clinical Linkage Models [Editorial]
PMCID:7362697
PMID: 32663090
ISSN: 1541-0048
CID: 4546042
Deprivation and Threat As Links between Early Life Ses and Executive Functioning Outcomes [Meeting Abstract]
Research on early life adversity has begun a shift from cumulative risk approaches to more dimensional approaches. One such dimensional approach to understanding early life adversity uses dimensions of deprivation and threat to differentially predict developmental outcomes, however this framework has not been applied to the context of poverty-related adversity, which encompasses more than deprivation and threat and is characterized by high levels of both these dimensions. Previous studies have found that experiences of deprivation, but not threat, predict executive functions (EF). We propose a model of deprivation and threat as dimensions of poverty-related adversity, and we hypothesized that deprivation, but not threat, would mediate links between early life socioeconomic status (SES) and EF. Data come from the 15-, 24-, and 48-month visits of the Family Life Project (n=1,292). We used latent variables of deprivation and threat in a multiple mediation model with SES as the main predictor, deprivation and threat as mediators predicting 48 month EF. Lower SES was related to higher levels of both deprivation (beta=-0.597, p < 0.01) and threat (beta=-0.628, p < 0.01). Additionally, deprivation (beta=-0.916, p < 0.01), but not threat (beta= 0.307, p=0.112) was significantly negatively related to EF outcomes. The indirect effect of SES on EF through deprivation was significant (beta= 0.548, p =0.013). Finally, deprivation and threat together fully mediated the relationship between SES and EF. Implications for mental and physical health for children growing up in high-poverty contexts will be discussed
EMBASE:633626678
ISSN: 1534-7796
CID: 4719892
Elevated Salivary Cortisol Across Early Childhood Predicts Glucocorticoid Resistance in Early Adolescence [Meeting Abstract]
A growing body of research demonstrates that early-life stress exposure is linked to later-life health outcomes, with disparities in outcomes emerging as early as childhood. However, the mechanisms by which early stress might contribute to adverse health effects remain poorly understood. One likely mechanism is via altered glucocorticoid activity. Glucocorticoids (e.g., cortisol in humans) are essential for myriad physiological functions, including the maintenance of cardiovascular tone, provision of anti-inflammatory effects, and regulation of growth, behavior, and cognition. Here we assessed if glucocorticoid levels across infancy and toddlerhood were associated with impaired tissue sensitivity to glucocorticoids (glucocorticoid resistance) in early adolescence. Data come from the Family Life Project, a longitudinal study of 1,292 children and their caregivers living in predominantly low-income non-urban communities. Children's resting levels of cortisol were assayed via saliva samples collected in their home at 6, 15, 24, and 48 months of age. Glucocorticoid resistance at 11-12 years of age was assessed using a well-established protocol whereby whole blood was diluted in phosphate buffered saline and cultured with and without endotoxin lipopolysaccharide (LPS) at a range of concentrations of hydrocortisone. Glucocorticoid resistance was quantified by the difference in inflammatory cytokine (IL-6) levels in response to LPS alone versus LPS with the highest concentration of hydrocortisone. Structural equation modeling was used to assess direct effects of a latent variable of early childhood cortisol on glucocorticoid resistance in early adolescence. All models adjusted for demographic covariates, including infant's race, gender, age, and mother's age, as well as child's body mass index, health status, time of blood draw, and body temperature. Analyses revealed a significant positive association between cortisol levels and glucocorticoid resistance, such that higher cortisol in early childhood predicted increased glucocorticoid resistance in early adolescence (b=0.893, p=0.023). Our findings support the idea that prolonged elevation of glucocorticoids in early life may result in a dysregulated response such that the expression and/or function of glucocorticoid receptors become downregulated, leading to glucocorticoid resistance
EMBASE:633626037
ISSN: 1534-7796
CID: 4719902
