Faculty Bibliography

INTRODUCTION/BACKGROUND:Smoking is a key determinant of mortality among people living with HIV (PLWH). METHODS:To better understand the effects of smoking cessation interventions in PLWH, we conducted a pooled analysis of four randomized controlled trials of hospital-initiated smoking interventions conducted through the Consortium of Hospitals Advancing Research on Tobacco (CHART). In each study, cigarette smokers were randomly assigned to usual care or a smoking cessation intervention. The primary outcome was self-reported past 30-day tobacco abstinence at 6-month follow-up. Abstinence rates were compared between PLWH and participants without HIV and by treatment arm, using both complete-case and intention-to-treat analyses. Multivariable logistic regression was used to determine the effect of HIV status on 6-month tobacco abstinence and to determine predictors of smoking cessation within PLWH. RESULTS:Among 5550 hospitalized smokers, there were 202 (3.6%) PLWH. PLWH smoked fewer cigarettes per day and were less likely to be planning to quit than smokers without HIV. At 6 months, cessation rates did not differ between intervention and control groups among PLWH (28.9% vs. 30.5%) or smokers without HIV (36.1% vs. 34.1%). In multivariable regression analysis, HIV status was not significantly associated with smoking cessation at 6 months. Among PLWH, confidence in quitting was the only clinical factor independently associated with smoking cessation (OR 2.0, 95% CI = 1.4 to 2.8, p < .01). CONCLUSIONS:HIV status did not alter likelihood of quitting smoking after hospital discharge, whether or not the smoker was offered a tobacco cessation intervention, but power was limited to identify potentially important differences. IMPLICATIONS/CONCLUSIONS:PLWH had similar quit rates to participants without HIV following a hospital-initiated smoking cessation intervention. The findings suggest that factors specific to HIV infection may not influence response to smoking cessation interventions and that all PLWH would benefit from efforts to assist in quitting smoking. TRIAL REGISTRATION/BACKGROUND:(1) Using "warm handoffs" to link hospitalized smokers with tobacco treatment after discharge: study protocol of a randomized controlled trial: NCT01305928. (2) Web-based smoking cessation intervention that transitions from inpatient to outpatient: NCT01277250. (3) Effectiveness of smoking-cessation interventions for urban hospital patients: NCT01363245. (4) Effectiveness of Post-Discharge Strategies for Hospitalized Smokers (HelpingHAND2): NCT01714323.

NYC Health + Hospitals (NYC H+H) is the largest safety net health care delivery system in the United States. Prior to the novel coronavirus disease (COVID-19) pandemic, NYC H+H served over one million patients, including the most vulnerable New Yorkers, and billed fewer than 500 telehealth visits monthly. Once the pandemic struck, we established a strategy to allow us to continue to serve existing patients and treat the surge of new patients. Starting in March 2020 we were able to transform the system using virtual care platforms through which we conducted almost 83,000 billable televisits in one month and more than 30,000 behavioral health encounters via telephone and video. Telehealth also enabled us to support patient-family communication, post-discharge follow-up, and palliative care for COVID-19 patients. Expanded Medicaid coverage and insurance reimbursement for telehealth played a pivotal role in this transformation. As we move to a new blend of virtual and in-person care, it is vital that the major regulatory and insurance changes undergirding our COVID-19 telehealth response be sustained to protect access for our most vulnerable patients. [Editor's Note: This Fast Track Ahead Of Print article is the accepted version of the manuscript. The final edited version will appear in an upcoming issue of Health Affairs.].

BACKGROUND:There are too many plausible permutations and scale-up scenarios of combination hepatitis C (HCV) interventions for exhaustive testing in experimental trials. Therefore, we used computer simulation to project the health and economic impact of alternative combination intervention scenarios for people who inject drugs (PWID), focusing on direct anti-viral agents (DAA) and medication-assisted treatment combined with syringe access programs (MAT+). METHODS:We performed an allocative efficiency study using a mathematical model simulating the progression of HCV in PWID and its related consequences. Two previously validated simulations were combined to estimate the cost-effectiveness of intervention strategies that included a range of coverage levels. Analyses were performed from a health sector and societal perspective with a 15-year time horizon and a discount rate of 3%. RESULTS:From a health-sector perspective (excluding criminal justice system-related costs), four potential strategies fell on the cost-efficiency frontier. DAA at 20% coverage had an ICER of $27,251/QALY. Combinations of DAA 20% with MAT+ at 20%, 40%, and 80% coverage had ICERs of $165,985/QALY, $325,860/QALY, and $399,189/QALY, respectively. When analyzed from a societal perspective (including criminal justice system-related costs), DAA 20% with MAT+ 80% was most effective and was cost saving. While DAA 20% with MAT+ 80% was more expensive (e.g., less cost-saving) than MAT+ 80% alone without DAA, it offered favorable value compared to MAT+ 80% alone ($23,932/QALY). CONCLUSION/CONCLUSIONS:When considering health sector costs alone, DAA alone was the most cost-effective intervention. However, with criminal justice system-related costs, DAA and MAT+ implemented together become the most cost-effective interventions.

BACKGROUND AND OBJECTIVES:Mortality from benzodiazepine/opioid interactions is a growing concern in light of the opioid epidemic. Patients on hemodialysis suffer from a high burden of physical/psychiatric conditions, which are treated with benzodiazepines, and they are three times more likely to be prescribed opioids than the general population. Therefore, we studied mortality risk associated with short- and long-acting benzodiazepines and their interaction with opioids among adults initiating hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:The cohort of 69,368 adults initiating hemodialysis (January 2013 to December 2014) was assembled by linking US Renal Data System records to Medicare claims. Medicare claims were used to identify dispensed benzodiazepines and opioids. Using adjusted Cox proportional hazards models, we estimated the mortality risk associated with benzodiazepines (time varying) and tested whether the benzodiazepine-related mortality risk differed by opioid codispensing. RESULTS:=0.72). CONCLUSIONS:Codispensing of opioids and short-acting benzodiazepines is common among patients on dialysis, and it is associated with higher risk of death.

BACKGROUND:Prevalence of self-reported methamphetamine use has remained relatively stable over the past decade; however, deaths and seizures involving methamphetamine have been increasing. Research is needed to determine if select subgroups in the US are at increased risk for use. METHODS:We examined data from individuals ages ≥12 from the 2015-2018 National Survey on Drug Use and Health (n = 226,632), an annual nationally representative cross-sectional survey of non-institutionalized individuals in the US. Log-linear trends in past-year methamphetamine use were examined, stratified by demographic and drug use characteristics. RESULTS:Methamphetamine use increased in the US from 2015 to 2018, including among those reporting past-year use of ecstasy/MDMA (6.1 % to 10.8 % [p = .018], a 78.2 % increase), cocaine (8.4 % to 11.8 % [p = .013], a 40.1 % increase), and among those reporting past-year prescription opioid misuse (5.4 % to 8.0 % [p = .019], a 49.2 % increase). Increases were particularly pronounced among those reporting past-year use of heroin (22.5 % to 37.4 % [p = .032], a 66.2 % increase) and LSD (5.1 %-= to 10.3 % [p = .002], a 100.4 % increase). Small increases were also detected among heterosexuals (0.6 % to 0.7 % [p = .044], a 16.2 % increase), those with a high school diploma or less (1.0 % to 1.2 % [p = .020], a 22.0 % increase), and among those receiving government assistance (1.4 % to 1.8 % [p = .046], a 26.2 % increase). CONCLUSIONS:Methamphetamine use is increasing among people who use other drugs with sharp increases among people who use heroin or LSD in particular, and this could have serious public health consequences. Results may signal that methamphetamine use may continue to increase in the general population.

BACKGROUND:Youth living with HIV (YLHIV) enrolled in HIV treatment experience higher loss to follow-up, suboptimal treatment adherence, and greater HIV-related mortality compared with younger children or adults. Despite poorer health outcomes, few interventions target youth specifically. Expanding access to mobile phone technology, in low- and middle-income countries (LMICs) in particular, has increased interest in using this technology to improve health outcomes. mHealth interventions may present innovative opportunities to improve adherence and retention among YLHIV in LMICs. OBJECTIVE:This study aimed to test the effectiveness of a structured support group intervention, Social Media to promote Adherence and Retention in Treatment (SMART) Connections, delivered through a social media platform, on HIV treatment retention among YLHIV aged 15 to 24 years and on secondary outcomes of antiretroviral therapy (ART) adherence, HIV knowledge, and social support. METHODS:We conducted a parallel, unblinded randomized controlled trial. YLHIV enrolled in HIV treatment for less than 12 months were randomized in a 1:1 ratio to receive SMART Connections (intervention) or standard of care alone (control). We collected data at baseline and endline through structured interviews and medical record extraction. We also conducted in-depth interviews with subsets of intervention group participants. The primary outcome was retention in HIV treatment. We conducted a time-to-event analysis examining time retained in treatment from study enrollment to the date the participant was no longer classified as active-on-treatment. RESULTS:A total of 349 YLHIV enrolled in the study and were randomly allocated to the intervention group (n=177) or control group (n=172). Our primary analysis included data from 324 participants at endline. The probability of being retained in treatment did not differ significantly between the 2 study arms during the study. Retention was high at endline, with 75.7% (112/163) of intervention group participants and 83.4% (126/161) of control group participants active on treatment. HIV-related knowledge was significantly better in the intervention group at endline, but no statistically significant differences were found for ART adherence or social support. Intervention group participants overwhelmingly reported that the intervention was useful, that they enjoyed taking part, and that they would recommend it to other YLHIV. CONCLUSIONS:Our findings of improved HIV knowledge and high acceptability are encouraging, despite a lack of measurable effect on retention. Retention was greater than anticipated in both groups, likely a result of external efforts that began partway through the study. Qualitative data indicate that the SMART Connections intervention may have contributed to retention, adherence, and social support in ways that were not captured quantitatively. Web-based delivery of support group interventions can permit people to access information and other group members privately, when convenient, and without travel. Such digital health interventions may help fill critical gaps in services available for YLHIV. TRIAL REGISTRATION:ClinicalTrials.gov NCT03516318; https://clinicaltrials.gov/ct2/show/NCT03516318.

OBJECTIVE:To test the association between reduced kidney function (assessed by estimated glomerular filtration rate [eGFR] and cystatin C [CysC]) and kidney damage (assessed by urinary albumin-to-creatinine ratio [ACR]) and intracranial atherosclerotic disease (ICAD) by high-resolution vessel wall MRI (VWMRI) in the Atherosclerosis Risk in Communities Neurocognitive Study (ARIC-NCS). METHODS:We conducted a cross-sectional analysis of ARIC participants with data on kidney measures and VWMRI in 2011 to 2013. The main outcomes were presence of intracranial plaques and luminal stenosis. Multivariable models were adjusted for demographics, cardiovascular risk factors, and use of antithrombotic medications. RESULTS:) had an increased OR of 1.41 (95% CI 1.06-1.87) for having 1 plaque (vs none) but no significant increase for multiple plaques; ACR ≥30 was associated with moderate (50%-70%) stenosis (OR 2.01, 95% CI 1.14-3.55) vs absent or less than 50% stenosis. CONCLUSION:In community-dwelling older adults, reduced kidney function or elevated kidney damage was associated with ICAD measured by VWMRI. This finding may help to better identify a population at high risk for ICAD.

Sexual and gender minority (SGM) individuals encompass a broad spectrum of sexual orientations and gender identities. Although SGM is a research term, this population is often known as lesbian, gay, bisexual, transgender, queer (LGBTQ). Typically, LGB refers to sexual orientation, T refers to gender identity, and Q may refer to either. Although each group is distinct, they share the common bond of experiencing health disparities that may be caused, in part, by stigma and discrimination, as well as by the oncology provider"™s lack of knowledge and, therefore, lack of comfort in treating this population. One challenge in improving the quality of care for SGM patients with cancer is the lack of collection of sexual orientation and gender identity (SOGI) data in the medical record. Furthermore, national studies suggest that many oncologists are unsure of what to do with this information, even when it is collected, and some are uncertain as to why they would need to know the SOGI of their patients. This clinical review offers insight into the health disparities experienced by SGM individuals and strategies for improving the clinical encounter and creating a welcoming environment.

Objective: Access to evidence-based psychosocial interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD) is a challenge in urban, socioeconomically disadvantaged communities. Approaches that leverage existing but underdeveloped workforces and connects these with well-established settings that treat ADHD offers an opportunity to address this barrier. This pilot study focused on a preliminary test of the potential utility of paraprofessional-delivered behavioral parent training (BPT) to parents of children with ADHD being treated in a developmental behavioral pediatric practice. Method: In an open clinical trial of 7 families, Family Peer Advocate paraprofessionals delivered BPT to parents of children with ADHD. Parent reports of their child's ADHD symptoms/ oppositional defiant behaviors and functional impairment were assessed before, weekly during BPT, and immediately after BPT. Parents report of their positive and negative parenting behaviors were assessed before and immediately after BPT. Results: Findings demonstrated that participation in BPT was associated with improvements in child-and parent-level outcomes, with moderate to large effects across outcomes. Conclusions: Integrating existing service systems with oversight through pediatric psychologists offers opportunities to efficiently utilize resources, thereby increasing access to evidence-based interventions for ADHD in urban, socioeconomically disadvantaged communities. This study advances the scope of paraprofessional involvement in formal pediatric settings. In addition, it highlights the potential effectiveness of peer-to-peer delivered services.

Prediabetes (intermediate hyperglycemia) consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) detected by a standardized 75-gram oral glucose tolerance test (OGTT). Individuals with isolated IGT or combined IFG and IGT have increased risk for developing type 2 diabetes (T2D) and cardiovascular disease (CVD). Diagnosing prediabetes early and accurately is critical in order to refer high-risk individuals for intensive lifestyle modification. However, there is currently no international consensus for diagnosing prediabetes with HbA1c or glucose measurements based upon American Diabetes Association (ADA) and the World Health Organization (WHO) criteria that identify different populations at risk for progressing to diabetes. Various caveats affecting the accuracy of interpreting the HbA1c including genetics complicate this further. This review describes established methods for detecting glucose disorders based upon glucose and HbA1c parameters as well as novel approaches including the 1-hour plasma glucose (1-h PG), glucose challenge test (GCT), shape of the glucose curve, genetics, continuous glucose monitoring (CGM), measures of insulin secretion and sensitivity, metabolomics, and ancillary tools such as fructosamine, glycated albumin (GA), 1,5- anhydroglucitol (1,5-AG). Of the approaches considered, the 1-h PG has considerable potential as a biomarker for detecting glucose disorders if confirmed by additional data including health economic analysis. Whether the 1-h OGTT is superior to genetics and omics in providing greater precision for individualized treatment requires further investigation. These methods will need to demonstrate substantially superiority to simpler tools for detecting glucose disorders to justify their cost and complexity.