Faculty Bibliography

This study provides data on the feasibility and impact of video-enabled telemedicine use among patients and providers and its impact on urgent and non-urgent health care delivery from one large health system (NYU Langone Health) at the epicenter of the COVID-19 outbreak in the United States. Between March 2nd and April 14th 2020, telemedicine visits increased from 369.1 daily to 866.8 daily (135% increase) in urgent care after the system-wide expansion of virtual health visits in response to COVID-19, and from 94.7 daily to 4209.3 (4345% increase) in non-urgent care post expansion. Of all virtual visits post expansion, 56.2% and 17.6% urgent and non-urgent visits, respectively, were COVID-19-related. Telemedicine usage was highest by patients aged 20-44, particularly for urgent care. The COVID-19 pandemic has driven rapid expansion of telemedicine use for urgent care and non-urgent care visits beyond baseline periods. This reflects an important change in telemedicine that other institutions facing the COVID-19 pandemic should anticipate.

BACKGROUND: Alcohol and drug use are often under-identified in primary care settings. While prior research indicates that patients are generally supportive of alcohol screening, less is known about attitudes toward drug screening or the collection of this information in electronic health records (EHRs). As a part of an implementation study of EHRintegrated substance use screening in primary care, conducted in the NIDA Clinical Trials Network, patients were surveyed on their attitudes toward screening for substance use during medical visits.
METHOD(S): Surveys were administered to patients in four urban academic primary care clinics on a quarterly basis, for one year following the introduction of a screening program. English-speaking adult patients presenting for a primary care visit were eligible. Participants were recruited from the waiting room and self-administered an 18-item survey exploring attitudes toward screening and discussing substance use with healthcare providers.
RESULT(S): A total of 479 patients completed the survey (mean age 54.1; 58% female; 58% white, 23% black; 19% Hispanic/Latino). Participants overwhelmingly felt that they should be asked about their substance use (91%), and deemed it appropriate for their doctor to recommend reducing use if it could adversely affect their health (92%). Most (87%) were equally comfortable discussing alcohol or drug use. A majority (63%) preferred discussing substance use with their doctor over other medical staff. Responses weremixed regarding screening modality: 55%preferred face-to-face, 22% had no preference, 14% preferred self- administration. Participants reported that they would be honest with their provider (94%), but 32% were concerned about medical record confidentiality.
CONCLUSION(S): Primary care patients strongly supported being screened for drug and alcohol use, and would be comfortable discussing it with their doctor. However, patients' concerns about having their substance use documented in their medical record could pose a barrier to achieving accurate responses. These findings suggest a need to educate patients on the confidentiality of medical records and the value of disclosing substance use for their medical care

BACKGROUND:Headache mobile health (mHealth) applications (apps) have gained popularity in use but there is little research into what people with migraine find important to track. This information is important for helping with adherence and determining meaningful data to patients. We conducted several clinical trials using a headache research app (RELAXaHEAD). The app contains a "notes" feature (a free-text input section) where patients could record notes related to their headache. OBJECTIVE:To identify what patients view as important when tracking migraine/headaches within a headache tracking mHealth app. METHODS:This was a retrospective study where smartphone diary notes inputted by people with migraine were qualitatively analyzed; notes were extracted, a preliminary codebook was developed and used to code each note. Using grounded theory, themes and subthemes emerged. RESULTS:About 288 subjects in the trials used the notes function. There were 5364 total notes with an average of 18.6 ± 39.2 notes/user. The qualitative analysis yielded 759 unique codes and the emergence of 4 major themes. The first theme was "Utility in free-text tracking of headache characteristics, medications, and sleep" which emerged as a space for users to elaborate on data that could have been inputted into other sections of the app. The second theme was "Monitoring coexisting conditions both related to and distinct from headache." The third theme was "Personal records of behavioral therapy adherence," which included a range of concepts from behavioral therapy session frequency/adherence to subjects' thoughts or emotions regarding the behavioral therapy. The fourth theme was "Migraine trigger, prevention, and relief patterns deciphered through consistent data tracking." CONCLUSION/CONCLUSIONS:We found that the majority of patients choose to expand on information beyond what can be inputted into specific icons in a headache app. Moreover, they want to be able to monitor not only headache-related symptoms but symptoms they experience from other conditions. In addition to tracking their pharmacologic treatment, they may choose to track their nonpharmacologic, that is, behavioral therapy use, and they also use a smartphone diary app to assess what triggers versus relieves a migraine. While the RELAXaHEAD app was designed with features to extract data that would be useful to physicians and patients in treating migraine, our study results indicated that users also prefer a range of tracking capabilities that may or may not be useful to physicians but may be important for headache smartphone user engagement.

This study examined the interrelated and longitudinal impacts of parent-child shared book reading, parenting stress, and early relational health, as measured by both parental warmth and parent sensitivity, from infancy to toddlerhood. To extend findings from previous studies of collateral effects that have been conducted in parenting interventions, we examined parenting behaviors in a broader context to determine whether shared book reading would confer collateral benefits to the parent and parent-child relationship beyond those expected (i.e., language and literacy). It was hypothesized that positive parent-child interactions, such as shared reading, would have positive impacts on parent outcomes such as parenting stress, parental warmth, and sensitivity. The sample consisted of 293 low-income mothers and their children who participated in a randomized controlled trial. Shared book reading, parenting stress, and parental warmth were assessed when children were 6 and 18 months old. We computed a series of cross-lagged structural equation models to examine longitudinal interrelations among these three factors. Results indicated that shared book reading at 6 months was associated with increases in observed and reported parental warmth and observed sensitivity and decreases in parenting stress at 18 months, controlling for baseline risk factors and treatment group status. These findings suggest that early parent-child book reading can have positive collateral impacts on parents' stress and the parent-child relationship over time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

OBJECTIVE:To characterize the population of subfertile and infertile men in the United States who lack access to infertility services. DESIGN/METHODS:Analysis of the 2011-2013, 2013-2015, and 2015-2017 waves of the National Survey for Family Growth (NSFG) dataset. SETTING/METHODS:Not applicable. PATIENT(S)/METHODS:Noninstitutionalized civilian men, ages 15-45 years, who were married or lived with a woman and had not undergone a vasectomy. INTERVENTION/METHODS:Not applicable. MAIN OUTCOME MEASURE(S)/METHODS:Access to infertility services. RESULT(S)/RESULTS:Compared with people who had used infertility services, unevaluated men who self-reported as infertile or subfertile were younger, had lower household incomes, were less educated, and were less likely to be married. Unevaluated infertile men were less likely to have a regular place where they received health care, were more likely to be uninsured, and had a poorer perception of their personal health. On multivariable logistic regression analysis, average household income, marital status, education level, and current insurance status remained significant. CONCLUSION(S)/CONCLUSIONS:Infertile men who had not used infertility services were less educated, were less likely to have been married, and had a lower household income and private insurance rate compared with men who had used infertility services. These demographic and health care utilization differences can help inform public policy related to fertility.

Air pollution is a major contributor to cardiovascular morbidity and mortality. Fine particulate matter <2.5 µm in diameter may be a modifiable risk factor for hypertension. The benefits of in-home air filtration on systolic blood pressure (BP) and diastolic BP are unclear. To examine the effects of in-home personal air cleaner use on fine particulate exposure and BP, we queried PubMed, Web of Science, Cochrane Central Register, Inspec, and EBSCO GreenFILE databases for relevant clinical trials. Included studies were limited to nonsmoking participants in smoke-free homes with active or sham filtration on indoor fine particulate concentrations and changes in systolic and diastolic BP. Of 330 articles identified, 10 trials enrolling 604 participants who met inclusion criteria were considered. Over a median 13.5 days, there was a significant reduction of mean systolic BP by ≈4 mm Hg (-3.94 mm Hg [95% CI, -7.00 to -0.89]; P=0.01) but a nonsignificant difference in mean diastolic BP (-0.95 mm Hg [95% CI, -2.81 to 0.91]; P=0.32). Subgroup analyses indicated no heterogeneity of effect by age, level of particulate exposure, or study duration. Given the variation in study design, additional study is warranted to confirm and better quantify the observed benefits in systolic BP found with personal air cleaner use.

Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.

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.