Faculty Bibliography

Colorectal cancer (CRC) screening has increased substantially in New York City in recent years. However, screening uptake measured by telephone surveys may not fully capture rates among underserved populations. We measured screening completion within one year of a primary care visit among previously unscreened patients in a large urban safety-net hospital and identified sociodemographic and health-related predictors of screening. We identified 21,256 patients aged 50-75 who were seen by primary care providers (PCPs) in 2014, of whom 14,425 (67.9%) were not up-to-date with screening. Since PCPs facilitate the majority of screening, we compared patients who received screening within one year of an initial PCP visit to those who remained unscreened using multivariable logistic regression. Among patients not up-to-date with screening at study outset, 11.5% (1,658 patients) completed screening within one year of a PCP visit. Asian race, more PCP visits, and higher area-level income were associated with higher screening completion. Factors associated with remaining unscreened included morbid obesity, ever smoking, Elixhauser comorbidity index of 0, and having Medicaid/Medicare insurance. Age, sex, language, and travel time to the hospital were not associated with screening status. Overall, 39.9% of patients were up-to-date with screening by 2015. In an underserved urban population, CRC screening disparities remain, and overall screening uptake was low. Since more PCP visits were associated with modestly higher screening completion at one year, additional community-level education and outreach may be crucial to increase CRC screening in underserved populations.

Background: Caregivers (CGs) of older-adults with Alzheimer's disease and related dementias (ADRD) and CGs of older-adults with diabetes (DM) report substantial CG burden. CG burden is known to be linked to patients' behavioral problems, poor cognition, and increased dependency. There is no literature addressing CG burden in CGs of individuals with co-occurring diabetes and dementia (DM-ADRD). The aim of this study was to identify CG and care-recipient (CR) factors associated with high levels of CG burden in CGs of DM-ADRD patients.
Method(s): This study used bivariate and descriptive statistics to analyze surveys collected as part of a quality improvement intervention being conducted at NYU Langone Health primary care and endocrine Faculty Group Practices and Family Health Centers. Inclusion criteria for patients were age >= 65, cognitive impairment, and DM with recent HbA1c > 6.4 or ever prescribed hyperglyemic medication. Telephonic surveys were conducted with CGs of eligible patients. The Treatment Burden Questionnaire (TBQ) was used to measure CG burden. TBQ results were analyzed for association with CG factors including age, sex, race, relationship to patient, education level, residence status, and level of social support, as well as CR factors including age, sex, race, dementia severity, Charlson comorbidity score, and recent HbA1c values.
Result(s): CGs that completed surveys (n=58) had a mean age of 54.3 years, 74% (n=43) female, 46% (n=27) white, 84% (n=49) were children of CRs, 70% (n=41) had education beyond 12th grade, and 55% (n=32) lived separately from CR. CRs of CGs that completed surveys (n=58) had a mean age of 80.5 years, 67% (n=39) female, 67% (n=37) white. We found CGs who were male, Asian, co-resident, with low level of social support, of CRs with more-advanced dementia, and of CRs with recent out-of-range HbA1c had significantly higher levels of CG burden (p<0.1).
Conclusion(s): Our study demonstrates there are several CG and CR factors that are associated with increased levels of CG burden in this population. Findings may assist in identification of CGs at risk for increased burden. If these results are found to be replicable, future studies should focus on the development of prevention and treatment plans consistent with these findings

Population health researchers from different fields often address similar substantive questions but rely on different study designs, reflecting their home disciplines. This is especially true in studies involving causal inference, for which semantic and substantive differences inhibit interdisciplinary dialogue and collaboration. In this paper, we group nonrandomized study designs into two categories: those that use confounder-control (such as regression adjustment or propensity score matching) and those that rely on an instrument (such as instrumental variables, regression discontinuity, or differences-in-differences approaches). Using the Shadish, Cook, and Campbell framework for evaluating threats to validity, we contrast the assumptions, strengths, and limitations of these two approaches and illustrate differences with examples from the literature on education and health. Across disciplines, all methods to test a hypothesized causal relationship involve unverifiable assumptions, and rarely is there clear justification for exclusive reliance on one method. Each method entails trade-offs between statistical power, internal validity, measurement quality, and generalizability. The choice between confounder-control and instrument-based methods should be guided by these tradeoffs and consideration of the most important limitations of previous work in the area. Our goals are to foster common understanding of the methods available for causal inference in population health research and the tradeoffs between them; to encourage researchers to objectively evaluate what can be learned from methods outside one's home discipline; and to facilitate the selection of methods that best answer the investigator's scientific questions.

BACKGROUND:Evidence shows community health workers (CHWs) can effectively deliver proven behavior-change strategies to prevent type 2 diabetes mellitus (diabetes) and enhance preventive care efforts in primary care for minority and low-income populations. However, operational details to integrate CHWs into primary care practice remain less well known. OBJECTIVE:To examine clinicians' perceptions about working with CHWs for diabetes prevention in safety-net primary care. SETTING/METHODS:Clinicians are primary care physicians and nurses at two New York City safety-net hospitals participating in CHORD (Community Health Outreach to Reduce Diabetes). CHORD is a cluster-randomized trial testing a CHW intervention to prevent diabetes. DESIGN/METHODS:Guided by the Consolidated Framework for Implementation Research, we studied how features of the CHW model and organizational context of the primary care practices influenced clinicians' perspectives about the acceptability, appropriateness, and feasibility of a diabetes-prevention CHW program. Data were collected pre-intervention using semi-structured interviews (n = 18) and a 20-item survey (n = 54). APPROACH/METHODS:Both survey and interview questions covered clinicians' perspectives on diabetes prevention, attitudes and beliefs about CHWs' role, expectations in working with CHWs, and use of clinic- and community-based diabetes- prevention resources. Survey responses were descriptively analyzed. Interviews were coded using a mix of deductive and inductive approaches for thematic analysis. KEY RESULTS/RESULTS:Eighty-seven percent of survey respondents agreed CHWs could help in preventing diabetes; 83% reported interest in working with CHWs. Ninety-one percent were aware of clinic-based prevention resources; only 11% were aware of community resources. Clinicians supported CHWs' cultural competency and neighborhood reach, but expressed concerns about the adequacy of CHWs' training; public and professional emphasis on diabetes treatment over prevention; and added workload and communication with CHWs. CONCLUSIONS:Clinicians found CHWs appropriate for diabetes prevention in safety-net settings. However, disseminating high-quality evidence about CHWs' effectiveness and operations is needed to overcome concerns about integrating CHWs in primary care.

Racial minorities experience a high burden of food insecurity relative to non-Hispanic whites. Government-subsidized nutrition programs can positively impact food insecurity and nutritional risk among older adults. Yet, in New York City, where nearly 60% of people over 65 years are non-white, older minorities participate in government nutrition programs at very low rates. In this commentary, we focus on 2 programs: the Child and Adult Care Food Program and Older Americans Act Nutrition Services Programs. We identify opportunities for strengthening these programs to improve their reach and engagement with diverse older adults in New York City and similarly diverse urban communities.

Background: Sleep disturbance is common among nursing home (NH) residents, yet impacts on mood and other health outcomes remain unclear. Evidence from community-dwelling older adults has demonstrated relationships between sleep quality, mood, and adverse health outcomes. The aim of this study was to describe and identify relationships between self-reported sleep quality, mood and cognition among NH residents participating in a large randomized trial.
Method(s): We analyzed baseline assessment data from residents of two New York City NHs participating in an ongoing trial of a novel non-pharmacological intervention to improve sleep disturbance (Sleep Using Mentored Behavioral and Environmental Restructuring, SLUMBER). Participants were English or Spanish speakers who had capacity to consent for research. Baseline assessments included sleep quality (Pittsburgh Sleep Quality Index, PSQI), depressive symptoms (Patient Health Questionnaire-9, PHQ-9 and Brief Anxiety and Depression Scale, BADS), and cognition (Brief Cognitive Assessment Tool, BCAT).
Result(s): Participants' (n=70) mean age was 76.6 +/- 15.1 years; 45 (64.2%) were female. The sample was ethnically diverse: 31.4% Black/African American, 11.4% Hispanic/Latino, and 2.9% Asian. Mean BCAT score was 28.3 +/- 1.2 (23-33 suggests mild dementia). Poor sleep was common; mean PSQI total score: 7.8 +/- 4.3 (> 5 = poor sleep). 31% (n=22) had PHQ-9 scores (>= 5) indicative of depression. Higher (worse) PSQI total score was strongly associated with higher (worse) PHQ-8 (less sleep item) and BADS depression (r2=0.42, p<0.01). Interestingly, PSQI-categorized "good sleepers" were more likely to have BCAT scores indicative of dementia (p=0.042).
Conclusion(s): A significant association between worse self-reported sleep and more depressive symptoms suggests an opportunity for sleep interventions to improve not only sleep quality but also mood in NH residents. The relationship between worse cognition and better self-reported sleep may indicate that objective sleep measurement (e.g., actigraphy) is an important component of sleep assessment in NH residents with cognitive impairment

Background: Delirium affects 14-56% of hospitalized older adults, and leads to higher morbidity and increased healthcare costs. At NYULH we implemented the EmpoweRing elder Novel Interventions (ERNI) program in 2017, modeled after Hospital Elder Life Program (HELP), but we utilize trained pre-med and pre-nursing volunteers to prevent delirium. We have shown reduced length of stay and a decreased incidence of delirium with ERNI. Here we report on ERNI as a novel method to grow the geriatrics workforce.
Method(s): Patients 65 years or older admitted to ICU, ED observation, neurology, cardiology, and general medicine units determined to be at high risk for delirium were visited by trained pre-med/ nursing volunteers who engaged them in conversations, listened to music, reoriented them, worked on puzzles, and advocated for patients' needs. We assessed nursing and volunteer satisfaction, and patient/family satisfaction using Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data from April 2017- July 2019.
Result(s): 26/31 (84%) nurses rated volunteers 7 or higher on a scale of 1-10, and 84% of nurses felt volunteers helped prevent delirium. The volunteers expressed satisfaction with the program, 17/18 (94%), and felt appreciated by patients and families[BC1]. 16/18 (89%) volunteers plan to pursue a career in healthcare, and 17/18 volunteers (94%) plan to work with older adults. 12/18 (67%) volunteers were the first in their families to work in healthcare. Although not directly related to ERNI, patient HCAHPS scores in the Observation Unit (measured by the hospital), improved after ERNI implementation, with nursing communication increasing from 70.5% to 77% and pain communication from 34.1% to 45.6%.
Conclusion(s): Our ERNI program demonstrated high rates of nursing and volunteer satisfaction, and patients in ED Observation had increased satisfaction. Exposing pre-med/nursing volunteers to older patients in a modified HELP program may be an important step toward increasing recruitment to the geriatrics workforce. For those already considering this career, the ERNI experience might solidify those intentions. Future plans are to expand this program by recruiting more college students as volunteers

Although it is well accepted that air pollution exposure exacerbates preexisting airway disease, it has not been firmly established that long-term pollution exposure increases the risk of new-onset asthma or chronic obstruction pulmonary disease (COPD). This Workshop brought together experts on mechanistic, epidemiological, and clinical aspects of airway disease to review current knowledge regarding whether air pollution is a causal factor in the development of asthma and/or COPD. Speakers presented recent evidence in their respective areas of expertise related to air pollution and new airway disease incidence, followed by interactive discussions. A writing committee summarized their collective findings. The Epidemiology Group found that long-term exposure to air pollution, especially metrics of traffic-related air pollution such as nitrogen dioxide and black carbon, is associated with onset of childhood asthma. However, the evidence for a causal role in adult-onset asthma or COPD remains insufficient. The Mechanistic Group concluded that air pollution exposure can cause airway remodeling, which can lead to asthma or COPD, as well as asthma-like phenotypes that worsen with long-term exposure to air pollution, especially fine particulate matter and ozone. The Clinical Group concluded that air pollution is a plausible contributor to the onset of both asthma and COPD. Available evidence indicates that long-term exposure to air pollution is a cause of childhood asthma, but the evidence for a similar determination for adult asthma or COPD remains insufficient. Further research is needed to elucidate the exact biological mechanism underlying incident childhood asthma, and the specific air pollutant that causes it.

Adult day centers (ADSCs) provide community-based long-term care, including meals, to racially diverse older adults, 47% of whom have dementia and consequently experience elevated nutritional risk. We examine nutritional practices for Chinese and Vietnamese persons living with dementia (PLWD) in ADSCs, and evaluate the extent to which ADSC's provide person-centered nutritional care. Multi-stakeholder interviews were conducted. Data was coded using Dedoose and analyzed using Braun and Clarke's six-step method. The Model for the Provision of Good Nutritional Care in Dementia guided analysis. Barriers to food intake included distracting meal environment, rigid meal-times, and excessively restrictive diets. Conversely, peer relationships, culturally-tailored meals and celebrations, and consistent staff assisting with feeding benefitted PLWD. ADSCs can support healthy weight and quality of life among PLWD through personcentered nutritional care. To optimize nutritional services, further exploration is needed with respect to the ADSC environment, users' culture and ethnicity, and liberalized diets for PLWD

Introduction: Functional decline, i.e., a decrement in performing every day activities necessary to live independently, is common after acute myocardial infarction (AMI) and associated with poor long-term outcomes; yet we do not have a tool to identify older AMI survivors at risk for this important patient-centered outcome.
Method(s): We used data from the ComprehenSIVe Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective longitudinal study of 3,041 AMI patients adults age >=75 years, recruited from 94 hospitals across the U.S. Participants underwent a structured interview and assessment during hospitalization and at six months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living (ADLs). Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (i.e., bathing, dressing, transferring, ambulation) from baseline to six months post-discharge. Backward selection was used to identify significant predictors of functional decline.
Result(s): Mean age of the sample was 82+/-5 years; 57% were male, 90% were white; and 13% reported ADL decline at six months post-discharge. Factors independently associated with increased risk of decline were older age, longer hospital stay, mobility impairment during hospitalization, higher comorbidity score, fall history, and depression. Revascularization during AMI hospitalization (e.g., PCI, CABG) and ability to walk mile prior to AMI were associated with decreased risk. Model discrimination (c=0.79) and calibration were very good.
Conclusion(s): We identified a parsimonious model that predicts risk of ADL decline among older AMI patients. This tool may aid in identifying older AMI patients who may benefit from physical therapy or cardiac rehab to optimize function after AMI.