Faculty Bibliography

RATIONALE & OBJECTIVE/OBJECTIVE:Despite national efforts, the uptake of home dialysis (peritoneal dialysis or home hemodialysis) remains low. Characteristics of the built environment may differentially impact home dialysis use. STUDY DESIGN/METHODS:Retrospective cohort study (2010-2019). SETTING & PARTICIPANTS/METHODS:1,103,695 adults (aged≥18 years) initiating dialysis in the US Renal Data System. EXPOSURE/METHODS:We examined 3 built environment domains based on residential ZIP code: (1) medically underserved areas (MUAs), defined as neighborhoods with limited primary care access; (2) distance to the nearest dialysis facility; and (3) distribution of housing characteristics (structure and overcrowding). OUTCOME/RESULTS:Uptake of home dialysis modalities at dialysis initiation. ANALYTICAL APPROACH/METHODS:We quantified associations between built environment characteristics and home dialysis initiation using multilevel logistic regression stratified by urbanicity type (urban, suburban, small-town, and rural). RESULTS:Among adults initiating dialysis, 40.8% lived in MUAs. Across ZIP codes, the mean percentage of overcrowded housing was 4.2% (SD, 4.7%), and the percentage of detached housing was 61.1% (SD, 21.1%); mean distance to the nearest dialysis facility was 5.5km (SD, 9.1km). Living in MUAs was associated with reduced home dialysis use only in urban (OR, 0.94; 95% CI, 0.91-0.96) and suburban (OR, 0.92; 95% CI, 0.89-0.94) areas. Similarly, housing overcrowding was associated with decreased home dialysis use only in urban (OR, 0.88; 95% CI, 0.86-0.89) and suburban (OR, 0.91; 95% CI, 0.90-0.93) areas. Longer distance to a dialysis facility was the most salient neighborhood factor associated with increased home dialysis use in small towns (OR, 1.14; 95% CI, 1.12-1.16) and rural areas (OR, 1.17; 95% CI, 1.15-1.19). LIMITATIONS/CONCLUSIONS:Housing characteristics were measured at the ZIP code level. CONCLUSIONS:Built environment characteristics associated with home dialysis uptake vary by urbanicity. Policies should address built environment barriers that are specific to urbanicity level. For example, increasing the frequency of dialysate delivery schedules could address housing space constraints in urban and suburban areas, and promoting home dialysis might be more effective for patients living far from dialysis centers in small-town and rural areas.

BACKGROUND:Hearing loss is prevalent in older adults and is associated with reduced daily physical activity, but whether hearing intervention attenuates declines in physical activity is unknown. We investigated the 3-year effect of a hearing intervention versus a health education control on accelerometer-measured physical activity in older adults with hearing loss. METHODS:This secondary analysis of the ACHIEVE randomized controlled trial included 977 adults aged 70-84 years with hearing loss. Participants were randomized to either a hearing intervention group or a health education control group. Physical activity was measured using wrist-worn accelerometers at baseline, 1, 2, and 3 years. Linear mixed models assessed the impact of the intervention on changes in total activity counts, active minutes per day, and activity fragmentation. RESULTS:Among 847 participants in the final analysis (mean age 76.2 years; 440 [52%] women; 87 [10%] Black; 5 [0.8%] Hispanic), total activity counts declined by 2.7% annually, and active minutes/day declined by 2.1% annually over 3 years in both intervention and control groups. Activity patterns also became more fragmented over time. No appreciable differences were observed between hearing intervention and health education control in the 3-year change in accelerometry-measured physical activity measures. CONCLUSIONS:Hearing intervention did not appreciably attenuate 3-year declines in physical activity compared to health education control in older adults with hearing loss. Alternative strategies beyond hearing treatment may be needed to enhance physical activity among older adults with hearing loss.

BACKGROUND/UNASSIGNED:The impact of preventing hypertension and maintaining normal blood pressure (BP) on life expectancy and healthy life expectancy (HLE) among Black adults, who are disproportionately affected by hypertension, has not been quantified. METHODS/UNASSIGNED:We used a discrete event simulation to estimate life expectancy and HLE among a cohort of Black adults from the Jackson Heart Study (n=4933) from age 20 to 100 years or until death. We modeled preventing hypertension as having BP <130/80 mm Hg and maintaining normal BP as having BP <120/80 mm Hg across the lifespan. In the primary analysis, we assumed that lowering BP decreased the risk of cardiovascular disease events, resulting in life expectancy and HLE gains. In a secondary analysis, we assumed that preventing hypertension and maintaining normal BP directly reduced both cardiovascular disease and mortality risk. RESULTS/UNASSIGNED:At age 20 years, the projected average life expectancy was age 80.8 (95% uncertainty interval [UI], 80.6-81.1) years, and HLE was 70.5 (95% UI, 70.3-70.7) healthy life years. In the primary analysis, preventing hypertension and maintaining normal BP added 0.9 (95% UI, 0.8-1.1) and 1.1 (95% UI, 0.9-1.3) years to life expectancy, respectively, and 2.7 (95% UI, 2.6-2.9) and 2.9 (95% UI, 2.7-3.1) healthy life years to HLE, respectively. In the secondary analysis, preventing hypertension and maintaining normal BP added 4.5 (95% UI, 4.3-4.6) and 4.6 (95% UI, 4.4-4.8) years to life expectancy, respectively, and 5.7 (95% UI, 5.6-5.8) and 5.9 (95% UI, 5.7-6.0) healthy life years to HLE, respectively. CONCLUSIONS/UNASSIGNED:Preventing hypertension and maintaining normal BP were projected to increase life expectancy and HLE among Black adults.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Healthcare is increasingly being delivered in the outpatient setting, but robust quality improvement programs and performance metrics are lacking in ambulatory care, particularly specialty-based ambulatory care. METHODS:To promote quality improvement in ambulatory care, we developed an infrastructure to create specialty-specific quality measures and dashboards that could be used to display providers' performance across relevant measures to individual providers and institutional leaders. RESULTS:The products of this program include a governance and infrastructure for specialty-specific ambulatory quality metrics as well as two distinct dashboards for data display. One dashboard is provider-facing, displaying provider's performance on specialty-specific measures as compared to institutional standards. The second dashboard is a leadership dashboard that provides overall and provider-level information on performance across measures. CONCLUSIONS:The Specialty-based Ambulatory Quality program reflects a systematic, institutionally-supported quality improvement framework that can be applied across diverse ambulatory specialties. As next steps, we plan to evaluate the program's impact on provider performance across measures and expand this program to other specialties practicing in the outpatient setting.

Although it is known that caregiver dietary behaviors influence child eating patterns, a gap remains in addressing the diet of a caregiver as much as their child in pediatric practice. A dyadic (caregiver-child) dietary approach would enhance the promotion of healthy eating patterns in children (and their caregivers) and achieve the population health goal of healthy eating across demographic groups. This study aimed to understand factors influencing dyadic dietary patterns (concordance, discordance) and contexts. Twenty professionals who provide nutrition-related expertise for families were recruited via maximum variation sampling. Qualitative thematic analysis of semi-structured interviews revealed 3 themes: (1) variable professional perspectives on what constitutes "healthy eating," (2) eating patterns of a child in the setting of variable caregiver eating practices, and (3) challenges to the promotion of a healthy caregiver-child dyadic diet within a social context. The results offer insight for future interventions that promote positive intergenerational transmission of health.

BACKGROUND/UNASSIGNED:Systematic screening individuals with non-invasive devices may improve diagnosis of atrial fibrillation (AF) and reduce adverse clinical events. We systematically reviewed the existing literature to determine the yield of new AF diagnosis associated with systematic AF screening, the relative increase in yield of new AF diagnosis with systematic screening compared to usual care, and the effect of systematic AF screening on clinical outcomes compared with usual care. METHODS/UNASSIGNED:The Medline, Embase, Web of Science and Cochrane Library databases were searched from inception through 1st February 2025 for prospective cohort studies or randomised clinical trials (RCTs) of systematic AF screening with the outcome of incidence of previously undiagnosed AF from screening. Incidence rates (IR) and relative risks were calculated and random effects meta-analysis performed to synthesise rates of AF in prospective cohort studies and RCTs, as well as outcomes in RCTs. FINDINGS/UNASSIGNED:From 3806 unique records we included 32 studies representing 735,542 participants from 8 RCTs and 24 prospective cohorts. The diagnosis rate for incident AF in prospective cohorts was 2.75% (95% CI 1.87-3.62), and the pooled relative risk in RCTs was 2.22 (95% CI 1.41-3.50). The use of age and NT-proBNP (IR 4.36%, 95% CI 3.77-5.08) or AF risk score classification (4.79%, 95% CI 3.62-6.29) led to higher new AF diagnosis yields than age alone (0.93%, 95% CI 0.28-2.99). Pooled data from RCTs did not demonstrate an effect of screening on death (RR 1.01, 95% CI 0.97-1.05), cardiovascular hospitalisation (1.00, 95% CI 0.97-1.03), stroke (0.95, 95% CI 0.87-1.04) or bleeding (1.08, 95% CI 0.91-1.29). INTERPRETATION/UNASSIGNED:Systematic screening for AF using non-invasive devices is associated with increased diagnosis of AF, but not reduced adverse clinical events. Screening studies of AF utilising alternative risk stratifications and outcome measures are required. FUNDING/UNASSIGNED:British Heart Foundation (grant reference CC/22/250026) and National Institute for Health and Care Research.

BACKGROUND/OBJECTIVES/OBJECTIVE:Patients often face uncertainty about what they should know after prostate cancer diagnosis. Web-based information is common but is at risk of being of poor quality or readability. SUBJECTS/METHODS/METHODS:We used ChatGPT, a freely available Artificial intelligence (AI) platform, to generate enquiries about prostate cancer that a newly diagnosed patient might ask and compared to Google search trends. Then, we evaluated ChatGPT responses to these questions for clinical appropriateness and quality using standardised tools. RESULTS:ChatGPT generates broad and representative questions, and provides understandable, clinically sound advice. CONCLUSIONS:AI can guide and empower patients after prostate cancer diagnosis through education. However, the limitations of the ChatGPT language-model must not be ignored and require further evaluation and optimisation in the healthcare field.

Unauthorized immigrants and permanent residents may experience challenges in accessing kidney transplantation due to limited healthcare access, socioeconomic and cultural barriers. Understanding the United States (US) national landscape of kidney transplantation for non-citizens may inform policy changes. To evaluate this, we utilized two cohorts from the US national registry (2013-2023): 287,481 adult candidates for first transplant listing and 190,176 adult first transplant recipients. Citizenship was categorized as US citizen (reference), permanent resident, and presumed unauthorized immigrant. Negative binomial regression was used to quantify the incidence rate ratio over time by citizenship status. Cause-specific hazards models, with clustering at the state of listing/transplant, were used to calculate the adjusted hazard ratio of waitlist mortality, kidney transplant, and post-transplant outcomes (mortality/death-censored graft failure) by citizenship category. The crude proportion of presumed unauthorized immigrants listed increased over time (2013: 0.9%, 2023:1.9%). However, after accounting for case mix and waitlist size, there was no change in listing over time. Presumed unauthorized immigrants were less likely to experience waitlist mortality (adjusted Hazard Ratio 0.54, 95% Confidence Interval: 0.46-0.62), were more likely to obtain deceased donor kidney transplant (1.11: 1.05-1.18), but less likely to receive live donor (0.80: 0.71-0.90) or preemptive kidney transplant (0.52: 0.43- 0.62). When stratified by insurance status, presumed unauthorized immigrants on Medicaid were less likely to receive deceased donor kidney transplants compared to their citizen counterparts; however, presumed unauthorized immigrants with Private insurance or Medicare were more likely to receive deceased donor kidney transplants. Presumed unauthorized immigrants were less likely to experience post-transplant death (0.56: 0.43-0.69) and graft failure (0.69: 0.57-0.84). Residents had similar pre- and post-transplant outcomes. Despite the barriers to kidney transplantation faced by presumed unauthorized immigrants and residents in the US, better post-transplant outcomes for presumed unauthorized immigrants compared to citizens persisted, even after accounting for differences in patient characteristics.