Faculty Bibliography

Positive airway pressure (PAP) adherence is lower in African Americans (AAs) and, possibly, Hispanics as compared to Whites. Access to other treatment modalities is also limited in these groups. In children, obstructive sleep apnea (OSA) prevalence is higher among AAs, Hispanics, and Asian Americans. AA children have lower rates of adenotonsillectomy. Interventions to dissipate misconceptions about sleep and OSA, better patient-provider communication, and standardized and targeted surveys and procedures are necessary to minimize this problem. This section will review disparities in PAP treatment and other options, as well as children's phenotypes, associated factors, and potential interventions.

OBJECTIVE/UNASSIGNED:The authors sought to examine substance use patterns across the sexual identity spectrum, particularly among individuals who describe their sexual identity using different terms or express uncertainty about their orientation-groups that remain poorly understood beyond lesbian, gay, or bisexual (LGB) categories. METHODS/UNASSIGNED:Using data from the 2023 National Survey on Drug Use and Health among individuals ≥12 years of age (N=52,525), the authors examined past-year substance use across five sexual identity groups: heterosexual, gay/lesbian, bisexual, those using a different term to describe their sexual identity, and those unsure of their identity. Associations were examined between sexual identity (overall and disaggregated by sex using sex-specific heterosexual reference groups) and past-year use of cannabis, hallucinogens, cocaine, inhalants, methamphetamine, and misuse of prescription opioids, tranquilizers/sedatives, and stimulants. RESULTS/UNASSIGNED:Substance use was higher across all other sexual identity groups compared with heterosexual individuals. Bisexual and gay/lesbian individuals showed elevated odds across most substances examined, particularly inhalants, hallucinogens, and cannabis. Both individuals using different terms and those unsure of their sexual identity showed elevated odds for inhalants, hallucinogens, cannabis, and prescription tranquilizer/sedative misuse, with those using different terms additionally showing elevated odds for prescription stimulant misuse. In sex-disaggregated analyses, both males and females showed elevated odds across multiple substances, with females generally showing elevations across a greater number of substances, although some estimates for males were suppressed due to small sample sizes. CONCLUSIONS/UNASSIGNED:These findings extend our understanding of substance use beyond LGB categories, revealing nuanced patterns among emerging identity groups, underscoring the importance of targeted screening and prevention strategies.

CONTEXT/UNASSIGNED:Plasticizers such as bisphenols and phthalates are endocrine-disrupting chemicals and lead to development of metabolic diseases. OBJECTIVE/UNASSIGNED:To examine associations of prenatal exposure to bisphenols and phthalates with metabolic dysfunction. DESIGN/UNASSIGNED:This study was nested in the New York University (NYU) Children's Health and Environment Study, a prospective birth cohort. SETTING/UNASSIGNED:Participants were recruited at three NYU-affiliated hospitals. PATIENTS OR OTHER PARTICIPANTS/UNASSIGNED:Eligible participants were ≥18 years old, <18 weeks pregnant, and had a medically stable pregnancy. EXPOSURES/UNASSIGNED:Twelve phthalate metabolites and two bisphenols were measured in early and mid-pregnancy (<18 and 18-25 weeks) urine samples. Bisphenols were summed, and phthalate metabolites were grouped based by molecular weights and relevant parent compounds. MAIN OUTCOME MEASURES/UNASSIGNED:Logistic and linear regression models assessed chemicals groups' associations with gestational diabetes mellitus (GDM), glucose disturbance (including impaired glucose tolerance (IGT)), and blood glucose response to glucose challenge test (GCT), adjusting for sociodemographic and pregnancy-related factors. RESULTS/UNASSIGNED:Seventy-nine (6.8%) had GDM, 303 (26.1%) had IGT, and blood glucose response to GCT ranged from 22-386 mg/dL. Bisphenol A (BPA) was negatively associated with blood glucose response to GCT (-1.47 [-2.84, -0.10]), while diethylhexyl phthalate (DEHP; 2.67 [0.98, 4.36]) and high molecular weight phthalates (1.94, [0.17, 3.71]) were positively associated with blood glucose response to GCT. DEHP was also linked to glucose disturbance (1.16 [1.02, 1.31]). CONCLUSION/UNASSIGNED:Our findings suggest that phthalate exposure is associated with GDM. Further mechanistic studies are warranted, particularly given the inverse associations with BPA exposure.

BACKGROUND:Age-related hearing loss is common and a particularly prevalent disability among Veterans. In response, comprehensive hearing services are available within the Veterans Affairs (VA) integrated healthcare system. Severe hearing loss may pose distinct communication challenges inadequately addressed by hearing aids, but data suggest severe hearing loss is often not treated differently. We sought to identify barriers and facilitators to evidence-based and individualized management of severe hearing loss from the perspectives of VA clinicians and Veterans. METHODS:We used purposeful sampling to conduct remote semi-structured video interviews with 33 current VA clinicians encompassing multiple disciplines and 39 Veterans with severe hearing loss over approximately an 18 month period (May 2022 to December 2023). We analyzed qualitative data using content thematic analysis. Coding categories were summarized within each participant; then across all participants to yield clinician-specific and Veteran themes. RESULTS:In the sample of 33 VA clinicians (20 audiologists, 9 otolaryngologists and 4 primary care clinicians), the overarching theme of qualitative data is that hearing loss is undertreated in the Veteran population. Across clinician groups, the qualitative data revealed multi-level factors (system-, clinician-, and patient-level) that influence the delivery of hearing care and management for Veterans with severe hearing loss. Interviews revealed that efficient access and collaborative care facilitate evidence-based practice. Among Veterans, inadequately managed hearing loss impacts quality of life; lack of knowledge and misconceptions about hearing care options and system-level barriers influence Veterans' perceptions of their hearing care and management. CONCLUSION/CONCLUSIONS:Although hearing care is available to Veterans, multi-level factors influence the delivery of hearing care and management for Veterans with severe hearing loss. Greater attention both in primary and specialty care is needed to ensure tailored treatments are available to Veterans with severe hearing loss across the integrated VA health care system.

OBJECTIVES/OBJECTIVE:To examine the effects of PlayReadVIP, a pediatric primary care intervention promoting early relational health, on child behaviors. STUDY DESIGN/METHODS:A factorial randomized controlled trial enrolled mother-child dyads postpartum. PlayReadVIP was delivered in two phases: birth to 3 years (PlayReadVIP 0-3) and 3 to 5 years (PlayReadVIP 3-5). At enrollment, dyads were assigned to PlayReadVIP 0-3 or control. At age 3, dyads were re-randomized to PlayReadVIP 3-5 or control. Analyses included dyads with a second randomization and complete data on the mediators and child outcomes. In PlayReadVIP, dyads attended one-on-one sessions with a parent coach, in which they received child development information, learning materials, and real-time, strengths-based feedback on brief video recordings of parent-child interactions. Cognitive stimulation and harsh discipline were reported by mothers. Child behaviors were assessed using the Behavior Assessment System for Children, Second Edition. RESULTS:grade. No significant indirect effects through harsh discipline were found. CONCLUSIONS:PlayReadVIP leads to sustained but small improvements in child behaviors by enhancing maternal cognitive stimulation, emphasizing the potential of early intervention in pediatric primary care for promoting child mental health in disadvantaged populations.

IMPORTANCE/UNASSIGNED:Lung cancer screening (LCS) with low-dose computed tomography (CT) remains underused in the US, partly because of incomplete smoking history documentation in electronic health records (EHRs) and limited time for shared decision-making in primary care. OBJECTIVE/UNASSIGNED:To determine whether a patient-facing, EHR-integrated tool combined with clinician-facing clinical decision support improves the identification of LCS-eligible patients and the ordering of low-dose CT compared with clinician-facing tools alone. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This pragmatic, unstratified, randomized clinical trial with parallel groups was conducted from March 29, 2024, to March 28, 2025, at primary care clinics at University of Utah Health and New York University Langone Health. Adults aged 50 to 79 years with a documented smoking history, an active patient portal account, and a primary care visit in the preceding year were included. Study 1 enrolled patients with uncertain LCS eligibility (10 to 19 pack-years, unknown pack-years, or missing quit date); study 2 enrolled patients with documented eligibility (20 or more pack-years and currently smoking or quit smoking within 15 years). INTERVENTIONS/UNASSIGNED:The control included the clinician-facing Decision Precision+ tool (preventive care reminders and a shared decision-making tool). The intervention included the Decision Precision+ tool as well as the MyLungHealth tool, which collected detailed smoking history (study 1) and delivered personalized education and risk/benefit information (studies 1 and 2) via the patient portal in English and Spanish. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcomes were the proportion of patients newly identified as eligible for LCS (study 1) and low-dose CT ordering rates (study 2) over 12 months. Analyses used intention-to-treat mixed-effects logistic regression. RESULTS/UNASSIGNED:There were 31 303 randomized participants, including 26 729 in study 1 (13 144 [49.2%] female; 13 580 [50.8%] male; median [IQR] age, 62 [55-69] years) and 4574 in study 2 (2230 [48.8%] female; 2344 [51.2%] male; median [IQR] age, 63 [56-69] years). In study 1, the MyLungHealth tool increased new LCS eligibility identification (635 of 13 412 [4.7%] vs 308 of 13 317 [2.3%]; adjusted odds ratio, 2.19; 95% CI, 1.99-2.42; P < .001). In study 2, low-dose CT ordering was higher in the intervention arm (474 of 2312 [20.5%] vs 434 of 2262 [19.2%]; adjusted odds ratio, 1.16; 95% CI, 1.04-1.30; P = .008). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this randomized clinical trial, integrating a patient-centered tool into primary care EHR workflows increased the identification of patients eligible for LCS and the ordering of low-dose CTs. The relative increases in these primary outcomes were substantial, but absolute increases were more modest. Research on more intensive interventions is warranted to evaluate their ability to further improve LCS screening. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT06338592.

BACKGROUND:The COVID-19 pandemic presented significant new needs and challenges for people experiencing homelessness (PEH) and people with substance use disorders (SUDs). In response, program leaders modified existing programs and developed new ones to meet these needs during a unique policy and public health environment. This study aimed to examine how these innovations unfolded and what lessons can be learned from their implementation. METHODS:We performed in-depth, semi-structured qualitative interviews with key informants (n = 37 informants) from programs serving PEH and addressing substance use created or adapted during the COVID-19 pandemic in the United States (U.S.) and Canada. Informants spanned a wide range of backgrounds, program types, and geographic locations. We completed rapid sequence qualitative analysis using templated summaries for each interview, which we compiled into a summary matrix. We reviewed the summary matrix to identify key topics and develop a code list that was applied to transcripts using line-by-line coding. Results from rapid analysis and line-by-line coding were discussed iteratively to develop and refine key themes. RESULTS:Key informants described innovations including SUD treatment and harm reduction interventions via telemedicine, hotel shelters, and street outreach. Interviews revealed four overarching themes related to innovation implementation: (1) Removal of usual bureaucratic barriers and easing of regulations facilitated action, (2) Individuals stepped up and said, "We're gonna do it," (3) Stigma and mixed attitudes about harm reduction impacted the implementation of pandemic innovations, and (4) Innovations in shelter and SUD care delivery for PEH during the COVID-19 pandemic resulted in durable lessons and new program models. CONCLUSIONS:A combination of individual action and systemic changes produced new innovations to address the intersecting issues of homelessness and substance use during the COVID-19 pandemic. Lessons from these innovations can inform sustained improvements in SUD care for PEH.

PURPOSE/OBJECTIVE:Prediction models can contribute to disparities in care by performing unequally across demographic groups. While fairness-aware methods have been explored for binary outcomes, applications to survival analysis remain limited. This study compares two fairness-aware deep learning survival models to mitigate racial disparities in predicting survival after radical prostatectomy for prostate cancer. METHODS:We used the National Cancer Database to train deep Cox proportional hazards models for overall survival. Two fairness-aware approaches, Fair Deep Cox Proportional Hazards Model (Fair DCPH) and Group Distributionally Robust Optimization Deep Cox Proportional Hazards Model (GroupDRO DCPH), were compared against a standard Deep Cox model (Baseline). Model fairness was assessed via cross-group and within-group concordance indices (C-index). RESULTS:Among 418,968 included patients, 78.5% were White, with smaller proportions of Black (13.2%), Hispanic (4.5%), Asian (1.9%), and Other (2.0%) patients. The baseline DCPH model achieved a cross-group C-index of 0.699 for White patients but showed reduced performance for Black (0.678) and Hispanic (0.689) patients. Fairness-aware models improved cross-group C-indices; for Black patients, cross-group C-index increased to 0.692 (Fair DCPH) and 0.696 (GroupDRO DCPH); for Hispanic patients, to 0.693 and 0.697, respectively. Cross-group C-index also improved in the Asian subgroup, where the C-index rose from 0.696 (Baseline DCPH) to 0.702 (Fair DCPH) and 0.707 (GroupDRO DCPH), with minimal performance loss observed for White patients. CONCLUSION/CONCLUSIONS:We benchmark two fairness-aware survival models that address racial disparities in post-prostatectomy survival prediction. These methods can be extended to other time-to-event models to ensure equitable care supported by fair prediction models.

Health literacy and language impact comprehension of and adherence to written educational materials, including those for gastrostomy tubes (g-tubes). Our objective was to evaluate the readability, understandability, actionability, content, and language availability of a national sample of written g-tube educational materials. We conducted a cross-sectional study of g-tube educational materials from top 20 children's hospitals (US News and World Report) obtained via a systematic online search and provided by the institutions. We assessed material: (1) readability, (2) understandability and actionability (Patient Education Materials Assessment Tool for Printable Materials, (3) content, and (4) language availability. Mean (standard deviation [SD]) reading grade level was 8.3 (1.9). Mean (SD) understandability and actionability scores were 81.6% (12.1%) and 65.9% (23.2%), respectively. Materials covered a mean (SD) of 46.1% (25.3%) of content items; 20% of institutions provided materials in non-English languages. Future research should examine how to improve educational materials for children with g-tubes.