Faculty Bibliography

A reformed approach to health care tackles health at its roots. Adverse childhood experiences (ACEs) in those exposed to them may contribute significantly to the root causes of many diseases of lifestyle. ACEs are traumatic experiences, such as physical and emotional abuse and exposure to risky family environments. In 1998, a ground-breaking study found that nearly 70% of Americans experience at least 1 ACE in their lifetime, and graded exposure is associated with the presence of mental health disorders, heart disease, cancer, and other chronic diseases. Over the past 20 years, evidence has demonstrated further disease risk, outcomes, and epigenetic underpinnings in children and adults with ACEs. Building resilience-the capacity to adapt in healthy ways to traumatic experiences-through lifestyle modification offers potential to combat the negative health effects associated with ACEs. Emerging research demonstrates resilience is cultivated through individual skills (emotional intelligence, coping, and fostering healthy lifestyle choices), and nurturing supportive relationships. Being mindful of the impact and prevalence of ACEs and diversity of individuals' experiences in society will help build resilience and combat the root cause of chronic disease. This review aims to cultivate that awareness and will discuss 3 objectives: to discuss the effects and hypothesized pathophysiological underpinnings of traumatic experiences in childhood on health and wellbeing throughout life, to present ways we can promote resilience in our daily lives and patient encounters, and to demonstrate how advocacy for the reduction of ACEs and promotion of resilient, trauma-informed environments are fundamental to health care reform.

INTRODUCTION/BACKGROUND:Material hardships, defined as difficulty meeting basic needs, are associated with adverse child health outcomes, including suboptimal health care utilization. Children with special health care needs (CSHCN) may be more vulnerable to the effects of hardships. Our objective was to determine associations between material hardships and health care utilization among CSHCN. METHODS:We conducted a cross-sectional study surveying caregivers of 2-12 year old CSHCN in a low-income, urban area. Independent variables were parent-reported material hardships: difficulty paying bills, food insecurity, housing insecurity, and health care hardship. Dependent variables were parent-reported number of emergency department (ED) visits, any hospital admission and any unmet health care need. We used negative binomial and logistic regression to assess for associations between each hardship and each outcome. RESULTS:205 caregivers were surveyed between July 2017 and May 2018, and data analyzed in 2018. After adjustment, difficulty paying bills (IRR 1.51, 95% CI 1.08, 2.12) and health care hardship (IRR 1.72, 95% CI 1.08, 2.75) were associated with higher rate of ED visits. There were no associations between hardships and hospital admission. Difficulty paying bills (AOR 2.13, 95% CI 1.14, 3.98), food insecurity (AOR 1.95, 95% CI 1.02, 3.71), and housing insecurity (AOR 2.71, 95% CI 1.36, 5.40) were associated with higher odds of unmet health care need. CONCLUSIONS:Material hardships were associated with higher rate of ED visits and greater unmet health care need among low-income CSHCN. Future examination of the mechanisms of these associations is needed to enhance support for families of CSHCN.

apoM is a minor HDL apolipoprotein and carrier for sphingosine-1-phosphate (S1P). HDL apoM and S1P concentrations are inversely associated with atherosclerosis progression in rodents. We evaluated associations between plasma concentrations of S1P, plasma concentrations of apoM, and HDL apoM levels with prevalent subclinical atherosclerosis and mortality in the African American-Diabetes Heart Study participants (N = 545). Associations between plasma S1P, plasma apoM, and HDL apoM with subclinical atherosclerosis and mortality were assessed using multivariate parametric, nonparametric, and Cox proportional hazards models. At baseline, participants' median (25th percentile, 75th percentile) age was 55 (49, 62) years old and their coronary artery calcium (CAC) mass score was 26.5 (0.0, 346.5). Plasma S1P, plasma apoM, and HDL apoM were not associated with CAC. After 64 (57.6, 70.3) months of follow-up, 81 deaths were recorded. Higher concentrations of plasma S1P [odds ratio (OR) = 0.14, P = 0.01] and plasma apoM (OR = 0.10, P = 0.02), but not HDL apoM (P = 0.89), were associated with lower mortality after adjusting for age, sex, statin use, CAC, kidney function, and albuminuria. We conclude that plasma S1P and apoM concentrations are inversely and independently associated with mortality, but not CAC, in African Americans with type 2 diabetes after accounting for conventional risk factors.

OBJECTIVE:To characterize the prevalence of tobacco, alcohol, and drug use and the acceptability of screening in university health centers. PARTICIPANTS/METHODS:Five hundred and two consecutively recruited students presenting for primary care visits in February and August, 2015, in two health centers. METHODS:Participants completed anonymous substance use questionnaires in the waiting area, and had the option of sharing results with their medical provider. We examined screening rates, prevalence, and predictors of sharing results. RESULTS:Past-year use was 31.5% for tobacco, 67.1% for alcohol (>4 drinks/day), 38.6% for illicit drugs, and 9.2% for prescription drugs (nonmedical use). A minority (43.8%) shared screening results. Sharing was lowest among those with moderate-high risk use of tobacco (OR =0.37, 95% CI 0.20-0.69), alcohol (OR =0.48, 95% CI 0.25-0.90), or illicit drugs (OR =0.38, 95% CI 0.20-0.73). CONCLUSIONS:Screening can be integrated into university health services, but students with active substance use may be uncomfortable discussing it with medical providers.

Background: In primary care, electronic self-administered screening and brief interventions for unhealthy alcohol may overcome some of the implementation barriers of face-to-face intervention. We developed an anonymous electronic self-administered screening brief intervention device for unhealthy alcohol use and assessed its feasibility and acceptability in primary care practice waiting rooms. Two modes of delivery were compared: with or without the presence of a research assistant (RA) to make patients aware of the device's presence and help users. Using the device was optional. Methods: The devices were placed in 10 participating primary care practices waiting rooms for 6 weeks, and were accessible on a voluntary basis. Number of appointments by each practice during the course of the study was recorded. Access to the electronic brief intervention was voluntary among those who screened positive. Screening and brief intervention rates and characteristics of users were compared across the modes of delivery. Results: During the study, there were 7270 appointments and 1511 individuals used the device (20.8%). Mean age of users was 45.3 (19.5), and 57.9% screened positive for unhealthy alcohol use. Of them, 53.8% accessed the brief intervention content. The presence of the RA had a major impact on the device's usage (59.6% vs 17.4% when absent). When the RA was present, participants were less likely to screen positive (49.4% vs 60.7%, P = 0.0003) but more likely to access the intervention (62.7% vs 51.4%, P = 0.009). Results from the satisfaction survey indicated that users found the device easy to use (93.5%), questions useful (89-95%) and 77.2% reported that their friends would be willing to use it. Conclusions: This pilot project indicates that the implementation of an electronic screening and brief intervention device for unhealthy alcohol is feasible and acceptable in primary care practices but that, without human support, its use is rather limited.

BACKGROUND:In 2016, a short message service text messaging intervention to titrate insulin in patients with uncontrolled type 2 diabetes was implemented at two health care facilities in New York City. OBJECTIVE:This study aimed to conduct a qualitative evaluation assessing barriers to and the facilitators of the implementation of the Mobile Insulin Titration Intervention (MITI) program into usual care. METHODS:We conducted in-depth interviews with 36 patients enrolled in the MITI program and the staff involved in MITI (n=19) in the two health care systems. Interviews were transcribed and iteratively coded by two study investigators, both inductively and deductively using a codebook guided by the Consolidated Framework for Implementation Research. RESULTS:Multiple facilitator themes emerged: (1) MITI had strong relative advantages to in-person titration, including its convenience and time-saving design, (2) the free cost of MITI was important to the patients, (3) MITI was easy to use and the patients were confident in their ability to use it, (4) MITI was compatible with the patients' home routines and clinic workflow, (5) the patients and staff perceived MITI to have value beyond insulin titration by reminding and motivating the patients to engage in healthy behaviors and providing a source of patient support, and (6) implementation in clinics was made easy by having a strong implementation climate, communication networks to spread information about MITI, and a strong program champion. The barriers identified included the following: (1) language limitations, (2) initial nurse concerns about the scope of practice changes required to deliver MITI, (3) initial provider knowledge gaps about the program, and (4) provider perceptions that MITI might not be appropriate for some patients (eg, older or not tech-savvy). There was also a theme that emerged during the patient and staff interviews of an unmet need for long-term additional diabetes management support among this population, specifically diet, nutrition, and exercise support. CONCLUSIONS:The patients and staff were overwhelmingly supportive of MITI and believed that it had many benefits and that it was compatible with the clinic workflow and patients' lives. Initial implementation efforts should address staff training and nurse concerns. Future research should explore options for integrating additional diabetes support for patients.

BACKGROUND:Public statements about the effect of smoking on cardiovascular disease are predominantly based on investigations of coronary heart disease (CHD) and stroke, although smoking is recognized as a strong risk factor for peripheral artery disease (PAD). No study has comprehensively compared the long-term association of cigarette smoking and its cessation with the incidence of 3 major atherosclerotic diseases (PAD, CHD, and stroke). OBJECTIVES:The aim of this study was to quantify the long-term association of cigarette smoking and its cessation with the incidence of the 3 outcomes. METHODS:A total of 13,355 participants aged 45 to 64 years in the ARIC (Atherosclerosis Risk In Communities) study without PAD, CHD, or stroke at baseline (1987 to 1989) were included. The associations of smoking parameters (pack-years, duration, intensity, and cessation) with incident PAD were quantified and contrasted with CHD and stroke using Cox models. RESULTS:Over a median follow-up of 26 years, there were 492 PAD cases, 1,798 CHD cases, and 1,106 stroke cases. A dose-response relationship was identified between pack-years of smoking and 3 outcomes, with the strongest results for PAD. The pattern was consistent when investigating duration and intensity separately. A longer period of smoking cessation was consistently related to lower risk of PAD, CHD, and stroke, but a significantly elevated risk persisted up to 30 years following smoking cessation for PAD and up to 20 years for CHD. CONCLUSIONS:All smoking measures showed significant associations with 3 major atherosclerotic diseases, with the strongest effect size for incident PAD. The risk due to smoking lasted up to 30 years for PAD and 20 years for CHD. Our results further highlight the importance of smoking prevention and early smoking cessation, and indicate the need for public statements to take PAD into account when acknowledging the impact of smoking on overall cardiovascular health.

Information regarding nutritional risk among users of American adult day health centers (ADHCs), 60% of whom are racial minorities, is scant. This study examined nutritional risk and associated factors in a diverse sample ADHC users aged 50+ using secondary cross-sectional analysis of data collected between 2013 and 2017. Risk was assessed using the DETERMINE checklist, and results were stratified by race. The majority of the sample (N = 188) was at moderate (45.2%) or high (38.5%) nutritional risk, with statistically significant racial differences. Blacks were at greater risk than any other group: 65% had high nutritional risk; 76.5% ate <5 servings of fruits, vegetables, or milk daily; 21% ate <2 meals daily, 48.5% reported involuntary weight loss/gain, and 41.2% had tooth loss/mouth pain. Older adults in ADHCs are at elevated risk of malnutrition, disproportionately so amongst blacks. Both routine nutrition screening and population-specific approaches are needed to attenuate risk.

INTRODUCTION/BACKGROUND:Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness. METHODS AND ANALYSIS/UNASSIGNED:This is the protocol for a pragmatic, cluster-randomised stepped wedge trial to test the effectiveness of PRIM-ER in 35 EDs across the USA. The intervention includes four core components: (1) evidence-based, multidisciplinary primary palliative care education; (2) simulation-based workshops; (3) clinical decision support; and (4) audit and feedback. The study is divided into two phases: a pilot phase, to ensure feasibility in two sites, and an implementation and evaluation phase, where we implement the intervention and test the effectiveness in 33 EDs over 2 years. Using Centers for Medicare and Medicaid Services (CMS) data, we will assess the primary outcomes in approximately 300 000 patients: ED disposition to an acute care setting, healthcare utilisation in the 6 months following the ED visit and survival following the index ED visit. Analysis will also determine the site, provider and patient-level characteristics that are associated with variation in impact of PRIM-ER. ETHICS AND DISSEMINATION/UNASSIGNED:Institutional Review Board approval was obtained at New York University School of Medicine to evaluate the CMS data. Oversight will also be provided by the National Institutes of Health, an Independent Monitoring Committee and a Clinical Informatics Advisory Board. Trial results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER/BACKGROUND:NCT03424109; Pre-results.