Faculty Bibliography
Searched for:
school:SOM
Department/Unit:Population Health
Total Results:
12818
A catalog of genetic loci associated with kidney function from analyses of a million individuals
Chronic kidney disease (CKD) is responsible for a public health burden with multi-systemic complications. Through trans-ancestry meta-analysis of genome-wide association studies of estimated glomerular filtration rate (eGFR) and independent replication (n = 1,046,070), we identified 264 associated loci (166 new). Of these, 147 were likely to be relevant for kidney function on the basis of associations with the alternative kidney function marker blood urea nitrogen (n = 416,178). Pathway and enrichment analyses, including mouse models with renal phenotypes, support the kidney as the main target organ. A genetic risk score for lower eGFR was associated with clinically diagnosed CKD in 452,264 independent individuals. Colocalization analyses of associations with eGFR among 783,978 European-ancestry individuals and gene expression across 46 human tissues, including tubulo-interstitial and glomerular kidney compartments, identified 17 genes differentially expressed in kidney. Fine-mapping highlighted missense driver variants in 11 genes and kidney-specific regulatory variants. These results provide a comprehensive priority list of molecular targets for translational research.
PMID: 31152163
ISSN: 1546-1718
CID: 3936112
Health Literacy: Implications for Child Health
Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.
PMID: 31152099
ISSN: 1526-3347
CID: 3923162
Factors associated with variation in hospital use at the end of life in England
OBJECTIVE:To identify the relative importance of factors influencing hospital use at the end of life. DESIGN/METHODS:Retrospective cohort study of person and health system effects on hospital use in the past 12 months modelling differences in admissions, bed days and whether a person died in hospital. SETTING/METHODS:Residents in England for the period 2009/2010 to 2011/2012 using Hospital Episodes Statistics (HES) data from all acute care hospitals in England funded by the National Health Service (NHS). PARTICIPANTS/METHODS:1 223 859 people registered with a GP in England who died (decedents) in England (April 2009-March 2012) with a record of NHS hospital care. MAIN OUTCOME MEASURES/METHODS:Hospital admissions, and hospital bed days and place of death (in or out of hospital) in the past 12 months of life. RESULTS:The mean number of admissions in the past 12 months of life averaged 2.28 occupying 30.05 bed days-excluding 9.8% of patients with no hospital history. A total of 50.8% of people died in hospital. Difference in hospital use was associated with a range of patient descriptors (age, gender and ethnicity). The variables with the greatest 'explanatory power' were those that described the diagnoses and causes of death. So, for example, 65% of the variability in the model of hospital admissions was explained by diagnoses. Only moderate levels of variation were explained by the hospital provider variables for admissions and deaths in hospital, though the impacts on total bed days was large. CONCLUSIONS:Comparative analyses of hospital utilisation should standardise for a range of patient specific variables. Though the models indicated some degree of variability associated with individual providers, the scale of this was not great for admissions and death in hospital but the variability associated with length of stay differences suggests that attempts to optimise hospital use should look at differences in lengths of stay and bed use. This study adds important new information about variability in admissions by diagnostic group, and variability in bed days by diagnostic group and eventual cause of death.
PMID: 27013618
ISSN: 2045-4368
CID: 3052252
A randomized pilot study comparing graft-first to fistula-first strategies in older patients with incident end-stage kidney disease: Clinical rationale and study design
Timely placement of an arteriovenous (AV) vascular access (native AV fistula [AVF] or prosthetic AV graft [AVG]) is necessary to limit the use of tunneled central venous catheters (TCVC) in patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD). National guidelines recommend placement of AVF as the AV access of first choice in all patients to improve patient survival. The benefits of AVF over AVG are less certain in the older adults, as age-related biological changes independently modulate patient outcomes. This manuscript describes the rationale, study design and protocol for a randomized controlled pilot study of the feasibility and effects of AVG-first access placement in older adults with no prior AV access surgery. Fifty patients age ≥65 years, with incident ESKD on HD via TCVC or advanced kidney disease facing imminent HD initiation, and suitable upper extremity vasculature for initial placement of an AVF or AVG, will be randomly assigned to receive either an upper extremity AVG-first (intervention) or AVF-first (comparator) access. The study will establish feasibility of randomizing older adults to the two types of AV access surgery, evaluate relationships between measurements of preoperative physical function and vascular access development, compare vascular access outcomes between groups, and gather longitudinal assessments of upper extremity muscle strength, gait speed, performance of activities of daily living, and patient satisfaction with their vascular access and quality of life. Results will assist with the planning of a larger, multicenter trial assessing patient-centered outcomes.
PMCID:6475715
PMID: 31016270
ISSN: 2451-8654
CID: 4318902
Autoimmune genetic risk variants as germline biomarkers of response to melanoma immune-checkpoint inhibition
Immune-checkpoint inhibition (ICI) treatments improve outcomes for metastatic melanoma; however, > 60% of treated patients do not respond to ICI. Current biomarkers do not reliably explain ICI resistance. Given the link between ICI and autoimmunity, we investigated if genetic susceptibility to autoimmunity modulates ICI efficacy. In 436 patients with metastatic melanoma receiving single line ICI or combination treatment, we tested 25 SNPs, associated with > 2 autoimmune diseases in recent genome-wide association studies, for modulation of ICI efficacy. We found that rs17388568-a risk variant for allergy, colitis and type 1 diabetes-was associated with increased anti-PD-1 response, with significance surpassing multiple testing adjustments (OR 0.26; 95% CI 0.12-0.53; p = 0.0002). This variant maps to a locus of established immune-related genes: IL2 and IL21. Our study provides first evidence that autoimmune genetic susceptibility may modulate ICI efficacy, suggesting that systematic testing of autoimmune risk loci could reveal personalized biomarkers of ICI response.
PMID: 30863922
ISSN: 1432-0851
CID: 3733172
Feasibility and Outcomes of an Electronic Health Record Intervention to Improve Hypertension Management in Immigrant-serving Primary Care Practices
BACKGROUND:South Asians experience a disproportionate burden of high blood pressure (BP) in the United States, arguably the most preventable risk factor for cardiovascular disease. OBJECTIVE:We report 12-month results of an electronic health record (EHR)-based intervention, as a component of a larger project, "Implementing Million Hearts for Provider and Community Transformation." The EHR intervention included launching hypertension patient registries and implementing culturally tailored alerts and order sets to improve hypertension control among patients treated in 14 New York City practices located in predominantly South Asian immigrant neighborhoods. DESIGN/METHODS:Using a modified stepped-wedge quasi-experimental study design, practice-level EHR data were extracted, and individual-level data were obtained on a subset of patients insured by a Medicaid insurer via their data warehouse. The primary aggregate outcome was change in proportion of hypertensive patients with controlled BP; individual-level outcomes included average systolic BP (SBP) and diastolic BP (DBP) at last clinic visit. Qualitative interviews were conducted to assess intervention feasibility. MEASURES/METHODS:Hypertension was defined as having at least 1 hypertension ICD-9/10 code. Well-controlled hypertension was defined as SBP<140 and DBP<90 mm Hg. RESULTS:Postintervention, we observed a significant improvement in hypertension control at the practice level, adjusting for age and sex patient composition (adjusted relative risk, 1.09; 95% confidence interval, 1.04-1.14). Among the subset of Medicaid patients, we observed a significant reduction in average SBP and DBP adjusting for time, age, and sex, by 1.71 and 1.13 mm Hg, respectively (P<0.05). Providers reported feeling supported and satisfied with EHR components. CONCLUSIONS:EHR initiatives in practices serving immigrants and minorities may enhance practice capabilities to improve hypertension control.
PMCID:6527132
PMID: 31095056
ISSN: 1537-1948
CID: 3903352
Optimism may moderate screening mammogram frequency in Medicare: A longitudinal study
Higher trait optimism and/or lower cynical hostility are associated with healthier behaviors and lower risk of morbidity and mortality, yet their association with health care utilization has been understudied. Whether these psychological attitudes are associated with breast cancer screening behavior is unknown. To assess the association of optimism and cynical hostility with screening mammography in older women and whether sociodemographic factors acted as mediators of these relationships, we used Women's Health Initiative (WHI) observational cohort survey data linked to Medicare claims. The sample includes WHI participants without history of breast cancer who were enrolled in Medicare Parts A and B for ≥2 years from 2005-2010, and who completed WHI baseline attitudinal questionnaires (n = 48,291). We used survival modeling to examine whether screening frequency varied by psychological attitudes (measured at study baseline) after adjusting for sociodemographic characteristics, health conditions, and healthcare-related variables. Psychological attitudes included trait optimism (Life Orientation Test-Revised) and cynical hostility (Cook Medley subscale), which were self-reported at study baseline. Sociodemographic, health conditions, and healthcare variables were self-reported at baseline and updated through 2005 as available. Contrary to our hypotheses, repeated events survival models showed that women with the lowest optimism scores (i.e., more pessimistic tendencies) received 5% more frequent screenings after complete covariate adjustment (p < .01) compared to the most optimistic group, and showed no association between cynical hostility and frequency of screening mammograms. Sociodemographic factors did not appear to mediate the relationship between optimism and screenings. However, higher levels of education and higher levels of income were associated with more frequent screenings (both p < .01). We also found that results for optimism were primarily driven by women who were aged 75 or older after January 2009, when changes to clinical guidelines lead to uncertainty about risks and benefits of screening in this age group. The study demonstrated that lower optimism, higher education, and higher income were all associated with more frequent screening mammograms in this sample after repeated events survival modeling and covariate adjustment.
PMID: 31192918
ISSN: 1536-5964
CID: 5724042
Comparing fertility preservation resources and policies between NCCN member and non-member institutions
PURPOSE/OBJECTIVE:The National Comprehensive Cancer Network (NCCN) created guidelines to facilitate implementation of fertility preservation (FP) discussions and referrals for adolescent and young adult patients. We assessed if availability of workplace FP resources and referral policies differed among learners in the Educating Nurses about Reproductive Health in Cancer Healthcare (ENRICH) training program based on NCCN membership. METHODS:Learners completed a baseline application, including demographic information and the availability of FP resources and referral policies. Learners were categorized as either NCCN members or non-members and chi-square tests compared resources between the two groups. RESULTS:Learners from NCCN institutions reported the highest rates of established FP referral guidelines (p < .01), reproductive endocrinologist and infertility specialist (REI) on staff (p < .01), partnerships with REI, educational materials for staff (p < .05), and patients (p < .01). CONCLUSION/CONCLUSIONS:FP resources and referral policies were highest among learners from NCCN member institutions, but areas for development with fertility issues still exist and learners from non-member institutions may assist their workplaces in improving rates of discussions and referrals based on their ENRICH training. PRACTICE IMPLICATIONS/CONCLUSIONS:The variation of available resources and referral policies between groups suggests more FP education and training; focusing on implementation programs is needed to make steps towards impactful institutional level resources and policies.
PMCID:6430706
PMID: 30244291
ISSN: 1433-7339
CID: 5070072
Racial Disparities in Nutritional Risk and Its Association with Chronic Disease and Health Outcomes Among Community-Dwelling Older Adults in the Adult Day Health Setting (P04-121-19)
Objectives/UNASSIGNED:Adult day health centers (ADHCs) serve >260,000 chronically ill individuals annually and are a preferred long-term care source for racial minorities, who also experience diet related disparities. Evidence regarding prevalence of nutritional risk is needed to inform dietary intervention planning in ADHCs. This study (1) identified prevalence of nutritional risk and associated factors, in a diverse sample of older ADHC users, (2) stratified differences in nutritional risk by race, and (3) explored associations between nutritional risk, chronic illness, and healthcare utilization. Methods/UNASSIGNED: < .05) differences among White Non-Hispanics, Blacks, Hispanics, and Asians aged >50. Bivariate chi-square tests were used to explore associations between nutritional risk and chronic disease, as well as healthcare utilization. Results/UNASSIGNED: = .01) were significant. Among blacks, 76.5% ate < 5 servings of fruits, vegetables, or milk daily, compared to 39.5% of whites; 21% of blacks ate <2 meals a day, compared to 2% of whites and Hispanics. Blacks (48.5%) more often reported involuntary weight loss/gain compared to whites (23.3%), and had the highest prevalence of tooth loss/mouth pain (41.2%) of any racial group. Conclusions/UNASSIGNED:Older adults in ADHCs are at elevated risk of malnutrition, and blacks disproportionately so. Routine nutritional screening in ADHCs should be considered, but customized population specific approaches are needed to address unique drivers of malnutrition risk. Funding Sources/UNASSIGNED:New York University Center for the Study of Asian American Health Pilot Project Program for Alzheimer's Disease & Thomas J. Long Foundation. Supporting Tables Images and/or Graphs/UNASSIGNED/:
PMCID:6573918
PMID: 31223775
ISSN: 2475-2991
CID: 3939442
Patient safety and the ageing physician: a qualitative study of key stakeholder attitudes and experiences
BACKGROUND:Unprecedented numbers of physicians are practicing past age 65. Unlike other safety-conscious industries, such as aviation, medicine lacks robust systems to ensure late-career physician (LCP) competence while promoting career longevity. OBJECTIVE:To describe the attitudes of key stakeholders about the oversight of LCPs and principles that might shape policy development. DESIGN:Thematic content analysis of interviews and focus groups. PARTICIPANTS:40 representatives of stakeholder groups including state medical board leaders, institutional chief medical officers, senior physicians (>65 years old), patient advocates (patients or family members in advocacy roles), nurses and junior physicians. Participants represented a balanced sample from all US regions, surgical and non-surgical specialties, and both academic and non-academic institutions. RESULTS:Stakeholders describe lax professional self-regulation of LCPs and believe this represents an important unsolved challenge. Patient safety and attention to physician well-being emerged as key organising principles for policy development. Stakeholders believe that healthcare institutions rather than state or certifying boards should lead implementation of policies related to LCPs, yet expressed concerns about resistance by physicians and the ability of institutions to address politically complex medical staff challenges. Respondents recommended a coaching and professional development framework, with environmental changes, to maximise safety and career longevity of physicians as they age. CONCLUSIONS:Key stakeholders express a desire for wider adoption of LCP standards, but foresee significant culture change and practical challenges ahead. Participants recommended that institutions lead this work, with support from regulatory stakeholders that endorse standards and create frameworks for policy adoption.
PMID: 30237318
ISSN: 2044-5423
CID: 4321822
