Faculty Bibliography

OBJECTIVE:To determine the optimal thresholds for inter-eye differences in retinal nerve fiber and ganglion cell+inner plexiform layer thicknesses for identifying unilateral optic nerve lesions in multiple sclerosis. BACKGROUND:Current international diagnostic criteria for multiple sclerosis do not include the optic nerve as a lesion site despite frequent involvement. Optical coherence tomography detects retinal thinning associated with optic nerve lesions. METHODS:In this multi-center international study at 11 sites, optical coherence tomography was measured for patients and healthy controls as part of the International Multiple Sclerosis Visual System Consortium. High- and low-contrast acuity were also collected in a subset of participants. Presence of an optic nerve lesion for this study was defined as history of acute unilateral optic neuritis. RESULTS:Among patients (n=1,530), receiver operating characteristic curve analysis demonstrated an optimal peripapillary retinal nerve fiber layer inter-eye difference threshold of 5 microns and ganglion cell+inner plexiform layer threshold of 4 microns for identifying unilateral optic neuritis (n=477). Greater inter-eye differences in acuities were associated with greater inter-eye retinal layer thickness differences (p≤0.001). INTERPRETATION/CONCLUSIONS:Inter-eye differences of 5 microns for retinal nerve fiber layer and 4 microns for macular ganglion cell+inner plexiform layer are robust thresholds for identifying unilateral optic nerve lesions. These thresholds may be useful to establish the presence of asymptomatic and symptomatic optic nerve lesions in multiple sclerosis and could be useful in a new version of the diagnostic criteria. Our findings lend further validation for utilizing the visual system in a multiple sclerosis clinical trial setting.

There are approximately 9.1 pelvic surgeries performed for every histologically confirmed adnexal malignancy in the United States, compared to 2.3 surgeries per malignancy (in oncology centers) and 5.9 surgeries per malignancy (in other centers) in Europe. An important prognostic factor in the long-term survival in patients with ovarian malignancy is the initial management by a gynecological oncologist. With high accuracy of imaging for adnexal mass characterization and consequent appropriate triage to subspecialty referral, the better use of gynecologic oncology can improve treatment outcomes. Ultrasound, including transabdominal, transvaginal, and duplex ultrasound, combined with MRI with contrast can diagnose adnexal masses as benign with specific features (ie, functional masses, dermoid, endometrioma, fibroma, pedunculated fibroid, hydrosalpinx, peritoneal inclusion cyst, Tarlov cyst), malignant, or indeterminate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background: Smoking rates are two times higher among people living in poverty. Low-income smokers face unique barriers to cessation, including high levels of financial distress. Reducing financial distress may improve cessation rates in this vulnerable population. Moreover, cessation of tobacco spending may further alleviate financial distress by freeing-up funds that could go toward essentials (e.g., food). We examined the efficacy of a program that integrates financial management coaching into smoking cessation coaching for low-income smokers.
Method(s): We recruited 359 smokers living below 200% of the federal poverty level in New York City and randomized them 1: 1 to receive up to 9 sessions of integrated financial management-smoking cessation coaching or usual care. The financial coaching aimed to help participants move from spending on cigarettes to spending on household essentials, and to help participants access financial resources. Participants completed surveys at baseline, 2 and 6 months to assess smoking and financial outcomes and treatment satisfaction.
Result(s): Intervention patients were more likely to have made a quit attempt by 6 months than Control participants (81% vs. 66%, p=.03). Abstinence was significantly higher for the Intervention group at 2 months (23% vs 9%, p=.01) and 6 months (30% vs. 10%, p<.005). At 6 months, Intervention participants were less likely to report high levels of stress about their general finances (44% vs. 66% Control, p=.01), high levels of worry about meeting monthly expenses (56% vs 73% Control, p=.01), or high dissatisfaction with their present financial situation (63% vs 75% Control, p<.05). Intervention participants were also less likely to report frequently living paycheck to paycheck (71% vs 88% Control, p=.01) or frequently being unable to afford leisure activities (51% vs 70% Control, p<.05). There was no group difference in the level of confidence in being able to pay for a $ 1,000 financial emergency (71% low confidence for both). Among the 71% of Intervention participants who began counseling, 85% reported being very satisfied with the integrated counseling. Fifty-one percent reported that the number of counseling sessions they received was " just right," while 36% reported that the number was " too few." Out of the participants who quit smoking, 100% reported that quitting smoking helped them financially and 58% described achieving one or more of their post-quit financial goals.
Conclusion(s): Integrating financial coaching into our smoking cessation program was feasible and produced significantly higher abstinence rates and reductions in financial distress than usual care. Participants were highly satisfied with the integrated program and felt it helped them financially. Our integrated program can serve as model for addressing the unique needs of low-income smokers

Background: Older adults with diabetes continue to be overtreated despite current guidelines recommending less aggressive target A1c levels based on life expectancy. The suboptimal management of this vulnerable population could be due to physicians having conflicting beliefs regarding this guideline or simply lacking awareness, and changing these behaviors is challenging. Clinical decision support (CDS) within the electronic health record (EHR) has the potential to address this issue, but effectiveness is undermined by alert fatigue and poor workflow integration. Incorporating behavioral economics into CDS tools is an innovative approach to improve adherence to these guidelines while reducing physician burden, and offers the promise of improving care in this population.
Method(s): We applied a systematic, user-centered approach to incorporate behavioral economic " nudges" into a CDS module and performed user testing in six pilot primary care practices in a large academic medical center. To build the nudges, we conducted: (1) semi-structured interviews with key informants (n=8); (2) a two-hour design thinking workshop to derive and refine initial module ideas; and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on the module components. Clinicians were observed using the module in practice; detailed field notes were collected and summarized by module idea and usability theme for rapid iteration and refinement. Frequency of firing and user action taken were assessed in the first month of implementation via EHR reporting to confirm that module components and reporting were working as expected, and to assess utilization.
Result(s): Insights from key stakeholder and clinician group interviews identified the refill protocol, inbasket lab result, and medication preference list as candidate EHR CDS targets for the module. A new EHR navigator section notification and peer comparison message, derived from the design workshop, were also prototyped and produced. User feedback from site visits confirmed compatibility with clinical workflows, and contributed to refinement of design and content. The initial prototypes were first piloted at two sites, refined, and then activated at an additional four additional sites. Preliminary Results for the six clinics indicate that over approximately 31 weeks: 1) the navigator alert fired 1047 times for 53 unique clinicians, and 2) the refill protocol alert fired 421 times for 53 unique clinicians. Reports for the other " nudges" are in development.
Conclusion(s): Integrating behavioral economic nudges into the EHR is a promising approach to enhancing guideline awareness and adherence for older adults with diabetes. This novel pilot will demonstrate the initial feasibility and preliminary efficacy of this strategy and determine if a full-scale effectiveness trial is warranted

INTRODUCTION/BACKGROUND:Disparities in survival for bladder and kidney cancer among the genders and patients with varying insurance coverage have been identified. Microhematuria (MH), a potential early clinical sign of genitourinary malignancy, should prompt a standardized diagnostic evaluation. However, many patients do not complete a full evaluation and may be at risk of a missed or delayed identification of genitourinary pathology. METHODS:Patients 35 and older with a new diagnosis of MH between 2007 and 2015 were retrospectively identified at a large health system. Our primary outcome of interest was completion of cystoscopy and imaging. Regression modeling was used to assess associations between gender and insurance status with completion of a MH evaluation, adjusted for clinical factors, urinalysis data, and patient demographics. RESULTS:Of 15,161 patients with MH, only 1,273 patients (8.4%) completed upper tract imaging and a cystoscopy; 899 (5.9%) within 1 year. Median time to imaging was 75 days and 68.5 days for cystoscopy. Of those with an incomplete evaluation, 23.7% underwent cystoscopy and 76.3% underwent imaging. Male gender, private insurance, and increased MH severity on UA were associated with a complete evaluation. More patients who completed an evaluation were diagnosed with bladder (4.8% vs. 0.3%) and kidney cancer (3.1% vs. 0.4%) when compared to those who did not. CONCLUSION/CONCLUSIONS:Few patients complete a timely evaluation of MH. Women and underinsured patients are disproportionately less likely to complete a work-up for microhematuria and this may have downstream implications for diagnosis.

OBJECTIVE:Breast cancer (BC) survivors with a genetic mutation are at higher risk for subsequent cancer; knowing genetic risk status could help survivors make decisions about follow-up screening. Uptake of genetic counseling and testing (GC/GT) to determine BRCA status is low among high risk BC survivors. This study assessed feasibility, acceptability, and preliminary efficacy of a newly developed psychoeducational intervention (PEI) for GC/GT. METHODS:High risk BC survivors (N = 119) completed a baseline questionnaire and were randomized to the intervention (PEI video/booklet) or control (factsheet) group. Follow-up questionnaires were completed 2 weeks after baseline (T2), and 4 months after T2 (T3). We analyzed recruitment, retention (feasibility), whether the participant viewed study materials (acceptability), intent to get GC/GT (efficacy), and psychosocial outcomes (eg, perceived risk, Impact of Events Scale [IES]). t tests or chi-square tests identified differences between intervention groups at baseline. Mixed models examined main effects of group, time, and group-by-time interactions. RESULTS:Groups were similar on demographic characteristics (P ≥ .05). Of participants who completed the baseline questionnaire, 91% followed through to study completion and 92% viewed study materials. A higher percentage of participants in the intervention group moved toward GC/GT (28% vs 8%; P = .027). Mixed models demonstrated significant group-by-time interactions for perceived risk (P = .029), IES (P = .027), and IES avoidance subscale (P = .012). CONCLUSIONS:The PEI was feasible, acceptable, and efficacious. Women in the intervention group reported greater intentions to pursue GC, greater perceived risk, and decreased avoidance. Future studies should seek to first identify system-level barriers and facilitators before aiming to address individual-level barriers.

Background: The Hitech Act of 2009 led to Federal funding on EHR incentives such as Advancing Care Information within MIPs and Meaningful Use. EPIC currently has a MyChart application which allows a patient to interface with their medical records and provider. The Family Health Centers (FHC) at NYU Langone is a network of 8 Federally Qualified Health Centers (FQHC) located in Brooklyn New York. The primary service area has a large immigrant population with 47% of the population reported as being foreign born, and a diverse payor mix with 12% of patients being self-pay/uninsured.
Method(s): Retrospective analysis was performed regarding 78,168 unique patients seen within the Family Health Center Network from January 2018 to December 3rd, 2018. Patient were identified by payor class and by utilization of MyChart. Given the diversity of healthcare plans afforded within New York State, payor classes were grouped into 7 broad categories: Medicaid/Managed Medicaid, commercial, Medicare/Managed Medicare, self-pay, no insurance, Child Health Plus and Med-icaid Expansion (Affordable Care Act). Patient MyChart data abstraction within the EPIC Clarity database included whether the patient was enrolled and when the last date of activity occurred. Enrollment with activity versus enrollment without activity within the last calendar year was used to gauge whether the patient would be considered an active subject in this retrospective review.
Result(s): Regarding percentage of patient enrolled in MyChart, the patient population most likely to enroll was found to be those who have commercial health plans at 41%, with Medicaid expansion plans at 37%, followed by Medicaid tied with self-pay coverage (23%) and Medicare at 18%. Utilization tells a different story with the highest utilizers found in the Medicare enrollees at 79%, followed by Medicaid expansion at 78%, then commercial plans at 77%. The next tier of active users was found to be no coverage (67%), self-pay (66%) and Medicaid (61%). Retrospective review with enrollment data was somewhat expected; high enrollment in patients with commercial plans and lower enrollment amongst Medicare beneficiaries. What was surprising was the utilization/activity data revealed an entirely different picture. Activity usage reflected two tiers. Patients who have Medicare utilize the application as much as patients who have commercial plans and Medicaid expansion. Despite connotations on patients who are self-pay or who have no coverage at all, these patients still use the application, with greater than 50% of those enrolled, actively using MyChartwithin the last calendar year.
Conclusion(s): As medical care becomes more immersed in web-based technologies, attention and opportunities exist for patients who traditionally were viewed as not having access nor inclination to use such technologies. Continued efforts should be maintained regarding enrollment regardless of the payor class or age

Background: Social risk factors are increasingly understood as important drivers of care utilization, including emergency department (ED) visits. As a result, new social risk screening initiatives are being implemented to direct interventions and inform care. There is limited information on patient acceptability of social risk screening in the ED. The Center for Medicare and Medicaid Innovation (CMMI) proposed a social risk screening tool for their Accountable Health Communities Model that focuses on five actionable domains. In this study, we used the CMMI tool to explore the acceptability of social risk screening to adult patients and caregivers of pediatric patients in EDs.
Method(s): A tablet-based, self-administered survey was administered to a convenience sample of adult ED patients and caregivers of pediatric patients at two adult and two pediatric academic EDs. The survey included the CMMI tool and questions on acceptability of screening. The primary acceptability measure was appropriateness of screening in the ED; a secondary outcome was comfort with including social risk data in electronic health records (EHRs). Cross-sectional data were analyzed using chi-square analyses for bivariate comparison.
Result(s): The survey was completed by 364 participants. 41% of participants screened positive for housing instability, 41% for food insecurity, 19% for transportation insecurity, 13% utilities insecurity, and 1% for interpersonal violence. 23% of respondents endorsed no social risk factors. 73% of patients felt that it was "somewhat" or "very appropriate" to conduct social risk screening in the ED. No statistically significant difference was observed in acceptability of screening between participants who endorsed one or more social risks (74% reported "somewhat" or "very appropriate" to screen) versus none (75%). 70% reported feeling "somewhat" or "completely comfortable" with screening information being included in the EHR.
Conclusion(s): In EDs caring for patients with significant social adversity, there was high patient and caregiver acceptability of social risk screening, and a high level of comfort with screening information being included in EHRs. Further investigation is needed to understand perspectives of patients who did not find social risk screening acceptable