Faculty Bibliography

Sex tourism affects the sexual health of tourists and locals with whom they interact. However, a few studies have examined whether sex tourism is a risk factor for the acquisition of HIV and other sexually transmitted infections among men who have sex with men, and no such studies have been conducted in Western Europe. Almost 28% of our respondents reported engaging in sex tourism in their lifetime. Sex tourism was associated with an elevated risk of engagement in condomless receptive anal intercourse, use of alcohol/drugs during sex, participation in group sex, and an elevated risk of diagnosis with any type of sexually transmitted infection over the previous year, specifically gonorrhea and chlamydia. Research with men who have sex with men who engage in sex tourism should explore high-risk sexual behavior during sex tourism and also the feasibility and acceptability of the use of episodic pre-exposure prophylaxis for short periods of participation in elevated risk behaviors by tourists and local sex partners.

BACKGROUND:Little is known about the risk and addiction perceptions of e-cigarettes among Asian populations. We examined e-cigarette perceptions among young adults in Hong Kong and the association between the perceptions and e-cigarette use patterns. METHODS:An online survey was administered to a convenience sample of Hong Kong residents aged 18-35 (N = 1186). Measures of e-cigarette perceptions included perceived harm and addictiveness of e-cigarettes, perceived harm of secondhand e-cigarette aerosol, and perceived popularity of e-cigarette use among peers. Separate multinomial logistic regression models were conducted to examine the associations between the four perceptions and former and current use of e-cigarettes relative to never use, controlling for demographics and current cigarette smoking status. Interactions of e-cigarette perceptions and current cigarette smoking were assessed in all models. Among current e-cigarette users, bivariate exact logistic regression models were used to examine the relationships between each of the perceptions and frequent e-cigarette use (≥3 days in past 30-day vs. 1-2 days). Among participants who had never used e-cigarettes, separate multivariable logistic regression models were conducted to examine the associations between e-cigarette perceptions and susceptibility to e-cigarette use. RESULTS:Overall, 97.2% of participants were aware of e-cigarettes, and 16.1% had tried e-cigarettes (11.3% former users; 4.8% current users). Young adults perceived e-cigarettes (and aerosol) as less harmful, less addictive, and less popular than cigarettes. Current cigarette smokers reported significantly lower perceived harmfulness and addictiveness of e-cigarettes, lower perceived harmfulness of e-cigarette aerosol, and higher perceived popularity than nonsmokers. The lower degree of harm and addiction perceptions, and higher levels of popularity perceptions were associated with greater odds of e-cigarette use, and these relationships were generally stronger among nonsmokers compared to current cigarette smokers. E-cigarette perceptions were not associated with frequent e-cigarette use. Perceiving e-cigarettes (and aerosol) as less harmful and less addictive were associated with greater susceptibility to e-cigarette use. Compared to nonsmokers, current smokers were more likely to report e-cigarette use and susceptibility. CONCLUSIONS:Continued monitoring of e-cigarette use and perceptions is needed. Educational programs should emphasize the potential harmful and addictive properties of e-cigarettes and the risks of secondhand exposure to e-cigarette aerosol.

Statement of Problem Or Question (One Sentence): The increasing complexity of admitted patients, shorter hospital stays and post-acute care adverse events demand a more sophisticated and effective coordination of care between hospitalists and Primary care providers (PCPS). Objectives of Program/Intervention (No More Than Three Objectives): 1. Standardizing communication between Hospitalist and PCP during hospitalization will lower the rate of readmission due to lack of PCP follow up and post-acute care adverse events. 2. Implementing this practice into our daily workflow will improve PCP satisfaction and increase referrals to our institution. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We reviewed a root-cause survey of 30 day readmissions between 1/2018-4/2018 as well as readmission rates for each of our hospitalists. We surveyed our PCPS' satisfaction with communication experiences with our hospitalist group. Finally, we conducted a semi-structured interview of the hospitalist with the lowest readmission (8% vs 12% average for other hospitalists) and highest PCP satisfaction rates, Dr. A, to develop best practices for closed loop communication. Based on this data, we designed a protocol and piloted on 5/1/2018, where the hospitalist contacts the PCP via phone call on admission and delivers a discharge narrative to the PCP via our EMR's routing capability. We used a trackable smart phrase to document the communication. For the prospective phase, we will operationalize these best practices in a study group, Family Health Center PCPS. A control group (community PCPS) will receive usual practice. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will compare readmission rates between the study group and control group, monitoring the proportion and absolute number of readmissions attributed to no PCP follow up or medication errors. Follow up satisfaction surveys will be sent to the PCPS 6 months after our revised communication practice. Finally, we will monitor the hospitalists' compliance with the smart phrase. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): A review of our institution's 30 day readmissions between 1/2018-4/2018 found that 19% were attributed to lack of PCP/outpatient provider follow-up. Surveys of our community PCPS showed 70% reported being contacted by the hospitalist group in less than 25% of the time. Results from Dr. A's interview revealed that after her encounter with the patient, she calls the patient's PCP highlighting the admitting diagnosis, significant events, pertinent labs, imaging and medications. Dr. A then delivers a discharge narrative to the PCP on the day of discharge highlighting any medication changes, incidental findings and follow up. On a random audit of 100 charts between 5/1/2018-10/30/2018 our preliminary data show that there was 88% compliance with using the smart phrase by the hospitalists. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Using a "positive deviance" approach, we identified best practices for hospitalist-PCP closed loop communication to develop an intervention to improve this aspect of care. If we are successful in reducing readmission rates and improving PCP satisfaction, we will expand to all of our PCPS and ultimately expand to other services to implement this program as best practice

Background: A relative dearth of literature exists on preferences of young gay male patients have regarding the sexual orientation and gender identity (SOGI) of their healthcare providers. Further research in this area is warranted to better serve the young MSM population.
Method(s): Data collection: A sample of 800 young adult gay men completed a brief survey on healthcare preferences between 2015-2016. Participant inclusion criteria were: age 18-29, male gender, self-identified gay sexual orientation, living in US for 5+ years, and being a resident of the New York City metropolitan area. Only participants who reported having a current PCP provided information on preferred PCP characteristics (i.e. male and/or LGBT). Data analysis: Multivariable logistic regression models were built to assess factors associated with participant preference for an LGBT or male PCP. Covariates for inclusion were considered based on prior literature as well as those identified as significant in bivariate logistic regression analyses. Backward model selection with variance inflation factor (VIF) analysis was used to eliminate collinearity and arrive at the most parsimonious models.
Result(s): In this sample, n=614 men (77%) reported having a PCP. Of those 614 with a PCP, 42% indicated a preference for male PCP, 36% preferred a gay or LGBT PCP, and a total of 20% preferred a male-LGBT provider. A preference for consolidated care and distrust in the health system were associated with preference for a sexual orientation concordant PCP. Preference for sexual orientation concordance was strongly associated with preference for gender concordance, and vice versa. Minority race was also found to be associated with preference for a gender-identity concordant (male) PCP.
Conclusion(s): Gay men who wish to discuss their overall health and sexual health with their primary care provider (ie, receive consolidated care) tend to prefer a LGBT provider. This is also true of gay men who distrust the healthcare system, possibly because they anticipate these providers will provide more culturally sensitive care. A surprising association was found between minority racial Background and preference for a gender concordant provider. Further research is warranted to explore the factors giving rise to this finding

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: Current guidelines for diabetes screening start at age 45, but disparities in certain subgroups exist and poor diabetic outcomes are known to cluster in specific neighborhoods. The objective of this study was to quantify disparities in the age distribution of patients with type 2 diabetes by sex, race/ethnicity, and geographic location. We also studied how patient age relates to diabetes-related hospital use and development of diabetic complications.
Method(s): Using all-payer hospital claims data, we performed a cross-sectional analysis of patients with type 2 diabetes. Our study included patients in New York City as identified by geocoded home address. Patients aged 10 to 100 years old were identified as having type 2 diabetes based on diagnosis codes from emergency claims data from 2011-2015. Our main measures included the estimated prevalence of type 2 diabetes at each year of life, the age distribution of patients as stratified by decade, and the comparison of patient age in geographic hotspots of frequent diabetes-related hospital use and diabetic complications.
Result(s): We identified 576,306 unique patients diagnosed with type 2 diabetes, which represented over half of all cases in New York City. Minority subgroups were on average 5.5 to 8.4 years younger than non-Hispanic White patients. Males with type 2 diabetes were 2.6 years younger than females. At 45 years of age, the estimated prevalence of type 2 diabetes was 10.9% among Black patients compared to 5.2% among White patients. In our geospatial analyses, patients with type 2 diabetes were on average 5.9 years younger in hotspots of diabetes-related emergency department use and inpatient hospitalizations. The average age of patients with type 2 diabetes was 1.5 to 2.2 years younger in hotspots of microvascular diabetic complications.
Conclusion(s): We identified profound disparities in the age of patients with type 2 diabetes among minorities and in neighborhoods with poor health outcomes. The younger age of these patients may be due to earlier onset of diabetes and/or earlier death from diabetes-related complications. Our findings demonstrate the need for geographically targeted interventions that promote earlier diagnosis and better glycemic control to reduce disparities in diabetes burden. [Figure Presented] Age Distribution of Patients with Type 2 Diabetes by Race and Ethnicity

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

Background: As research supporting potential benefits of social risk screening in health settings continues to emerge, there is little data on the patient perspective on social screening. The aim of this study is to describe the perspectives and preferences of patients and caregivers on being screened for social risks in diverse health care settings.
Method(s): As part of a larger mixed Methods multi-site study, we conducted semi-structured interviews lasting approximately 30 minutes with patients or caregivers who had completed the Center for Medicare and Medicaid Innovation (CMMI) social risk screening tool. After completion of the screening questions, 5 randomly selected respondents from each of 10 study sites were invited to participate in an interview. Interviews were conducted in English or Spanish. The interview guide asked about reactions to social risk screening and screening acceptability, preferences on screening administration, prior experiences that informed perspectives, and expectations for social assistance. Interviews were recorded, transcribed and translated. Two coders used basic thematic analysis and constant comparative Methods to identify codes, group codes into unified themes and map themes into domains of screening acceptability.
Result(s): Fifty adult patients or caregivers participated in semi-structured interviews across all study sites, which included 6 primary care clinics and 4 emergency departments. Respondents were 78% female, 36% Black, 32% Hispanic, 20% caregivers, and 71% reported having one or more social risk factor. There was broad consensus among interviewees across all clinical sites that social risk screening was acceptable. Several themes emerged: (1) respondents felt screening was the " right thing to do; " (2) respondents identified framing and compassionate approach as the most important aspects of administration; (3) respondents had insight into the connections between social risks and physical and mental health. Despite overall agreement that social risk screening is appropriate, respondents did not expect their health care team to address or resolve all of the identified issues. Interviewees felt referrals out to social services and resource sheets were adequate, and that there was benefit to the act of screening itself. Patients emphasized that screening should be done with empathy while protecting patient confidentiality.
Conclusion(s): Respondents agree that social risk screening is important, acceptable, and relevant to health. Respondents believed social risk screening would be most acceptable when implemented by a clinic staff member trained to ensure privacy and compassion. Despite published concerns about futility of social risk screening when social resources are inadequate, respondents expressed that they did not expect the health care system, and physicians in particular, to solve unmet social problems. Done appropriately, screening for social risk can build trust and strengthen relationships between patients and health care providers

Growing epidemiologic evidence supports chronic inflammation as a mechanism of ovarian carcinogenesis. An association between a circulating marker of inflammation, C-reactive protein (CRP), and ovarian cancer risk has been consistently observed, yet, potential heterogeneity of this association by tumor and patient characteristics has not been adequately explored. In this study, we pooled data from case-control studies nested within six cohorts in the Ovarian Cancer Cohort Consortium (OC3) to examine the association between CRP and epithelial ovarian cancer risk overall, by histologic subtype and by participant characteristics. CRP concentrations were measured from pre-diagnosis serum or plasma in 1,091 cases and 1,951 controls. Multivariable conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). When CRP was evaluated using tertiles, no associations with ovarian cancer risk were observed. A 67% increased ovarian cancer risk was found for women with CRP concentrations >10mg/L compared to <1mg/L (OR=1.67, 95% CI=1.12, 2.48). A CRP concentration >10mg/L was positively associated with risk of mucinous (OR=9.67, 95% CI=1.10, 84.80) and endometrioid carcinoma (OR=3.41, 95% CI=1.07, 10.92), and suggestively positive, though not statistically significant, for serous (OR=1.43, 95% CI=0.82, 2.49) and clear cell carcinoma (OR=2.05, 95% CI=0.36, 11.57; p-heterogeneity=0.20). Heterogeneity was observed with oral contraceptive use (p-interaction=0.03), where the increased risk was present only among ever users (OR=3.24, 95% CI=1.62, 6.47). The present study adds to the existing evidence that CRP plays a role in ovarian carcinogenesis, and suggests that inflammation may be particularly implicated in the etiology of endometrioid and mucinous carcinoma.