Faculty Bibliography

OBJECTIVE:/UNASSIGNED:Despite the potential benefits of mobile mental health apps, real-world results indicate engagement issues because of low uptake and sustained use. This review examined how studies have measured and reported on user engagement indicators (UEIs) for mental health apps. METHODS:/UNASSIGNED:A systematic review of multiple databases was performed in July 2018 for studies of mental health apps for depression, bipolar disorder, schizophrenia, and anxiety that reported on UEIs, namely usability, user satisfaction, acceptability, and feasibility. The subjective and objective criteria used to assess UEIs, among other data, were extracted from each study. RESULTS:/UNASSIGNED:Of 925 results, 40 studies were eligible. Every study reported positive results for the usability, satisfaction, acceptability, or feasibility of the app. Of the 40 studies, 36 (90%) employed 371 indistinct subjective criteria that were assessed with surveys, interviews, or both, and 23 studies used custom subjective scales, rather than preexisting standardized assessment tools. A total of 25 studies (63%) used objective criteria-with 71 indistinct measures. No two studies used the same combination of subjective or objective criteria to assess UEIs of the app. CONCLUSIONS:/UNASSIGNED:The high heterogeneity and use of custom criteria to assess mental health apps in terms of usability, user satisfaction, acceptability, or feasibility present a challenge for understanding real-world low uptake of these apps. Every study reviewed claimed that UEIs for the app were rated highly, which suggests a need for the field to focus on engagement by creating reporting standards and more carefully considering claims.

Policy Points Although it is well established that educational attainment improves health and longevity, the economic value of this benefit is unknown. We estimate that the economic value of education for longer, healthier lives is comparable to or greater than the value of education for lifetime earnings. Policies that increase rates of completion of high school and college degrees could result in longer, healthier lives and substantial economic value for the population. We provide a template for assigning an economic value to the health benefits associated with education or other social determinants, allowing policymakers to prioritize those interventions that yield the greatest value for the population.

OBJECTIVES/OBJECTIVE:Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI. DESIGN/METHODS:Qualitative study using thematic analysis. SETTING/METHODS:In-depth semistructured telephone and in-person interviews. PARTICIPANTS/METHODS:Twenty-two older adults who participated in the PHPI process. MEASUREMENTS/METHODS:Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement. RESULTS:Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits. CONCLUSIONS:Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.

Objective:This study explored the relationships between participation in group sex and risk for HIV and other sexually transmissible infections (STIs). Methods: An anonymous online survey collected data from 580 gay and bisexual men using a mobile sex and dating application in Paris, France. Logistic regression analyses were conducted, which controlled for HIV status, HIV pre-exposure prophylaxis (PrEP) use and participants' sociodemographic characteristics. Results: Compared with men with no recent group sex experience, those reporting group sex in the 3 months before the survey (30.7% of the sample) were more likely to have had condomless receptive anal sex at least once in the same period [adjusted odds ratio (aOR)=1.6, 95% confidence interval (CI)=1.1-2.4, P = 0.02], condomless insertive anal sex (aOR=2.0, 95%CI: 2.4-8.7, P < 0.001) and substance use before or during sex (aOR=1.6, 95%CI: 1.1-2.3, P = 0.02). Even when controlling for condom use, men involved with group sex were more likely to be have been diagnosed with a bacterial STI in the previous year (aOR=2.1, 95%CI: 1.3-3.3, P = 0.002). Conclusions: Group sex remains a useful marker of risk among gay and bisexual men, but research is needed that moves beyond individual practice in order to assess the epidemiological networks comprising group sex and the risks they pose relevant to HIV and other STIs.

BACKGROUND:The adverse consequences of major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) affect a significant portion of the US population every year (i.e., 15 million for MDD; 8 million for PTSD) and are of public health concern. The current study examines tobacco, alcohol, and marijuana use as possible longitudinal predictors of MDD and/or PTSD. METHODS:A community sample of 674 participants (53% African Americans and 47% Puerto Ricans; 405 females and 269 males) were recruited from the Harlem Longitudinal Development Study. We used Mplus software to obtain the triple trajectories of tobacco, alcohol, and marijuana use from mean age 14 to 36. Logistic regression analyses were then conducted to examine the associations between those triple trajectory groups and a single diagnosis of MDD or PTSD as well as a dual diagnosis of MDD with PTSD at age 36. RESULTS:The observed percentages of MDD, PTSD, and the comorbidity of MDD and PTSD were 17%, 8%, and 5%, respectively. The heavy use of all 3 substances group was associated with an increased likelihood of having MDD (adjusted odds ratio [AOR] = 3.14, P < .01), PTSD (AOR = 3.91, P < .05), and MDD with PTSD (AOR = 6.64, P < .01), as compared with the tobacco and alcohol use group. CONCLUSIONS:Treatment programs to quit or reduce the use of tobacco, alcohol, and marijuana may help decrease the prevalence of MDD and PTSD. This could lead to improvements in individualized treatments for patients who use tobacco, alcohol, and marijuana and who have both MDD and PTSD.

OBJECTIVE:To determine whether prenatal social support was associated with infant adiposity in the first 18 months of life in a low-income, Hispanic sample, known to be at high risk of early child obesity. STUDY DESIGN/METHODS:We performed a longitudinal analysis of 262 low-income, Hispanic mother-infant pairs in the control group of the Starting Early child obesity prevention trial. Prenatal social support was measured using an item from the Maternal Social Support Index. We used multilevel modeling to predict weight-for-length z-score trajectories from birth to age 18 months and logistic regression to predict macrosomia and overweight status at ages 6, 12, and 18 months. RESULTS:High prenatal social support was independently associated with lower infant adiposity trajectories from birth to age 18 months (B = -0.40; 95% CI, -0.63 to -0.16), a lower odds of macrosomia (aOR = 0.35; 95% CI, 0.15-0.80), and a lower odds of overweight at ages 12 (aOR = 0.28; 95% CI, 0.10-0.74) and 18 months (aOR = 0.35; 95% CI, 0.14-0.89). Prenatal social support was not significantly associated with overweight status at age 6 months. CONCLUSIONS:Prenatal social support may protect against excessive infant adiposity and overweight in low-income, Hispanic families. Further research is needed to elucidate mechanisms underlying these associations and to inform preventive strategies beginning in pregnancy.

BACKGROUND:Models that accurately predict risk of breast cancer are needed to help younger women make decisions about when to begin screening. Premenopausal concentrations of circulating anti-Müllerian hormone (AMH), a biomarker of ovarian reserve, and testosterone have been positively associated with breast cancer risk in prospective studies. We assessed whether adding AMH and/or testosterone to the Gail model improves its prediction performance for women aged 35-50. METHODS:In a nested case-control study including ten prospective cohorts (1762 invasive cases/1890 matched controls) with pre-diagnostic serum/plasma samples, we estimated relative risks (RR) for the biomarkers and Gail risk factors using conditional logistic regression and random-effects meta-analysis. Absolute risk models were developed using these RR estimates, attributable risk fractions calculated using the distributions of the risk factors in the cases from the consortium, and population-based incidence and mortality rates. The area under the receiver operating characteristic curve (AUC) was used to compare the discriminatory accuracy of the models with and without biomarkers. RESULTS:The AUC for invasive breast cancer including only the Gail risk factor variables was 55.3 (95% CI 53.4, 57.1). The AUC increased moderately with the addition of AMH (AUC 57.6, 95% CI 55.7, 59.5), testosterone (AUC 56.2, 95% CI 54.4, 58.1), or both (AUC 58.1, 95% CI 56.2, 59.9). The largest AUC improvement (4.0) was among women without a family history of breast cancer. CONCLUSIONS:AMH and testosterone moderately increase the discriminatory accuracy of the Gail model among women aged 35-50. We observed the largest AUC increase for women without a family history of breast cancer, the group that would benefit most from improved risk prediction because early screening is already recommended for women with a family history.

Importance/UNASSIGNED:Better understanding of the emergency care needs of patients with cancer will inform outpatient and emergency department (ED) management. Objective/UNASSIGNED:To provide a benchmark description of patients who present to the ED with active cancer. Design, Setting, and Participants/UNASSIGNED:This multicenter prospective cohort study included 18 EDs affiliated with the Comprehensive Oncologic Emergencies Research Network (CONCERN). Of 1564 eligible patients, 1075 adults with active cancer were included from February 1, 2016, through January 30, 2017. Data were analyzed from February 1 through August 1, 2018. Main Outcomes and Measures/UNASSIGNED:The proportion of patients reporting symptoms (eg, pain, nausea) before and during the ED visit, ED and outpatient medications, most common diagnoses, and suspected infection as indicated by ED antibiotic administration. The proportions observed, admitted, and with a hospital length of stay (LOS) of no more than 2 days were identified. Results/UNASSIGNED:Of 1075 participants, mean (SD) age was 62 (14) years, and 51.8% were female. Seven hundred ninety-four participants (73.9%; 95% CI, 71.1%-76.5%) had undergone cancer treatment in the preceding 30 days; 674 (62.7%; 95% CI, 59.7%-65.6%) had advanced or metastatic cancer; and 505 (47.0%; 95% CI, 43.9%-50.0%) were 65 years or older. The 5 most common ED diagnoses were symptom related. Of all participants, 82 (7.6%; 95% CI, 6.1%-9.4%) were placed in observation and 615 (57.2%; 95% CI, 54.2%-60.2%) were admitted; 154 of 615 admissions (25.0%; 95% CI, 21.7%-28.7%) had an LOS of 2 days or less (median, 3 days; interquartile range, 2-6 days). Pain during the ED visit was present in 668 patients (62.1%; 95% CI, 59.2%-65.0%; mean [SD] pain score, 6.4 [2.6] of 10.0) and in 776 (72.2%) during the prior week. Opioids were administered in the ED to 228 of 386 patients (59.1%; 95% CI, 18.8%-23.8%) with moderate to severe ED pain. Outpatient opioids were prescribed to 368 patients (47.4%; 95% CI, 3.14%-37.2%) of those with pre-ED pain, including 244 of 428 (57.0%; 95% CI, 52.2%-61.8%) who reported quite a bit or very much pain. Nausea in the ED was present in 336 (31.3%; 95% CI, 28.5%-34.1%); of these, 160 (47.6%; 95% CI, 12.8%-17.1%) received antiemetics in the ED. Antibiotics were administered in the ED to 285 patients (26.5%; 95% CI, 23.9%-29.2%). Of these, 209 patients (73.3%; 95% CI, 17.1%-21.9%) were admitted compared with 427 of 790 (54.1%; 95% CI, 50.5%-57.6%) not receiving antibiotics. Conclusions and Relevance/UNASSIGNED:This initial prospective, multicenter study profiling patients with cancer who were treated in the ED identifies common characteristics in this patient population and suggests opportunities to optimize care before, during, and after the ED visit. Improvement requires collaboration between specialists and emergency physicians optimizing ED use, improving symptom control, avoiding unnecessary hospitalizations, and appropriately stratifying risk to ensure safe ED treatment and disposition of patients with cancer.