Faculty Bibliography

BACKGROUND:Heart failure (HF) is associated with cognitive impairment. However, we know little about the time course of cognitive change after HF diagnosis, the importance of comorbid atrial fibrillation, or the role of ejection fraction. We sought to determine the associations of incident HF with rates of cognitive decline and whether these differed by atrial fibrillation status or reduced versus preserved ejection fraction. METHODS AND RESULTS/RESULTS:=0.734). CONCLUSIONS:Decline in global cognitive ability tends to be faster after HF diagnosis than without HF. Clinical and public health implications of this finding warrant further attention.

OBJECTIVE: To determine whether educational media as actually used by low-income families promotes parent-child cognitive stimulation activities. METHODS: Secondary analysis of the control group of a longitudinal cohort of mother-infant dyads enrolled post-partum in urban public hospital. Educational media exposure (via a 24-hour recall diary) and parent-child activities that may promote cognitive stimulation in the home (using StimQ) were assessed at 6, 14, 24, and 36 months. RESULTS: 149 mother-child dyads; 93.3% Latino. Mean (standard deviation) educational media exposure at 6, 14, 24, and 36 months was: 25 (40), 42 (58), 39 (49), and 39 (50) mins/day. In multilevel model analyses, prior educational media exposure had small positive relationship with subsequent total StimQ (beta=0.11, P=.03), but was non-significant (beta = 0.08, P = .09) after adjusting for confounders (child: age, gender, birth order, non-educational media exposure, language; mother: age, ethnicity, marital status, country of origin, language, depressive symptoms)Educational media did predict small increases in verbal interactions and toy provision (adjusted models, respectively: beta = 0.13, P = .02; beta = 0.11; P = .03). In contrast, more consistent relationships were seen for models of the relationship between prior StimQ (total, verbal interactions and teaching; adjusted models, respectively: beta = 0.20, P = .002; beta = 0.15, P = .006; beta = 0.20, P = .001) and predicted subsequent educational media. CONCLUSIONS: Educational media as used by this sample of low-income families does not promote cognitive stimulation activities important for early child development or activities such as reading and teaching.

BACKGROUND: Frailty is a syndrome of decreased physiologic reserve that results from compromise of multiple physiologic systems including cardiovascular. We aimed to determine the association between the frail phenotype and cardiac abnormalities in liver transplant (LT) candidates through evaluation of transthoracic echocardiography (TTE) indices. METHODS: Included were consecutive outpatients listed for LT who underwent a frailty assessment from 1/1/14-6/30/16 (using the Liver Frailty Index) and a 2-dimensional/doppler TTE exam. Patients were categorized as robust, intermediate frail, or frail by the Liver Frailty Index based on scores of <3.2, between 3.2-4.5 or >/=4.5. Linear regression assessed associations between the Liver Frailty Index and TTE indices. RESULTS: Of 335 patients, 19% were robust, 65% intermediate frail, and 16% frail. TTE indices of left atrial (LA) dilatation differed significantly by frailty status: median LA dimension (p=0.03), LA volume index (LAVIcc/m; p<0.001) and %LAVI>34cc/m (p= 0.001). In linear regression adjusted for age, sex, hypertension and diabetes, the Liver Frailty Index was positively associated with LA dimension (coeff 0.20, 95%CI 0.07-0.34), LAVIcc/m (coeff 0.01, 95%CI 0.005-0.02), ejection fraction (coeff 1.59, 95%CI 0.32-2.85) and pulmonary artery systolic pressure (coeff 0.01, 95%CI 0.003-0.02) and negatively associated with LV hypertrophy (coeff -0.22, 95%CI -0.37, -0.06). CONCLUSION: In LT candidates, frailty is associated with cardiac structural and functional changes, independent of known risk factors. Our study provides evidence to support that measures of frailty in cirrhotic patients encompass abnormalities of the cardiovascular system and may inform assessments of cardiovascular reserve in this population.

BACKGROUND:Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced. METHODS:This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services. RESULTS:We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015. CONCLUSIONS:Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.

BACKGROUND:While the Affordable Care Act's (ACA) Medicaid expansion has increased insurance coverage, its effects on health outcomes have been mixed. This may be because previous research did not disaggregate mental and physical health or target populations most likely to benefit. OBJECTIVE:To examine the association between Medicaid expansion and changes in mental health, physical health, and access to care among low-income childless adults with and without chronic conditions. DESIGN/METHODS:We used a difference-in-differences analytical framework to assess differential changes in self-reported health outcomes and access to care. We stratified our analyses by chronic condition status. PARTICIPANTS/METHODS:Childless adults, aged 18-64, with incomes below 138% of the federal poverty level in expansion (n = 69,620) and non-expansion states (n = 57,628). INTERVENTION/METHODS:Active Medicaid expansion in state of residence. MAIN MEASURES/METHODS:Self-reported general health; total days in past month with poor health, poor mental health, poor physical health, or health-related activity restrictions; disability; depression; insurance coverage; cost-related barriers; annual check-up; and personal doctor. KEY RESULTS/RESULTS:Medicaid expansion was associated with reductions in poor health days (-1.2 days [95% CI, -1.6,-0.7]) and days limited by poor health (-0.94 days [95% CI, -1.4,-0.43]), but only among adults with chronic conditions. Trends in general health measures appear to be driven by fewer poor mental health days (-1.1 days [95% CI, -1.6,-0.6]). Expansion was also associated with a reduction in depression diagnoses (-3.4 percentage points [95% CI, -6.1,-0.01]) among adults with chronic conditions. Expansion was associated with improvements in access to care for all adults. CONCLUSIONS:Medicaid expansion was associated with substantial improvements in mental health and access to care among low-income adults with chronic conditions. These positive trends are likely to be reversed if Medicaid expansion is repealed.

BACKGROUND: The Veterans Health Administration (VA) is investing considerable resources into providing remote management care to patients for disease prevention and management. Remote management includes online patient portals, e-mails between patients and providers, follow-up phone calls, and home health devices to monitor health status. However, little is known about patients' attitudes and preferences for this type of care. This qualitative study was conducted to better understand patient preferences for receiving remote care. METHODS: Ten focus groups were held comprising 77 patients with hypertension or tobacco use history at two VA medical centers. Discussion questions focused on experience with current VA remote management efforts and preferences for receiving additional care between outpatient visits. RESULTS: Most participants were receptive to remote management for referrals, appointment reminders, resource information, and motivational and emotional support between visits, but described challenges with some technological tools. Participants reported that remote management should be personalized and tailored to individual needs. They expressed preferences for frequency, scope, continuity of provider, and mode of communication between visits. Most participants were open to nonclinicians contacting them as long as they had direct connection to their medical team. Some participants expressed a preference for a licensed medical professional. All groups raised concerns around confidentiality and privacy of healthcare information. Female Veterans expressed a desire for gender-sensitive care and an interest in complementary and alternative medicine. CONCLUSIONS: The findings and specific recommendations from this study can improve existing remote management programs and inform the design of future efforts.

30% of kidney transplant recipients are readmitted in the first month post-transplant. Those with donor-specific antibody requiring desensitization and incompatible live donor kidney transplantation (ILDKT) constitute a unique subpopulation that might be at higher readmission risk. Drawing on a 22-center cohort, 379 ILDKTs with Medicare primary insurance were matched to compatible transplant matched controls and to waitlist-only matched controls on panel reactive antibody, age, blood group, renal replacement time, prior kidney transplantation, race, gender, diabetes, and transplant date/waitlisting date. Readmission risk was determined using multilevel, mixed-effects Poisson regression. In the first month, ILDKTs had a 1.28-fold higher readmission risk than compatible controls (95%CI: 1.13-1.46; P<0.001). Risk peaked at 6-12 months (RR 1.67; 95%CI: 1.49-1.87; P<0.001), attenuating by 24-36 months (RR 1.24; 95%CI: 1.10-1.40; P<0.001). ILDKTs had a 5.86-fold higher readmission risk (95%CI: 4.96-6.92; P<0.001) in the first month compared to waitlist-only controls. At 12-24 (RR 0.85; 95%CI: 0.77-0.95; P=0.002) and 24-36 months (RR 0.74; 95% CI: 0.66-0.84; P<0.001), ILDKTs had a lower risk than waitlist-only controls. These findings of ILDKTs having a higher readmission risk than compatible controls, but a lower readmission risk after the first year than waitlist-only controls should be considered in regulatory/payment schemas and planning clinical care.

OBJECTIVE:The key objective of this paper is to provide a phenomenological account of the mental health challenges and experiences of adolescent new mothers. We explore the role of social support and the absence of empathy plays in depression among pregnant adolescents. The project also collected data on the adolescents' caregiving environment which includes the adolescents' mothers, their partners, the community, and health care workers, as well as feedback from staff nurses at the maternal and child health centers. The caregivers provide additional insight into some of the barriers to access of mental health services and pregnancy care, and the etiology of adolescents' distress. METHODS:The interviews were conducted in two health facilities of Kariobangi and Kangemi's maternal and child health (MCH) centers that cover a huge low-income and low-middle-income formal and informal settlements of Nairobi. A grounded theory approach provided a unique methodology to facilitate discussion around adolescent pregnancy and depression among the adolescents and their caregivers. Our interviews were cut across four samples with 36 participants in total. The sample 1 comprised of eight pregnant adolescents who screened positive for depression in Kariobangi, sample 2 were six caregivers from both sites, and sample 3 were 22 new adolescent mothers from both sites. After individual interviews, we carried out one focused group discussion (FDG) in order to understand the cross-cutting issues and to gather some consensus on key issues, and the sample 4 were 20 community health workers, health workers, and nurses from both sites. We had one FGD with all health facility-based workers to understand the cross-cutting issues. The interviews in sample 1 and 2 were individual interviews with pregnant and parenting adolescents, and their caregivers. All our adolescent participants interviewed in sample 1 were screened for depression. Individual interviews followed the FGD. FINDINGS/RESULTS:Pregnant and parenting adolescents faced several adversities such as social stigma, lack of emotional support, poor healthcare access, and stresses around new life adjustments. We highlighted a few useful coping mechanisms and strategies that these adolescents were thinking to reduce their stress. Primary social support for pregnant and parenting teens comes from the adolescent's mother. The external family and male partners provide negligible support in the rearing of the child. While the mother's reactions to the daughters' pregnancy were empathetic sometimes, absence of food and resources made the mother distant and constraint in lending support. For those adolescents who were living with partners, in their new mother role, they had to negotiate additional challenges such as solutions to everyday childcare responsibilities and other family duties. The health care workers and community health workers confirmed that adolescent mothers have multiple needs, but there is a lack of holistic approach of service, and that their own training and capacities were very limited. CONCLUSIONS:Our paper highlights several individual stakeholder-related and system-level barriers in the MCH primary care setting that affect delivery of psychosocial support for pregnant adolescent. We have identified these knowledge, practice, and institutional gaps that need addressing through careful community and health service staff engagement using implementation strategies that are effective in low-resource settings. Pregnant adolescents are highly vulnerable group and mental health services needs to be understood better.