Faculty Bibliography

Much progress has been made in chronic kidney disease (CKD) epidemiology in the last decade to establish CKD as a condition that is common, harmful and treatable. The introduction of the new equations for estimating glomerular filtration rate (GFR) and the publication of international reference standards for creatinine and cystatin measurement paved the way for improved global estimates of CKD prevalence. The addition of albuminuria categories to the staging of CKD paved the way for research linking albuminuria and GFR to a wide range of renal and cardiovascular adverse outcomes. The advent of genome-wide association studies ushered in insights into genetic polymorphisms underpinning some types of CKD. Finally, a number of new randomized clinical trials and meta-analyses have informed evidence-based guidelines for the treatment and prevention of CKD. In this review, we discuss the lessons learnt from epidemiological investigations of the staging, etiology, prevalence and prognosis of CKD between 2007 and 2016.

OBJECTIVE: To explore the association of sleep duration and awakening frequency with cognitive outcomes in young children. METHODS: Mothers of 2,800 children from the Generation R cohort reported sleep duration and awakenings at children's age 24 months. At age 6 years, validated Dutch measures were used to assess children's nonverbal intelligence and language comprehension. RESULTS: We found a nonlinear association of total sleep time at 24 months with nonverbal intelligence (p = 0.03) and language comprehension (p = 0.04) at 6 years. Toddlers sleeping within the recommended 11-14 hr had more favorable cognitive development compared with both extremes. Frequent awakenings were negatively associated with nonverbal intelligence, but not with verbal comprehension. CONCLUSION: Sleep duration in toddlerhood has an inverted-U-shaped relation with childhood cognitive measures. Frequent awakenings are associated with lower nonverbal intelligence. Given the marked decline in sleep duration and awakenings in toddlerhood, developmental changes of sleep patterns might be important for cognitive development.

Medical-legal partnerships (MLPs) represent an innovative service model in which lawyers are integrated into health care teams to address diverse legal problems that affect vulnerable populations. The Veterans Health Administration (VHA) operates the largest safety-net health care system in the country and serves many low-income and disabled veterans who could benefit from MLP services. In this column, the authors describe the development and operations of MLPs at four VHA medical centers that serve veterans who are homeless or who have serious mental illness. The authors also briefly report on the characteristics of 700 veterans served by these MLPs from 2014 to 2016. MLPs can fit within the interdisciplinary, comprehensive system of care provided by VHA, and they offer opportunities to expand VHA-community partnerships to address social determinants of health.

STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): T2D patients needing insulin adjustments require multiple clinic visits for titration, but face barriers (missed work, transportation costs, clinic co-pays) all of which disproportionately affect vulnerable populations. OBJECTIVES OF PROGRAM/INTERVENTION (NO MORE THAN THREE OBJECTIVES): MITI aims to be clinically efficacious, patientcentered, and highly accessible (only requires text messaging and phone calls). DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): MITI is an efficacious, patient-centered, accessible program that remotely guides T2D patients to their correct basal insulin dose (glargine, detemir). Eligible patients have T2D, an A1c >8%, a phone that can text, and need titration of basal insulin. Patients referred by their providers are enrolled on a secure website which sends a weekday text message asking 'What was your fasting blood sugar this morning?' Each day the MITI nurse checks the website for alarm values (extreme high or low values). Once a week, the MITI nurse calls patients and, using the MITI titration algorithm, advises them on dose adjustments. The goal of the program is to find the optimal basal insulin dose (OID), which is the dose that achieves a fasting blood sugar between 80 and 130 (or the maximal dose of 50 units). MITI lasts a maximum of 12 weeks. When the program ends, patients return to usual care. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVE METRICS WHICH WILL BE USED TO EVALUATE PROGRAM/INTERVENTION): Using a single-group, quasiexperimental approach, we examined the proportion of patients reaching OID within 12 weeks, the mean number of days required to reach OID, and reductions in fasting glucose and A1c. We described participant response rates, staff time required to deliver the intervention, and patient time saved. Qualitative interviews were also conducted. FINDINGS TO DATE (IT IS NOT SUFFICIENT TOSTATE FINDINGS WILL BE DISCUSSED): Of the 71 participants who completed the program, 86% reached OID, 5.6% did not reach OID, and 8.5% terminated the program early. Those reaching OID did so in a mean of 21 (SD 21) days. Fasting glucose levels decreased from 209 (SD 77) mg/dl to 140 (SD 45), and mean A1c (for those with follow up labs thus far) decreased from 11.6% (SD 1.9) to 10.0% (SD 2.2). Ninety-one percent of text prompts received a response from the participant. Mean staff time required to deliver MITI was 16 min (SD 5) per participant per week, and patients reported a mean time saving of 150 (SD 74) min each time an in-person visit was averted. Qualitative interviews suggest that clinical staff perceived MITI to be a preferred alternative to clinic-based insulin titration, one that resulted in good care without interfering with clinic flow. Patients reported that the enrollment process was easy and that MITI motivated them to eat healthier food, take their insulin, and check their blood sugars. Because of MITI they reported feeling more connected to their medical team. KEYLESSONS FORDISSEMINATION(WHAT CANOTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY?): MITI is a clinically efficacious, patient-centered and accessible program for the titration of basal insulin for T2D patients. By eliminating the need for in-person access, MITI proves especially helpful for vulnerable populations. Patients and staff found MITI to be convenient, time-saving, and motivating for patients

BACKGROUND:Motor vehicle traffic (MVT) crashes kill or seriously injure approximately 4250 people in New York City (NYC) each year. Traditionally, NYC surveillance practices use hospitalization and crash data separately to monitor trends in MVT-related injuries, but key information linking crash circumstances to health outcomes is lost when analyzing these data sources in isolation. Our objective was to match crash reports to hospitalization records to create a traffic injury surveillance dataset that can be used to describe crash circumstances and related injury outcomes. The linkage of the two systems presents a unique challenge since the system tracking crashes and the system tracking hospitalizations and emergency department (ED) visits lack key identifying data such as names and dates of birth. METHODS:NYC Department of Transportation provided electronic records based on reports of motor vehicle crashes submitted to the New York State Department of Motor Vehicles for all crashes occurring in NYC from 2009 to 2013. New York Statewide Planning and Research Cooperative System (SPARCS) ED and hospitalization administrative data from NYC hospitals were used to identify unintentional MVT-related injuries using external cause of injury codes. Since the two systems do not share unique individual identifiers, probabilistic record linkage was conducted using LinkSolv9.0. Sensitivity/specificity calculations and chi-square analyses of linkage rates were conducted to assess linkage results. RESULTS:From 2009-2013, there were 1,054,344 individuals involved in MVT crashes in NYC and 280,340 ED visits and hospitalizations from MVT-related injuries. There were 145,003 linked pairs, giving a linkage rate of 52% of the total MVT-related hospital records. This linkage had a sensitivity of 74% and a specificity of 93%. Linkage rates were comparable by age, sex, crash role, collision type, hospital county, injury location, hospital type, and hospital status, indicating no apparent biases in the match by these variables. CONCLUSIONS:Performing a probabilistic linkage between MVT crash reports and hospitalization records is possible with a limited set of identifying variables. These linked data will inform traffic safety policies by providing new information on how crash circumstances translate to health outcomes.

BACKGROUND:Local ancestry may contribute to the disproportionate burden of subclinical and clinical cardiovascular disease among admixed African Americans compared with other populations, suggesting a rationale for admixture mapping. METHODS AND RESULTS/RESULTS:gene (lipoma high mobility group protein I-C fusion partner-like 2) with hard and all coronary heart disease. CONCLUSIONS:We identified several novel LEA regions, in addition to previously identified genetic variations, associated with cCIMT and cardiovascular disease events among African Americans.

OBJECTIVE: To measure variation in payment rates under Medicare's Inpatient Prospective Payment System (IPPS) and identify the main payment adjustments that drive variation. DATA SOURCES/STUDY SETTING: Medicare cost reports for all Medicare-certified hospitals, 1987-2013, and Dartmouth Atlas geographic files. STUDY DESIGN: We measure the Medicare payment rate as a hospital's total acute inpatient Medicare Part A payment, divided by the standard IPPS payment for its geographic area. We assess variation using several measures, both within local markets and nationally. We perform a factor decomposition to identify the share of variation attributable to specific adjustments. We also describe the characteristics of hospitals receiving different payment rates and evaluate changes in the magnitude of the main adjustments over time. DATA COLLECTION/EXTRACTION METHODS: Data downloaded from the Centers for Medicare and Medicaid Services, the National Bureau of Economic Research, and the Dartmouth Atlas. PRINCIPAL FINDINGS: In 2013, Medicare paid for acute inpatient discharges at a rate 31 percent above the IPPS base. For the top 10 percent of discharges, the mean rate was double the IPPS base. Variations were driven by adjustments for medical education and care to low-income populations. The magnitude of variation has increased over time. CONCLUSIONS: Adjustments are a large and growing share of Medicare hospital payments, and they create significant variation in payment rates.