Faculty Bibliography

BACKGROUND: There are high levels of prescription and consumption of prescription opioids in the US. Misuse of prescription opioids has been shown to be highly correlated with prescription opioid-related morbidity and mortality including fatal and non-fatal overdose. We characterized the past-year prevalence of prescription opioid misuse among those 11-30years of age in the US. METHODS: A systematic review and meta-analysis were carried out following a published protocol and PRISMA guidelines. We searched electronic databases; reports were eligible if they were published between 1/1/1990-5/30/2014, and included data on individuals 11-30years of age from the US. Study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: A total of 3211 abstracts were reviewed for inclusion; after discarding duplicates and identifying non-eligible reports, a total of 19 unique reports, providing 34 estimates, were included in the final systematic review and meta-analysis. The range of past-year prescription opioid misuse prevalence the reports was 0.7%-16.3%. An increase in prevalence of 0.4% was observed over the years of data collection. CONCLUSIONS: This systematic review and meta-analysis found a high prevalence of past-year prescription opioid misuse among individuals 11-30years of age. Importantly, we identified an increase in past-year prevalence 1990-2014. Misuse of prescription opioids has played an important role in national increases of fatal and non-fatal drug overdose, heroin use and injection, and HIV and HCV infection among young people. The observed high and increasing prevalence of prescription opioid misuse is an urgent public health issue.

BACKGROUND AND OBJECTIVE: Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents. METHODS: Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English. RESULTS: Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter. CONCLUSIONS: Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

BACKGROUND: Alcohol and drug use is a leading cause of morbidity and mortality that frequently goes unidentified in medical settings. As part of a multi-phase study to implement the NIDA Common Data Elements for collecting substance use screening information in electronic health records (EHRs), we interviewed key clinical stakeholders with a goal of identifying barriers and facilitators affecting the implementation of substance use screening in primary care clinics. METHODS: Focus groups and individual qualitative interviews were conducted with 67 stakeholders, including primary care patients, medical providers (faculty and resident physicians, nurses), and medical assistants, in two urban academic health systems. Themes were identified, discussed, and revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework (Graham, 2006), which guides the selection and implementation of new clinical practices. RESULTS: Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants unanimously agreed that having knowledge of a patient's substance use is important because of its impacts on health andmedical care, that substance use is not properly identified in medical settings, and that universal screening is the best approach. Adapting knowledge: The majority of patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. There was discrepancy of opinion regarding the optimal approach to delivering screening. Some felt that patients should self-administer questionnaires, while others thought that patients would be more comfortable having face-to-face discussions with their primary care provider - though not with other members of the care team. Many providers reported that being able to take effective action once unhealthy substance use is identified is crucial. Assessing barriers: Patients expressed concerns about confidentiality, 'denial', and providers' lack of empathy. Barriers identified by providers included individual-level factors such as lack of knowledge and training, and systems-level factors including lack of time, resources, and space, disjointed communication between members of the medical team, and difficulty accessing addiction treatment. CONCLUSIONS: Based on these findings, we designed and are testing an implementation strategy utilizing universal screening, patient self-administered questionnaires, and EHR-integrated clinical decision support to assist providers in conducting brief motivational counseling and linking patients to behavioral health services, to address unhealthy substance use in primary care clinics

BACKGROUND: National surveys indicate high rates of burnout, particularly among primary care physicians. Despite concerns about the impact of burnout on health outcomes, this relationship is not well studied. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality is evaluating the effectiveness of practice facilitation to improve adoption of Million Hearts' evidence-based ABCS guidelines (Aspirin, Blood pressure control (BP), Cholesterol management, and Smoking cessation) in small-to-medium size primary care practices. This study examined the association between site characteristics and physicians' burnout, as well as the relationship with the ABCS outcomes. METHODS: We present data on 99 small practices working with the NYCDOHMH Primary Care Information Project, and 8 Federally Qualified Health Centers (FQHC) from the Community Health Care Association of New York State. Each provider from participating practice sites completed a survey that included a validated question assessing burnout that used a 5-point scale ranging from 1- no symptoms of burnout to 5- completely burned out. For sites with multiple providers, we calculated a site burnout score by extracting the maximum score within each site. The burnout level was dichotomously coded as 1- burned out, and 0- not burned out. Each site completed a practice survey to report site characteristics, including the number of providers (1 vs. 2 or more), Patient Centered Medical Home (PCMH) status (recognized vs. not recognized), average number of patient visits per week, and total number of support staff. We used logistic regression analysis to assess the association of practice site characteristics and burnout. We also calculated a composite measure for patients with multiple CVD risk factors to capture the extent to which targets are met across three of the outcome measures (ABC). We used ttests to assess the difference in ABCS and composite measures by burnout status. RESULTS: Overall, 19% of physicians reported burnout. A significant difference was detected for all ABCS measures by the sites' burnout status. Sites reporting burnout had higher rates of meeting aspirin, smoking, and composite measure targets, but lower rates of meeting BP and cholesterol target measures and were more likely to have achieved PCMH recognition. FQHCs reported higher rates of burnout compared with small practices. CONCLUSIONS: The overall rates of burnout were lower than reported in previous surveys. Lower burnout rates among small independent practices compared with FQHCs may be related to small practice providers' greater level autonomy. We will present additional data exploring organizational factors that may explain variation in burnout across these different practice settings. Finally, previous research has similarly found inconsistent associations between quality and burnout. Further studies are required to determine whether healthier workplaces also result in higher quality care

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: There is a need for a rapid substance use screening instrument to detect unhealthy tobacco, alcohol, and other drug use among primary care patients. The Tobacco, Alcohol, Prescription Medications, and other Substances Tool (TAPS Tool) is a combined 2-part screening and brief assessment developed for adult primary care patients. Its screening component (TAPS-1) consists of 4 items asking about past 12-month use of four substance categories (any tobacco, 5 or more drinks/day for men [4 for women] of alcohol, any illicit drug use, and any non-medical use of prescription drugs. Categorical response options are: never, less than monthly, monthly, weekly, and daily or almost daily. The objective of this preplanned secondary analysis was to validate the TAPS-1 against the DSM-5 substance use disorder (SUD) criteria. METHODS: This was a multi-site study evaluating the concurrent validity of the TAPS-1 compared to SUD criteria conducted among 2,000 adult primary care patients in 5 clinics located in 4 Eastern US states. Participants completed the TAPS Tool in a self- administered version on a tablet computer and in an interviewer-administered format, in random order. They were then administered a modified version of the Composite International Diagnostic Interview (CIDI) to determine DSM-5 criteria. Optimal cut points for identifying SUDs were obtained using receiver operating characteristics (ROC) analysis to obtain sensitivity (sens), specificity (spec), positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC). RESULTS: The optimal cut-point on the interviewer-administered TAPS-1 for identifying SUDs was '> monthly use' for tobacco (sens = .95, spec = .80, PPV= .62, NPV = .98, AUC = .88) and for alcohol (sens = .68, spec = .87, PPV = .45, NPV = .94, AUC = .77). In contrast, 'any use' was the optimal cut-point for illicit drugs (sens = .93, spec = .86, PPV = .50, NPV = .99, AUC = .89) and for nonmedical use of prescription drugs (sens = .90, spec = .95, PPV = .41, NPV = 1.0, AUC= .93). The self-administered format had similar performance. CONCLUSIONS: The TAPS-1 was able to rapidly screen adult primary care patients for SUDs. Thus, the TAPS-1 could assist health care providers in determining which patients might need a focused, in-depth substance use assessment

BACKGROUND: In the Spring and Summer of 2016, a text-messaging intervention to titrate basal insulin in patients with type 2 diabetes and poor glycemic control was implemented at two safety net health care systems in New York City. The goal of the current study was to conduct a qualitative evaluation assessing barriers to, and facilitators of, implementation of the mobile insulin titration intervention (called "MITI"). METHODS: We conducted in-depth qualitative interviews with patients (N = 36) and physician, nursing and administrative staff (N = 19) at the two health care systems implementing MITI. Interviews were transcribed and coded by two study investigators using a codebook guided by the Consolidated Framework for Implementation Research and through iterative, consensus driven content analysis. RESULTS: Patients and staff perceived MITI as convenient and timesaving for patients, easy to use, and effective at achieving its clinical goals. Patients were comfortable sharing health information via text, and felt good about communicating with their health team remotely. Interviewees across stakeholder groups felt that MITI was helpful beyond insulin titration by reminding and motivating patients to engage in healthy behaviors and improving medication adherence. Staff felt MITI worked well with existing workflows and expressed a desire to see MITI expanded to other chronic conditions. Nurses responsible for weekly titration reported initial concerns over safety/liability, time required to deliver the program, difficulties reaching patients for titration calls and the need for ongoing support/training in using the online texting platform. Perceived barriers to MITI implementation reported by providers included perceived lack of patient cell phone access or texting capabilities and patient language barriers. There was also a theme that emerged across interviewees of an unmet need for additional diabetes management support among this population, beyond insulin support provided by MITI. The project team made several modifications to MITI operations in response to these findings. CONCLUSIONS: Patients and staff were overwhelmingly supportive of MITI and believed it had many benefits. Initial implementation of MITI should address nurse comfort, workload and training, and sites should provide ongoing support and training for nurses after implementation. Future research should explore options for integrating additional diabetes support for patients enrolled in MITI or after they are discharged from the program

OBJECTIVE: Hispanic parents in the United States are disproportionately affected by low health literacy and limited English proficiency (LEP). We examined associations between health literacy, LEP, and liquid medication dosing errors in Hispanic parents. METHODS: Cross-sectional analysis of data from a multisite randomized controlled experiment to identify best practices for the labeling/dosing of pediatric liquid medications (SAFE Rx for Kids study); 3 urban pediatric clinics. Analyses were limited to Hispanic parents of children aged 20% dose deviation. Predictor variables included health literacy (Newest Vital Sign) (limited = 0-3; adequate = 4-6) and LEP (speaks English less than "very well"). RESULTS: A total of 83.1% made dosing errors (mean [SD] errors per parent = 2.2 [1.9]). Parents with limited health literacy and LEP had the greatest odds of making a dosing error compared to parents with adequate health literacy who were English proficient (trials with errors per parent = 28.8 vs 12.9%; adjusted odds ratio = 2.2 [95% confidence interval 1.7-2.8]). Parents with limited health literacy who were English proficient were also more likely to make errors (trials with errors per parent = 18.8%; adjusted odds ratio = 1.4 [95% confidence interval 1.1-1.9]). CONCLUSIONS: Dosing errors are common among Hispanic parents; those with both LEP and limited health literacy are at particular risk. Further study is needed to examine how the redesign of medication labels and dosing tools could reduce literacy- and language-associated disparities in dosing errors.