Faculty Bibliography

Background: Improving quality of care for people with multiple chronic conditions (MCCs) requires performance measures reflecting the heterogeneity and scope of their care. Since most existing measures are disease specific, performance measures must be refined and new measures must be developed to address the complexity of care for those with MCCs. Objectives: To describe development of the Performance Measurement for People with Multiple Chronic Conditions (PM-MCC) conceptual model. Study Design: Framework development and a national stakeholder panel. Methods: We used reviews of existing conceptual frameworks of performance measurement, review of the literature on MCCs, input from experts in the multistakeholder Steering Committee, and public comment. Results: The resulting model centers on the patient and family goals and preferences for care in the context of multiple care sites and providers, the type of care they are receiving, and the national priority domains for healthcare quality measurement. Conclusions: This model organizes measures into a comprehensive framework and identifies areas where measures are lacking. In this context, performance measures can be prioritized and implemented at different levels, in the context of patients' overall healthcare needs.

Bioactive nanoscale arrays were constructed to ligate activating cell surface receptors on T cells (the CD3 component of the TCR complex) and natural killer (NK) cells (CD16). These arrays are formed from biofunctionalized gold nanospheres with controlled interparticle spacing in the range 25-104 nm. Responses to these nanoarrays were assessed using the extent of membrane-localized phosphotyrosine in T cells stimulated with CD3-binding nanoarrays and the size of cell contact area for NK cells stimulated with CD16-binding nanoarrays. In both cases, the strength of response decreased with increasing spacing, falling to background levels by 69 nm in the T cell/anti-CD3 system and 104 nm for the NK cell/anti-CD16 system. These results demonstrate that immune receptor triggering can be influenced by the nanoscale spatial organization of receptor/ligand interactions.

Substance use and substance use disorders (SUDs) have been linked with marital discord. Relatively little is known, however, about the antecedents of SUDs, the mediators of these factors over time, or their associations with the spousal/partner relationship among urban adults. A better understanding of the longitudinal pathways to marital conflict and to SUDs should help prevention and intervention programs target their precursors within the developmental period in which they occur. The present study, therefore, examined the longitudinal predictors of an unsupportive spousal/partner relationship and SUDs among a community sample of urban African American and Puerto Rican adults from East Harlem, NY. Participants (N = 816) completed structured questionnaires at five time waves, from adolescence to adulthood (mean ages = 14, 19, 24, 29, and 32 years). Structural equation modeling examined the effects of earlier environmental and social stressors and intrapersonal and interpersonal factors on later SUDs in adulthood. There was a good fit of the structural equation model (CFI = 0.91; RMSEA = 0.06; and SRMR = 0.06), which revealed three main pathways from adolescence to the spousal/partner relationship and SUDs in adulthood. One pathway linked a weak parent-adolescent attachment relationship with the participant's psychological symptoms in emerging adulthood (p < 0.01), which in turn were related to affiliation with deviant and drug-using peers, also in emerging adulthood (p < 0.001). Peer deviance and drug use were associated with the participant's substance use in young adulthood (p < 0.001), which predicted both an unsupportive spousal/partner relationship (p < 0.05) and SUDs (p < 0.001) later in adulthood. Other pathways highlighted the continuity of psychological symptoms as related to both substance use in young adulthood (p < 0.001) and an unsupportive spousal/partner relationship in adulthood (p < 0.001). Findings showed that the associations of both distal stressors and the parent-adolescent relationship with more proximal intra- and interpersonal problems predicted unsupportive spousal/partner relationships and SUDs among urban adults. Several aspects of the individual's life, at different developmental stages, provide opportunities for interventions to prevent or reduce unsupportive spousal/partner relationships and SUDs.

BACKGROUND: As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension. METHODS: We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team. RESULTS: Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas -- continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs. CONCLUSIONS: Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. Trial registration: NCT01677533 (www.clinicaltrials.gov).

CONTEXT: Prostate biopsy is commonly performed for cancer detection and management. The benefits and risks of prostate biopsy are germane to ongoing debates about prostate cancer screening and treatment. OBJECTIVE: To perform a systematic review of complications from prostate biopsy. EVIDENCE ACQUISITION: A literature search was performed using PubMed and Embase, supplemented with additional references. Articles were reviewed for data on the following complications: hematuria, rectal bleeding, hematospermia, infection, pain, lower urinary tract symptoms (LUTS), urinary retention, erectile dysfunction, and mortality. EVIDENCE SYNTHESIS: After biopsy, hematuria and hematospermia are common but typically mild and self-limiting. Severe rectal bleeding is uncommon. Despite antimicrobial prophylaxis, infectious complications are increasing over time and are the most common reason for hospitalization after biopsy. Pain may occur at several stages of prostate biopsy and can be mitigated by anesthetic agents and anxiety-reduction techniques. Up to 25% of men have transient LUTS after biopsy, and <2% have frank urinary retention, with slightly higher rates reported after transperineal template biopsy. Biopsy-related mortality is rare. CONCLUSIONS: Preparation for biopsy should include antimicrobial prophylaxis and pain management. Prostate biopsy is frequently associated with minor bleeding and urinary symptoms that usually do not require intervention. Infectious complications can be serious, requiring prompt management and continued work into preventative strategies.

OBJECTIVE: Obesity is a pressing public health problem without proven population-wide solutions. Researchers sought to determine whether a city-mandated policy requiring calorie labeling at fast food restaurants was associated with consumer awareness of labels, calories purchased and fast food restaurant visits. DESIGN AND METHODS: Difference-in-differences design, with data collected from consumers outside fast food restaurants and via a random digit dial telephone survey, before (December 2009) and after (June 2010) labeling in Philadelphia (which implemented mandatory labeling) and Baltimore (matched comparison city). Measures included: self-reported use of calorie information, calories purchased determined via fast food receipts, and self-reported weekly fast-food visits. RESULTS: The consumer sample was predominantly Black (71%), and high school educated (62%). Postlabeling, 38% of Philadelphia consumers noticed the calorie labels for a 33% point (P < 0.001) increase relative to Baltimore. Calories purchased and number of fast food visits did not change in either city over time. CONCLUSIONS: While some consumers report noticing and using calorie information, no population level changes were noted in calories purchased or fast food visits. Other controlled studies are needed to examine the longer term impact of labeling as it becomes national law.