Faculty Bibliography

OBJECTIVE:To develop a natural language processing (NLP) algorithm that identifies social determinants of health (SDoH), including housing, transportation, food, and medication insecurities, social isolation, abuse, neglect, or exploitation, and financial difficulties for patients with Alzheimer's disease and related dementias (ADRD) from unstructured electronic health records (EHRs). DATA SOURCES AND STUDY SETTING:We leveraged 1000 medical notes randomly selected from 7401 emergency department and inpatient social worker notes generated between 2015 and 2019 for 231 unique patients diagnosed with ADRD at Michigan Medicine. STUDY DESIGN:We developed a rule-based NLP algorithm for the identification of seven domains of SDoH noted above. We also compared the rule-based algorithm with deep learning and regularized logistic regression approaches. These models were compared using accuracy, sensitivity, specificity, F1 score, and the area under the receiver operating characteristic curve (AUC). All notes were split into 700 notes for training NLP algorithms, and 300 notes for validation. DATA COLLECTION/EXTRACTION METHODS:Social worker notes used in this study were extracted from the Michigan Medicine EHR database. PRINCIPAL FINDINGS:Of the 700 notes for training, F1 and AUC for the rule-based algorithm were at least 0.94 and 0.95, respectively, for all SDoH categories. Of the 300 notes for validation, F1 and AUC were at least 0.80 and 0.97, respectively, for all SDoH except housing and medication insecurities. The deep learning and regularized logistic regression algorithms had unsatisfactory performance. CONCLUSIONS:The rule-based algorithm can accurately extract SDoH information in all seven domains of SDoH except housing and medication insecurities. Findings from the algorithm can be used by clinicians and social workers to proactively address social needs of patients with ADRD and other vulnerable patient populations.

BACKGROUND:Podcasts, or episodic digital audio recordings, represent a novel way to reach large audiences for public education. Genetic evaluation has important implications for prostate cancer (PCa) care but is underutilized. We created a series of five podcasts about PCa genetics and tested their usefulness in raising awareness and providing education to lay audiences. METHODS:We recruited 157 men and women from the general public and 100 patients with PCa from across the U.S., who listened to a podcast and completed an online survey. The primary outcome was the perceived usefulness of the podcast (score ≥5 on a published 7-point Likert scale). Secondary outcomes were relevance to informational needs, satisfaction and ease of use, as well as genetic knowledge and attitudes toward genetic testing after listening to the podcasts. RESULTS:The podcasts were associated with high mean scores for perceived usefulness (5.6/7), relevance to informational needs (5.6/7), satisfaction (5.8/7), and ease of use (5.9/7). After listening to the podcasts, 80-100% correctly answered most key knowledge questions about PCa genetics, and 85% had a positive attitude toward genetic testing. On multivariable analysis, the perceived usefulness of the podcasts was higher among Black/Hispanic adults (p = 0.05) and those with a family history of PCa (p = 0.01). CONCLUSIONS:A podcast series on PCa genetics was perceived as useful and associated with high rates of knowledge for patients with PCa and the general public. Podcasts represent a promising new educational tool to raise awareness about PCa genetic evaluation, particularly for high-risk groups.

Air pollution, especially exposure to particulate matter 2.5 (PM_2.5), has been associated with an increase in morbidity and mortality around the world. Specifically, it seems that PM_2.5 promotes the development of cardiovascular risk factors such as hypertension and atherosclerosis, while being associated with an increased risk of cardiovascular diseases, including myocardial infarction (MI), stroke, heart failure, and arrhythmias. In this review, we seek to elucidate the pathophysiological mechanisms by which exposure to PM_2.5 can result in adverse cardiovascular outcomes, in addition to understanding the link between exposure to PM_2.5 and cardiovascular events. It is hypothesized that PM_2.5 functions via 3 mechanisms: increased oxidative stress, activation of the inflammatory pathway of the immune system, and stimulation of the autonomic nervous system which ultimately promote endothelial dysfunction, atherosclerosis, and systemic inflammation that can thus lead to cardiovascular events. It is important to note that the various cardiovascular associations of PM_2.5 differ regarding the duration of exposure (short vs long) to PM_2.5, the source of PM_2.5, and regulations regarding air pollution in the area where PM_2.5 is prominent. Current strategies to reduce PM_2.5 exposure include personal strategies such as avoiding high PM_2.5 areas such as highways or wearing masks outdoors, to governmental policies restricting the amount of PM_2.5 produced by organizations. This review, by highlighting the significant impact between PM_2.5 exposure and cardiovascular health will hopefully bring awareness and produce significant change regarding dealing with PM_2.5 levels worldwide.

CONTEXT/UNASSIGNED:Minoritized populations such as racial and ethnic minorities and individuals of less privileged socioeconomic status experience a disproportionate burden of poor hypertension (HTN) control in the United States. Multilevel systems interventions have been shown to improve patient-level outcomes in minoritized populations; however, there remains a large translational gap in implementing these approaches into federally qualified health centers (FQHC), which serve those at highest risk of HTN-related morbidity and mortality. The paucity of purposeful collaborations between academic researchers and practice staff throughout the research process remains a significant roadblock to the timely translation of evidence to practice. DESIGN/UNASSIGNED:This commentary describes the key principles and best practices that underlie the development and sustainment of an equitable research-practice alignment, which is supporting the implementation of multilevel systems intervention for improved HTN care in a large FQHC in Brooklyn, New York. The key principles, which are derived from the central tenants of relationship development and maintenance in community-engaged participatory research, patient-centered outcomes research, and organizational alignment theory include (1) cocreation of a shared mental model, (2) bridging multilevel communication, (3) ensuring mutual accountability, and (4) creating a culture of continuous improvement. CONCLUSIONS/UNASSIGNED:Together, the principles guide how the research and practice teams work together to achieve a shared goal of improving the health and well-being of minoritized patients through the provision of high quality, community-oriented HTN care. Best practices to sustain our alignment require an ongoing and deliberate investment in honest and transparent communication by all members.

INTRODUCTION/UNASSIGNED:Epidemiological studies commonly use residential addresses at birth to estimate exposures throughout pregnancy, ignoring residential mobility. Lack of consideration for residential mobility during pregnancy might lead to exposure misclassification that should be addressed in environmental epidemiology. METHODS/UNASSIGNED:), temperature, and greenness (Enhanced Vegetation Index [EVI]). RESULTS/UNASSIGNED:) and EVI (range -0.305 to 0.307, average -0.013), but not temperature. Overestimations were significantly larger for mothers with higher socioeconomic status. Our findings indicate that the error for prenatal exposure can occur when residential mobility is not considered and is disproportional by maternal characteristics. CONCLUSIONS/UNASSIGNED:Epidemiological studies should consider residential mobility in exposure assessments based on geolocation when possible, and results based on mother's residence at birth should be interpreted with understanding of potential differential exposure misclassification.

PURPOSE/OBJECTIVE:To examine processes, barriers, and facilitators to sperm banking counseling and decision-making for adolescent males newly diagnosed with cancer from the perspective of clinicians who completed Oncofertility communication training. We also identify opportunities for improvement to inform future interventions and implementation. METHODS:A survey (N=104) and subsequent focus groups (N=15) were conducted with non-physician clinicians practicing in pediatric oncology who completed Oncofertility communication training. RESULTS:Most survey participants were confident in communicating about the impact of cancer on fertility (n=87, 83.7%) and fertility preservation options (n=80, 76.9%). Most participants reported never/rarely using a sperm banking decision tool (n=70, 67.3%), although 98.1% (n=102) said a decision tool with a family-centered approach would be beneficial. Primary themes in the subsequent focus groups included variable processes/workflows (inconsistent approaches to consult initiation; involvement of adolescents, caregivers, and various clinician types; assessment of puberty/sexual experience), structural and psychosocial barriers (cost and logistics, developmental, cultural, clinical acuity/prognosis), and facilitators (educational materials, alternative options for banking). Opportunities and strategies for improvement (including fertility preservation in existing research protocols; additional staffing/resources; oncologist education and buy-in; and development of decision tools) were informed by challenges identified in the other themes. CONCLUSION/CONCLUSIONS:Barriers to adolescent sperm banking remain, even among clinicians who have completed Oncofertility training. Although training is one factor necessary to facilitate banking, structural and psychosocial barriers persist. Given the complexities of offering sperm banking to pediatric populations, continued efforts are needed to mitigate structural barriers and develop strategies to facilitate decision-making before childhood cancer treatment.

Access to and utilization of consumer credit remains an understudied social determinant of health. We examined associations between a novel, small-area, multidimensional credit insecurity index (CII), and the prevalence of self-reported frequent mental distress across US cities in 2020. The census tract-level CII was developed by the Federal Reserve Bank of New York using Census population information and a nationally representative sample of anonymized Equifax credit report data. The CII was calculated for tracts in 766 cities displayed on the City Health Dashboard at the time of analysis, predominantly representing cities with over 50,000 residents. The CII combined data on tract-level participation in the formal credit economy with information on the percent of individuals without revolving credit, percent with high credit utilization, and percent with deep subprime credit scores. Tracts were classified as credit-assured, credit-likely, mid-tier, at-risk, or credit-insecure. We used linear regression to examine associations between the CII and a modeled tract-level measure of frequent mental distress, obtained from the CDC PLACES project. Regression models were adjusted for neighborhood economic and demographic characteristics. We examined effect modification by US region by including two-way interaction terms in regression models. In adjusted models, credit-insecure tracts had a modestly higher prevalence of frequent mental distress (prevalence difference = 0.38 percentage points; 95% CI = 0.32, 0.44), compared to credit-assured tracts. Associations were most pronounced in the Midwest. Local factors impacting credit access and utilization are often modifiable. The CII, a novel indicator of community financial well-being, may be an independent predictor of neighborhood health in US cities and could illuminate policy targets to improve access to desirable credit products and downstream health outcomes.

BACKGROUND:In children with chronic kidney disease (CKD), certain risk factors are associated with faster eGFR decline and earlier kidney failure. Whether these factors have lingering effects on post-transplant eGFR trajectory remains unclear. We characterized pre- and post-transplant eGFR trajectories in pediatric kidney transplant recipients by their pre-kidney replacement therapy (KRT) risk factors. METHODS:We studied eGFR trajectories before KRT initiation and after transplantation among Chronic Kidney Disease in Children (CKiD) Study participants. We used mixed-effects models to compare pre-KRT versus post-transplant eGFR trajectories within individual participants by 7 pre-KRT risk factors: glomerular/non-glomerular etiology, race, preemptive transplant, proteinuria, albuminuria, and systolic/diastolic blood pressure (SBP/DBP). RESULTS:We analyzed 1602 pre-KRT and 592 post-transplant eGFR measurements from 246 transplant recipients. Mean annual eGFR decline was decreased from 18.0% pre-KRT (95%CI, 16.1-19.8) to 5.0% post-transplant (95%CI, 3.3-6.7). All 7 pre-KRT risk factors showed strong associations with faster pre-KRT eGFR decline, but not with post-transplant eGFR decline; only albuminuria, high SBP, and high DBP reached statistical significance with notably attenuated associations. In our multivariable model of the pre-KRT risk factors, post-transplant eGFR decline was more rapid only when albuminuria and high SBP were both present. CONCLUSIONS:eGFR decline substantially slows down after transplant even among children with rapidly progressing forms of CKD. Nonetheless, those who had albuminuria and high SBP before KRT might continue to show faster eGFR decline after transplant, specifically when both risk factors were present. This subgroup might benefit from intensive pre-transplant management for at least one of the two risk factors. A higher resolution version of the Graphical abstract is available as Supplementary information.

BACKGROUND/UNASSIGNED:Advancements in medical technology, healthcare delivery, and organ allocation resulted in improved patient/graft survival for older (age ≥65) kidney transplant (KT) recipients. However, the recent trends in these post-KT outcomes are uncertain in light of the mounting burden of cardiovascular disease, changing kidney allocation policies, heterogeneity in candidates' risk profile, and the coronavirus disease 2019 pandemic. Thus, we examined secular trends in post-KT outcomes among older and younger KT recipients over the last 3 decades. METHODS/UNASSIGNED:We identified 73 078 older and 378 800 younger adult (aged 18-64) recipients using Scientific Registry of Transplant Recipients (1990-2022). KTs were grouped into 6 prepandemic eras and 1 postpandemic-onset era. Kaplan-Meier and Cox proportional hazards models were used to examine temporal trends in post-KT mortality and death-censored graft failure. RESULTS/UNASSIGNED:From 1990 to 2022, a 19-fold increase in the proportion of older KT recipients was observed compared to a 2-fold increase in younger adults despite a slight decline in the absolute number of older recipients in 2020. The mortality risk for older recipients between 2015 and March 14, 2020, was 39% (adjusted hazard ratio [aHR] = 0.61, 95% confidence interval [CI], 0.50-0.75) lower compared to 1990-1994, whereas that for younger adults was 47% lower (aHR = 0.53, 95% CI, 0.48-0.59). However, mortality risk during the pandemic was 25% lower (aHR = 0.75, 95% CI, 0.61-0.93) in older adults and 37% lower in younger adults (aHR = 0.63, 95% CI, 0.56-0.70) relative to 1990-1994. For both populations, the risk of graft failure declined over time and was unaffected during the pandemic relative to the preceding period. CONCLUSIONS/UNASSIGNED:The steady improvements in 5-y mortality and graft survival were disrupted during the pandemic, particularly among older adults. Specifically, mortality among older adults reflected rates seen 20 y prior.