Benefits and Harms of Mammography Screening in 75 + Women to Inform Shared Decision-making: a Simulation Modeling Study.

BACKGROUND: Guidelines recommend shared decision-making (SDM) around mammography screening for women ≥ 75 years old. OBJECTIVE: To use microsimulation modeling to estimate the lifetime benefits and harms of screening women aged 75, 80, and 85 years based on their individual risk factors (family history, breast density, prior biopsy) and comorbidity level to support SDM in clinical practice. DESIGN, SETTING, AND PARTICIPANTS: We adapted two established Cancer Intervention and Surveillance Modeling Network (CISNET) models to evaluate the remaining lifetime benefits and harms of screening U.S. women born in 1940, at decision ages 75, 80, and 85 years considering their individual risk factors and comorbidity levels. Results were summarized for average- and higher-risk women (defined as having breast cancer family history, heterogeneously dense breasts, and no prior biopsy, 5% of the population). MAIN OUTCOMES AND MEASURES: Remaining lifetime breast cancers detected, deaths (breast cancer/other causes), false positives, and overdiagnoses for average- and higher-risk women by age and comorbidity level for screening (one or five screens) vs. no screening per 1000 women. RESULTS: Compared to stopping, one additional screen at 75 years old resulted in six and eight more breast cancers detected (10% overdiagnoses), one and two fewer breast cancer deaths, and 52 and 59 false positives per 1000 average- and higher-risk women without comorbidities, respectively. Five additional screens over 10 years led to 23 and 31 additional breast cancer cases (29-31% overdiagnoses), four and 15 breast cancer deaths avoided, and 238 and 268 false positives per 1000 average- and higher-risk screened women without comorbidities, respectively. Screening women at older ages (80 and 85 years old) and high comorbidity levels led to fewer breast cancer deaths and a higher percentage of overdiagnoses. CONCLUSIONS: Simulation models show that continuing screening in women ≥ 75 years old results in fewer breast cancer deaths but more false positive tests and overdiagnoses. Together, clinicians and 75 + women may use model output to weigh the benefits and harms of continued screening.

The Risk of and Associated Demographic and Laboratory Variables for Amputations for Inpatients with Diabetic Foot Ulcers.

OBJECTIVE: Diabetic foot ulcers (DFUs) are a leading cause of morbidity and mortality, which disproportionately impacts underserved populations. This study aimed to provide data regarding the rates and outcomes of amputation in patients admitted with DFU in our health system, which cares for an ethnically diverse and underserved population. METHODS: This retrospective study examined the electronic medical records of adult patients hospitalized with DFU at 3 hospitals in our health system between June 1, 2016, and May 31, 2021. RESULTS: Among 650 patients admitted with DFU, 88% self-identified as non-White race. Male sex (odds ratio [OR], 0.62), low body mass index (OR, 0.98), and history of smoking (OR, 1.45) were significantly associated with amputation during the study period. A higher erythrocyte sedimentation rate (OR, 1.01), C-reactive protein level (OR, 1.05), and white blood cell count (OR, 1.11) and low albumin level (OR, 0.41) were found to be significantly associated with amputation versus no amputation during admission. The amputation risk during the index admission for DFU was 44%. CONCLUSION: Our study identified a high DFU-related amputation risk (44%) among adult patients who were mostly Black and/or Hispanic. The significant risk factors associated with DFU amputation included male sex, low body mass index, smoking, and high levels inflammation or low levels of albumin during admission. Many of these patients required multidisciplinary care and intravenous antibiotic therapy, necessitating a longer length of stay and high readmission rate.

Analysis of Breast Cancer Mortality in the US-1975 to 2019.

Importance: Breast cancer mortality in the US declined between 1975 and 2019. The association of changes in metastatic breast cancer treatment with improved breast cancer mortality is unclear. Objective: To simulate the relative associations of breast cancer screening, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer with improved breast cancer mortality. Design, Setting, and Participants: Using aggregated observational and clinical trial data on the dissemination and effects of screening and treatment, 4 Cancer Intervention and Surveillance Modeling Network (CISNET) models simulated US breast cancer mortality rates. Death due to breast cancer, overall and by estrogen receptor and ERBB2 (formerly HER2) status, among women aged 30 to 79 years in the US from 1975 to 2019 was simulated. Exposures: Screening mammography, treatment of stage I to III breast cancer, and treatment of metastatic breast cancer. Main Outcomes and Measures: Model-estimated age-adjusted breast cancer mortality rate associated with screening, stage I to III treatment, and metastatic treatment relative to the absence of these exposures was assessed, as was model-estimated median survival after breast cancer metastatic recurrence. Results: The breast cancer mortality rate in the US (age adjusted) was 48/100 000 women in 1975 and 27/100 000 women in 2019. In 2019, the combination of screening, stage I to III treatment, and metastatic treatment was associated with a 58% reduction (model range, 55%-61%) in breast cancer mortality. Of this reduction, 29% (model range, 19%-33%) was associated with treatment of metastatic breast cancer, 47% (model range, 35%-60%) with treatment of stage I to III breast cancer, and 25% (model range, 21%-33%) with mammography screening. Based on simulations, the greatest change in survival after metastatic recurrence occurred between 2000 and 2019, from 1.9 years (model range, 1.0-2.7 years) to 3.2 years (model range, 2.0-4.9 years). Median survival for estrogen receptor (ER)-positive/ERBB2-positive breast cancer improved by 2.5 years (model range, 2.0-3.4 years), whereas median survival for ER-/ERBB2- breast cancer improved by 0.5 years (model range, 0.3-0.8 years). Conclusions and Relevance: According to 4 simulation models, breast cancer screening and treatment in 2019 were associated with a 58% reduction in US breast cancer mortality compared with interventions in 1975. Simulations suggested that treatment for stage I to III breast cancer was associated with approximately 47% of the mortality reduction, whereas treatment for metastatic breast cancer was associated with 29% of the reduction and screening with 25% of the reduction.

Collaborative Modeling to Compare Different Breast Cancer Screening Strategies: A Decision Analysis for the US Preventive Services Task Force.

Importance: The effects of breast cancer incidence changes and advances in screening and treatment on outcomes of different screening strategies are not well known. Objective: To estimate outcomes of various mammography screening strategies. Design, Setting, and Population: Comparison of outcomes using 6 Cancer Intervention and Surveillance Modeling Network (CISNET) models and national data on breast cancer incidence, mammography performance, treatment effects, and other-cause mortality in US women without previous cancer diagnoses. Exposures: Thirty-six screening strategies with varying start ages (40, 45, 50 years) and stop ages (74, 79 years) with digital mammography or digital breast tomosynthesis (DBT) annually, biennially, or a combination of intervals. Strategies were evaluated for all women and for Black women, assuming 100% screening adherence and "real-world" treatment. Main Outcomes and Measures: Estimated lifetime benefits (breast cancer deaths averted, percent reduction in breast cancer mortality, life-years gained), harms (false-positive recalls, benign biopsies, overdiagnosis), and number of mammograms per 1000 women. Results: Biennial screening with DBT starting at age 40, 45, or 50 years until age 74 years averted a median of 8.2, 7.5, or 6.7 breast cancer deaths per 1000 women screened, respectively, vs no screening. Biennial DBT screening at age 40 to 74 years (vs no screening) was associated with a 30.0% breast cancer mortality reduction, 1376 false-positive recalls, and 14 overdiagnosed cases per 1000 women screened. Digital mammography screening benefits were similar to those for DBT but had more false-positive recalls. Annual screening increased benefits but resulted in more false-positive recalls and overdiagnosed cases. Benefit-to-harm ratios of continuing screening until age 79 years were similar or superior to stopping at age 74. In all strategies, women with higher-than-average breast cancer risk, higher breast density, and lower comorbidity level experienced greater screening benefits than other groups. Annual screening of Black women from age 40 to 49 years with biennial screening thereafter reduced breast cancer mortality disparities while maintaining similar benefit-to-harm trade-offs as for all women. Conclusions: This modeling analysis suggests that biennial mammography screening starting at age 40 years reduces breast cancer mortality and increases life-years gained per mammogram. More intensive screening for women with greater risk of breast cancer diagnosis or death can maintain similar benefit-to-harm trade-offs and reduce mortality disparities.

Altered gene expression and PTSD symptom dimensions in World Trade Center responders.

Despite experiencing a significant trauma, only a subset of World Trade Center (WTC) rescue and recovery workers developed posttraumatic stress disorder (PTSD). Identification of biomarkers is critical to the development of targeted interventions for treating disaster responders and potentially preventing the development of PTSD in this population. Analysis of gene expression from these individuals can help in identifying biomarkers of PTSD. We established a well-phenotyped sample of 371 WTC responders, recruited from a longitudinal WTC responder cohort using stratified random sampling, by obtaining blood, self-reported and clinical interview data. Using bulk RNA-sequencing from whole blood, we examined the association between gene expression and WTC-related PTSD symptom severity on (i) highest lifetime Clinician-Administered PTSD Scale (CAPS) score, (ii) past-month CAPS score, and (iii) PTSD symptom dimensions using a 5-factor model of re-experiencing, avoidance, emotional numbing, dysphoric arousal and anxious arousal symptoms. We corrected for sex, age, genotype-derived principal components and surrogate variables. Finally, we performed a meta-analysis with existing PTSD studies (total N = 1016), using case/control status as the predictor and correcting for these variables. We identified 66 genes significantly associated with total highest lifetime CAPS score (FDR-corrected p < 0.05), and 31 genes associated with total past-month CAPS score. Our more granular analyses of PTSD symptom dimensions identified additional genes that did not reach statistical significance in our analyses with total CAPS scores. In particular, we identified 82 genes significantly associated with lifetime anxious arousal symptoms. Several genes significantly associated with multiple PTSD symptom dimensions and total lifetime CAPS score (SERPINA1, RPS6KA1, and STAT3) have been previously associated with PTSD. Geneset enrichment of these findings has identified pathways significant in metabolism, immune signaling, other psychiatric disorders, neurological signaling, and cellular structure. Our meta-analysis revealed 10 genes that reached genome-wide significance, all of which were downregulated in cases compared to controls (CIRBP, TMSB10, FCGRT, CLIC1, RPS6KB2, HNRNPUL1, ALDOA, NACA, ZNF429 and COPE). Additionally, cellular deconvolution highlighted an enrichment in CD4 T cells and eosinophils in responders with PTSD compared to controls. The distinction in significant genes between total lifetime CAPS score and the anxious arousal symptom dimension of PTSD highlights a potential biological difference in the mechanism underlying the heterogeneity of the PTSD phenotype. Future studies should be clear about methods used to analyze PTSD status, as phenotypes based on PTSD symptom dimensions may yield different gene sets than combined CAPS score analysis. Potential biomarkers implicated from our meta-analysis may help improve therapeutic target development for PTSD.

Reflecting on 20 years of breast cancer modeling in CISNET: Recommendations for future cancer systems modeling efforts.

Since 2000, the National Cancer Institute's Cancer Intervention and Surveillance Modeling Network (CISNET) modeling teams have developed and applied microsimulation and statistical models of breast cancer. Here, we illustrate the use of collaborative breast cancer multilevel systems modeling in CISNET to demonstrate the flexibility of systems modeling to address important clinical and policy-relevant questions. Challenges and opportunities of future systems modeling are also summarized. The 6 CISNET breast cancer models embody the key features of systems modeling by incorporating numerous data sources and reflecting tumor, person, and health system factors that change over time and interact to affect the burden of breast cancer. Multidisciplinary modeling teams have explored alternative representations of breast cancer to reveal insights into breast cancer natural history, including the role of overdiagnosis and race differences in tumor characteristics. The models have been used to compare strategies for improving the balance of benefits and harms of breast cancer screening based on personal risk factors, including age, breast density, polygenic risk, and history of Down syndrome or a history of childhood cancer. The models have also provided evidence to support the delivery of care by simulating outcomes following clinical decisions about breast cancer treatment and estimating the relative impact of screening and treatment on the United States population. The insights provided by the CISNET breast cancer multilevel modeling efforts have informed policy and clinical guidelines. The 20 years of CISNET modeling experience has highlighted opportunities and challenges to expanding the impact of systems modeling. Moving forward, CISNET research will continue to use systems modeling to address cancer control issues, including modeling structural inequities affecting racial disparities in the burden of breast cancer. Future work will also leverage the lessons from team science, expand resource sharing, and foster the careers of early stage modeling scientists to ensure the sustainability of these efforts.

Identifying Equitable Screening Mammography Strategies for Black Women in the United States Using Simulation Modeling.

BACKGROUND: Screening mammography guidelines do not explicitly consider racial differences in breast cancer epidemiology, treatment, and survival. OBJECTIVE: To compare tradeoffs of screening strategies in Black women versus White women under current guidelines. DESIGN: An established model from the Cancer Intervention and Surveillance Modeling Network simulated screening outcomes using race-specific inputs for subtype distribution; breast density; mammography performance; age-, stage-, and subtype-specific treatment effects; and non-breast cancer mortality. SETTING: United States. PARTICIPANTS: A 1980 U.S. birth cohort of Black and White women. INTERVENTION: Screening strategies until age 74 years with varying initiation ages and intervals. MEASUREMENTS: Outcomes included benefits (life-years gained [LYG], breast cancer deaths averted, and mortality reduction), harms (mammographies, false positives, and overdiagnoses), and benefit-harm ratios (tradeoffs) by race. Efficiency (benefits per unit resource), mortality disparity reduction, and equity in tradeoffs were evaluated. Equitable strategies for Black women were defined as those with tradeoffs closest to benchmark values for screening White women biennially from ages 50 to 74 years. RESULTS: Biennial screening from ages 45 to 74 years was most efficient for Black women, whereas biennial screening from ages 40 to 74 years was most equitable. Initiating screening 10 years earlier in Black versus White women reduced Black-White mortality disparities by 57% with similar LYG per mammogram for both populations. Selection of the most equitable strategy was sensitive to assumptions about disparities in real-world treatment effectiveness: The less effective treatment was for Black women, the more intensively Black women could be screened before tradeoffs fell short of those experienced by White women. LIMITATION: Single model. CONCLUSION: Initiating biennial screening in Black women at age 40 years reduces breast cancer mortality disparities and yields benefit-harm ratios that are similar to tradeoffs of White women screened biennially from ages 50 to 74 years. PRIMARY FUNDING SOURCE: National Cancer Institute at the National Institutes of Health.

Distress and Type 2 Diabetes Self-Care: Putting the Pieces Together.

BACKGROUND: Conflicting research emphasizes depression, diabetes distress, or well-being in relation to diabetes self-care and risk for poor health outcomes. PURPOSE: The purpose of this study was to test whether a latent variable for general psychological distress derived from shared variance of depression symptoms, diabetes distress, and well-being predicts a latent variable of diabetes self-care and to examine evidence for unique effects once shared effects are adjusted for. METHODS: Adults with suboptimally controlled diabetes were recruited from the South Bronx, NY, for a telephonic diabetes self-management support trial. Baseline diabetes self-care, medication adherence, depression symptoms, diabetes distress, and well-being were measured by validated self-report. Structural equation modeling specified a latent variable for general psychological distress derived from shared variance of depression symptoms, diabetes distress, and well-being. Diabetes self-care was a latent variable indicated by diet, glucose self-monitoring, and medication adherence. RESULTS: Participants (N = 627, 65% female) were predominantly ethnic minority (70% Hispanic; 45% Black) and 77% reported household income <$20K/year. Mean (standard deviation) age = 56 (12) years; A1c = 9.1% (1.9%); body mass index = 32 (8) kg/m2. The latent variable for psychological distress was a robust predictor of poorer diabetes self-care (coefficient = -0.59 [confidence interval = -0.71, -0.46], p < .001) with good model fit. Unique paths from depression symptoms, diabetes distress, and well-being (all ps > .99) to self-care were not observed. CONCLUSIONS: In this population of disadvantaged adults with suboptimally controlled diabetes, general psychological distress was strongly associated with poorer diabetes self-care and fully accounted for the effects of depression, diabetes distress, and positive well-being. This suggests that general distress may underlie previously reported associations between these constructs and diabetes self-care.

Mental health stigma and barriers to care in World Trade Center responders: Results from a large, population-based health monitoring cohort.

BACKGROUND: Nearly 20 years after the terrorist attacks of September 11, 2001, multiple studies have documented the adverse mental consequences among World Trade Center (WTC) rescue, recovery, and clean-up workers. However, scarce research has examined mental health stigma and barriers to care in WTC-exposed individuals, and no known study has examined whether rates of endorsement may differ between police and "nontraditional" responders, the latter comprising a heterogeneous group of workers and volunteers. OBJECTIVE: To identify the prevalence and correlates of mental health stigma and barriers to care in WTC responders. METHODS: Mental health stigma and barriers to care and their correlates were examined in 6,777 police and 6,272 nontraditional WTC responders. RESULTS: Nontraditional responders endorsed more stigma or barriers to care concerns than police responders. Within a subsample who screened positive for a psychiatric disorder, police were more likely than nontraditional responders to endorse "concerns that negative job consequences might result" (17.9% vs. 9.1%), while nontraditional responders were more likely to endorse "I don't know where to go to find counseling services" (18.4% vs.6.6%). Within this subsample, mental health service need and more severe WTC-related posttraumatic stress disorder symptoms were associated with increased likelihood of endorsing stigma or barriers; pre-9/11 psychiatric history and non-Hispanic Black race/ethnicity were associated with lower likelihood of endorsing stigma or barriers. CONCLUSIONS: Results of this study underscore the burden of mental health stigma and barriers to care in WTC responders, and highlight the need for targeted interventions to address these concerns and promote mental healthcare utilization in this population.

Clinical Benefits, Harms, and Cost-Effectiveness of Breast Cancer Screening for Survivors of Childhood Cancer Treated With Chest Radiation : A Comparative Modeling Study.

BACKGROUND: Surveillance with annual mammography and breast magnetic resonance imaging (MRI) is recommended for female survivors of childhood cancer treated with chest radiation, yet benefits, harms, and costs are uncertain. OBJECTIVE: To compare the benefits, harms, and cost-effectiveness of breast cancer screening strategies in childhood cancer survivors. DESIGN: Collaborative simulation modeling using 2 Cancer Intervention and Surveillance Modeling Network breast cancer models. DATA SOURCES: Childhood Cancer Survivor Study and published data. TARGET POPULATION: Women aged 20 years with a history of chest radiotherapy. TIME HORIZON: Lifetime. PERSPECTIVE: Payer. INTERVENTION: Annual MRI with or without mammography, starting at age 25, 30, or 35 years. OUTCOME MEASURES: Breast cancer deaths averted, false-positive screening results, benign biopsy results, and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS: Lifetime breast cancer mortality risk without screening was 10% to 11% across models. Compared with no screening, starting at age 25 years, annual mammography with MRI averted the most deaths (56% to 71%) and annual MRI (without mammography) averted 56% to 62%. Both strategies had the most screening tests, false-positive screening results, and benign biopsy results. For an ICER threshold of less than $100 000 per quality-adjusted life-year gained, screening beginning at age 30 years was preferred. RESULTS OF SENSITIVITY ANALYSIS: Assuming lower screening performance, the benefit of adding mammography to MRI increased in both models, although the conclusions about preferred starting age remained unchanged. LIMITATION: Elevated breast cancer risk was based on survivors diagnosed with childhood cancer between 1970 and 1986. CONCLUSION: Early initiation (at ages 25 to 30 years) of annual breast cancer screening with MRI, with or without mammography, might reduce breast cancer mortality by half or more in survivors of childhood cancer. PRIMARY FUNDING SOURCE: American Cancer Society and National Institutes of Health.

Healthful and less-healthful foods and drinks from storefront and non-storefront businesses: implications for 'food deserts', 'food swamps' and food-source disparities.

OBJECTIVE: Conceptualisations of 'food deserts' (areas lacking healthful food/drink) and 'food swamps' (areas overwhelm by less-healthful fare) may be both inaccurate and incomplete. Our objective was to more accurately and completely characterise food/drink availability in urban areas. DESIGN: Cross-sectional assessment of select healthful and less-healthful food/drink offerings from storefront businesses (stores, restaurants) and non-storefront businesses (street vendors). SETTING: Two areas of New York City: the Bronx (higher-poverty, mostly minority) and the Upper East Side (UES; wealthier, predominantly white). PARTICIPANTS: All businesses on 63 street segments in the Bronx (n 662) and on 46 street segments in the UES (n 330). RESULTS: Greater percentages of businesses offered any, any healthful, and only less-healthful food/drink in the Bronx (42·0 %, 37·5 %, 4·4 %, respectively) than in the UES (30 %, 27·9 %, 2·1 %, respectively). Differences were driven mostly by businesses (e.g. newsstands, gyms, laundromats) not primarily focused on selling food/drink - 'other storefront businesses' (OSBs). OSBs accounted for 36·0 % of all food/drink-offering businesses in the Bronx (more numerous than restaurants or so-called 'food stores') and 18·2 % in the UES (more numerous than 'food stores'). Differences also related to street vendors in both the Bronx and the UES. If street vendors and OSBs were not captured, the missed percentages of street segments offering food/drink would be 14·5 % in the Bronx and 21·9 % in the UES. CONCLUSIONS: Of businesses offering food/drink in communities, OSBs and street vendors can represent substantial percentages. Focusing on only 'food stores' and restaurants may miss or mischaracterise 'food deserts', 'food swamps', and food/drink-source disparities between communities.

Government data v. ground observation for food-environment assessment: businesses missed and misreported by city and state inspection records.

OBJECTIVE: To assess the accuracy of government inspection records, relative to ground observation, for identifying businesses offering foods/drinks. DESIGN: Agreement between city and state inspection records v. ground observations at two levels: businesses and street segments. Agreement could be 'strict' (by business name, e.g. 'Rizzo's') or 'lenient' (by business type, e.g. 'pizzeria'); using sensitivity and positive predictive value (PPV) for businesses and using sensitivity, PPV, specificity and negative predictive value (NPV) for street segments. SETTING: The Bronx and the Upper East Side (UES), New York City, USA. PARTICIPANTS: All food/drink-offering businesses on sampled street segments (n 154 in the Bronx, n 51 in the UES). RESULTS: By 'strict' criteria, sensitivity and PPV of government records for food/drink-offering businesses were 0·37 and 0·57 in the Bronx; 0·58 and 0·60 in the UES. 'Lenient' values were 0·40 and 0·62 in the Bronx; 0·60 and 0·62 in the UES. Sensitivity, PPV, specificity and NPV of government records for street segments having food/drink-offering businesses were 0·66, 0·73, 0·84 and 0·79 in the Bronx; 0·79, 0·92, 0·67, and 0·40 in the UES. In both areas, agreement varied by business category: restaurants; 'food stores'; and government-recognized other storefront businesses ('gov. OSB', i.e. dollar stores, gas stations, pharmacies). Additional business categories - 'other OSB' (barbers, laundromats, newsstands, etc.) and street vendors - were absent from government records; together, they represented 28·4 % of all food/drink-offering businesses in the Bronx, 22·2 % in the UES ('other OSB' and street vendors were sources of both healthful and less-healthful foods/drinks in both areas). CONCLUSIONS: Government records frequently miss or misrepresent businesses offering foods/drinks, suggesting caveats for food-environment assessments using such records.

Mental Healthcare Needs in World Trade Center Responders: Results from a Large, Population-Based Health Monitoring Cohort.

Nearly two decades after the 9/11 attacks on the World Trade Center (WTC), the prevalence of mental disorders remains elevated among traditional (e.g., police) and non-traditional (e.g., construction workers) responders who were involved in the WTC rescue, recovery, and clean-up efforts. To date, however, scarce research has examined factors associated with perceived need for mental health care, which is critical to promoting engagement in mental health treatment in this population. Data were analyzed from 16,170 WTC responders, including 8881 police responders and 7289 non-traditional responders, who completed their first annual health monitoring visit with the WTC Health Program an average of 6.5 years after September 11, 2001. Predisposing, enabling, and need-based factors associated with perceived need for mental health care were examined using multivariable logistic regression analyses. Nearly half (48.7%) of non-traditional responders and a fifth (20.6%) of police responders reported a need for mental health care. The most common perceived needs were for psychotropic medication, individual psychotherapy, and stress management counseling. Predisposing (e.g., female gender) and need-based factors (e.g., WTC-related posttraumatic stress disorder) predicted perceived need for mental health care in both groups. Among non-traditional responders, Hispanic ethnicity and current suicidal ideation were additionally associated with this outcome. Non-traditional WTC responders are substantially more likely than police WTC responders to perceive a need for mental health treatment. Characterization of factors associated with perceived need for treatment can help inform population-based outreach and monitoring efforts designed to promote engagement in mental health treatment in WTC responders.

IMPACT OF MULTIDISCIPLINARY PROCESS IMPROVEMENT INTERVENTIONS ON GLUCOMETRICS IN A NONCRITICALLY ILL SETTING.

Objective: This study aimed to assess the impact of multidisciplinary process improvement interventions on glycemic control in the inpatient setting of an urban community hospital, utilizing the daily simple average as the primary glucometric measure. Methods: From 2010-2014, five process of care interventions were implemented in the noncritical care inpatient units of the study hospital. Interventions included education of medical staff, implementation of hyperglycemia and hypoglycemia protocols, computerized insulin order entry, and coordination of meal tray delivery with finger stick and insulin administration. Unpaired t tests compared pre- and postintervention process measures. Simple average daily glucose measure was the primary glucometric outcome. Secondary outcome measures included frequency of hyperglycemia and hypoglycemia. Glucose outcomes were compared with an in-network hospital that did not implement the respective interventions. Results: A total of 180,431 glucose measurements were reported from 4,705 and 4,238 patients from the intervention and comparison hospitals, respectively. The time between bolus-insulin administration and breakfast tray delivery was significantly reduced by 81.7 minutes (P<.00005). The use of sliding scale insulin was sustainably reduced. Average daily glucose was reduced at both hospitals, and overall rates of hypoglycemia were low. Conclusion: A multidisciplinary approach at an urban community hospital with limited resources was effective in improving and sustaining processes of care for improved glycemic control in the noncritical care, inpatient setting. Abbreviations: IQR = interquartile range; JMC = Jacobi Medical Center; NCBH = North Central Bronx Hospital.

Unreliable and Difficult-to-Access Food for Those in Need: A Qualitative and Quantitative Study of Urban Food Pantries.

For individuals who are food insecure, food pantries can be a vital resource to improve access to adequate food. Access to adequate food may be conceptualized within five dimensions: availability (item variety), accessibility (e.g., hours of operation), accommodation (e.g., cultural sensitivity), affordability (costs, monetary or otherwise), and acceptability (e.g., as related to quality). This study examined the five dimensions of access in a convenience sample of 50 food pantries in the Bronx, NY. The design was cross-sectional. Qualitative data included researcher observations and field notes from unstructured interviews with pantry workers. Quantitative data included frequencies for aspects of food access, organized by the five access dimensions. Inductive analysis of quantitative and qualitative data revealed three main inter-related findings: (1) Pantries were not reliably open: only 50% of pantries were open during hours listed in an online directory (several had had prolonged or indefinite closures); (2) Even when pantries were open, all five access dimensions showed deficiencies (e.g., limited inventory, few hours, pre-selected handouts without consideration of preferences, opportunity costs, and inferior-quality items); (3) Open pantries frequently had insufficient food supply to meet client demand. To deal with mismatch between supply and demand, pantries developed rules for food provision. Rules could break down in cases of pantries receiving food deliveries, leading to workarounds, and in cases of compelling client need, leading to exceptions. Adherence to rules, versus implementation of workarounds and/or exceptions, was worker- and situation-dependent and, thus, unpredictable. Overall, pantry food provision was unreliable. Future research should explore clients' perception of pantry access considering multiple access dimensions. Future research should also investigate drivers of mismatched supply and demand to create more predictable, reliable, and adequate food provision.

Foods and Drinks Available from Urban Food Pantries: Nutritional Quality by Item Type, Sourcing, and Distribution Method.

The overall nutritional quality of foods/drinks available at urban food pantries is not well established. In a study of 50 pantries listed as operating in the Bronx, NY, data on food/drink type (fresh, shelf-stable, refrigerated/frozen) came from direct observation. Data on food/drink sourcing (food bank or other) and distribution (prefilled bag vs. client choice for a given client's position in line) came from semi-structured interviews with pantry workers. Overall nutritional quality was determined using NuVal® scores (range 1-100; higher score indicates higher nutritional quality). Twenty-nine pantries offered zero nutrition at listed times (actually being closed or having no food/drinks in stock). Of the 21 pantries that were open as listed and had foods/drinks to offer, 12 distributed items in prefilled bags (traditional pantries), 9 allowed for client choice. Mean NuVal® scores were higher for foods/drinks available from client-choice pantries than traditional pantries (69.3 vs. 57.4), driven mostly by sourcing fresh items (at 28.3% of client-choice pantries vs. 4.8% of traditional pantries). For a hypothetical 'balanced basket' of one of each fruit, vegetable, grain, dairy and protein item, highest-NuVal® items had a mean score of 98.8 across client-choice pantries versus 96.6 across traditional pantries; lowest-NuVal® items had mean scores of 16.4 and 35.4 respectively. Pantry workers reported lower-scoring items (e.g., white rice) were more popular-appeared in early bags or were selected first-leaving higher-scoring items (e.g., brown rice) for clients later in line. Fewer than 50% of sampled pantries were open and had food/drink to offer at listed times. Nutritional quality varied by item type and sourcing and could also vary by distribution method and client position in line. Findings suggest opportunities for pantry operation, client and staff education, and additional research.

Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors: A Randomized Clinical Trial.

Importance: Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective: To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. Design, Setting, and Participants: This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. Interventions: Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). Main Outcomes and Measures: The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). Results: Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings (P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions. Conclusions and Relevance: A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors. Trial Registration: clinicaltrials.gov Identifier: NCT02876588.

Can a gastric cancer risk survey identify high-risk patients for endoscopic screening? A pilot study.

BACKGROUND: A questionnaire that distinguishes how variability in gastric cancer prevalence is associated with ethnicity/birth country/immigration/cultural diet along with known risk factors may improve targeting populations for gastric cancer screening in the United States. METHODS: Existing literature was used to identify the item pool. Cluster analysis, focus groups, and cognitive interviewing were used to reduce collinear items and refine the questionnaire. Logistic regression analysis was used to determine which items distinguished gastric cancer cases from the primary care and community controls. RESULTS: The results of analysis of data from 40 cases and 100 controls (primary care = 47; community = 53) were used to reduce the 227 item pool to 12 items. After ranking these variables using model bootstrapping, a logistic regression model using the highest ranked eight variables was chosen as the final model. Older age, foreign nativity, daily consumption of cultural food at ages 15-18, less than high-school education, and greater acculturation were significantly associated with being a gastric cancer case compared with the controls. CONCLUSIONS: An eight-item survey that addresses gastric cancer risk factors, ethnicity, cultural habits, and immigration patterns has potential to identify high-risk persons from multicultural areas within the US, who might benefit from endoscopic screening for gastric cancer.

Parental posttraumatic stress and child behavioral problems in world trade center responders.

BACKGROUND: We investigated trans-generational associations between Post Traumatic Stress Disorder (PTSD) symptoms in World Trade Center (WTC) responders and behavioral problems in their children. METHODS: Participants were WTC responders-8034 police and 8352 non-traditional (eg, construction workers)-with one or more children at the time of their first visit to the World Trade Center Health Program (WTC-HP). Self-report questionnaires were administered approximately 4 years after the 9/11 WTC attack. RESULTS: A total of 31.4% of non-traditional and 20.0% of police responders reported behavioral problems in their children. Non-traditional responder status, female sex, Hispanic ethnicity, more life stressors, more WTC-related PTSD symptoms, and dysphoric arousal symptoms were significant correlates of behavioral problems in responders' children. CONCLUSIONS: Specific parental sociodemographic, psychosocial and clinical characteristics, as well as PTSD symptom severity, were significant correlates of child behavior problems. Findings encourage monitoring and early intervention for children of disaster responders, particularly those at highest risk.

Sources of Foods That Are Ready-to-Consume ('Grazing Environments') Versus Requiring Additional Preparation ('Grocery Environments'): Implications for Food-Environment Research and Community Health.

Local businesses that offer foods may create different 'grazing environments' (characterized by sources of ready-to-consume foods) and 'grocery environments' (characterized by source of foods for later preparation). Such environments may be relevant to different populations at different times and may vary by neighborhood. In neighborhoods within two demographically distinct areas of the Bronx, NY [Area A (higher-poverty, greater minority representation, lesser vehicle ownership) vs. Area B], researchers assessed all storefront businesses for food offerings. Food offerings could be ready-to-consume or require additional preparation. 'Healthful' offerings included fruits and vegetables, whole grains, and nuts; 'less-healthful' offerings included 'refined sweets' and 'salty/fatty fare.' 'Food businesses' (those primarily focused on selling food) were distinguished from 'other businesses' (not focused primarily on food selling). Area A had a higher percentage of street segments on which foods were available (28.6% vs. 6.9% in Area B; difference 21.7% points [95% CI 17.0, 26.5]) and a higher percentage of businesses offering foods (46.9% vs. 41.7% in Area B; difference 5.2% points [95% CI - 2.0, 12.4]). 'Less-healthful' items predominated in both 'grazing environments' and overall environments ('grazing' plus 'grocery environments'; the environments researchers typically measure) in both Areas A and B. 'Other businesses' represented about 2/3 of all businesses and accounted for nearly 1/3 of all the businesses offering food in both geographic areas. The lower-income area with greater minority representation and less private transportation had more businesses offering foods on more streets. There was near-perfect overlap between 'grazing environments' and overall environments in both geographic areas. Future research should consider the extent of 'grazing' and 'grocery environments,' and when each might be most relevant to populations of interest.