Lessons learned from implementing a diversity, equity, and inclusion curriculum for health research professionals at a large academic research institution.

Objective: Despite advances in incorporating diversity and structural competency into medical education curriculum, there is limited curriculum for public health research professionals. We developed and implemented a four-part diversity, equity, and inclusion (DEI) training series tailored for academic health research professionals to increase foundational knowledge of core diversity concepts and improve skills. Methods: We analyzed close- and open-ended attendee survey data to evaluate within- and between-session changes in DEI knowledge and perceived skills. Results: Over the four sessions, workshop attendance ranged from 45 to 82 attendees from our 250-person academic department and represented a mix of staff (64%), faculty (25%), and trainees (11%). Most identified as female (74%), 28% as a member of an underrepresented racial and ethnic minority (URM) group, and 17% as LGBTQI. During all four sessions, attendees increased their level of DEI knowledge, and within sessions two through four, attendees' perception of DEI skills increased. We observed increased situational DEI awareness as higher proportions of attendees noted disparities in mentoring and opportunities for advancement/promotion. An increase in a perceived lack of DEI in the workplace as a problem was observed; but only statistically significant among URM attendees. Discussion: Developing applied curricula yielded measurable improvements in knowledge and skills for a diverse health research department of faculty, staff, and students. Nesting this training within a more extensive program of departmental activities to improve climate and address systematic exclusion likely contributed to the series' success. Additional research is underway to understand the series' longer-term impact on applying skills for behavior change.

Associations between abrupt transition, dialysis-requiring AKI, and early mortality in ESKD among U.S. veterans.

BACKGROUND: Mortality is high within the first few months of starting chronic dialysis. Pre-ESKD trajectory of kidney function has been shown to be predictive of early death after dialysis initiation. We aim to better understand how two key aspects of pre-dialysis kidney function-an abrupt transition pattern and an episode of dialysis-requiring AKI (AKI-D) leading directly to ESKD-are associated with early mortality after dialysis initiation. METHODS: We extracted national data from U.S. Veterans Health Administration cross-linked with the United States Renal Data System (USRDS) to identify patients who initiated hemodialysis during 2009-2013. We defined abrupt transition as having a mean outpatient eGFR ≥ 30 ml/min/1.73m2 within 1 year prior to ESKD. AKI-D was identified using inpatient serum creatinine measurements (serum Cr increase by at least 50% from baseline) along with billing codes for inpatient receipt of dialysis for AKI within 30 days prior to the ESKD start date. We used multivariable proportional hazards models to examine the association between patterns of kidney function prior to ESKD and all-cause mortality within 90 days after ESKD. RESULTS: Twenty-two thousand eight hundred fifteen patients were identified in the final analytic cohort of Veterans who initiated hemodialysis and entered the USRDS. We defined five patterns of kidney function decline. Most (68%) patients (N = 15,484) did not have abrupt transition and did not suffer an episode of AKI-D prior to ESKD (reference group). The remaining groups had abrupt transition, AKI-D, or both. Patients who had an abrupt transition with (N = 503) or without (N = 3611) AKI-D had the highest risk of early mortality after ESKD onset after adjustment for demographics and comorbidities (adjusted HR 2.10, 95% CI 1.66-2.65 for abrupt transition with AKI-D; adjusted HR 2.10, 95% CI 1.90-2.33 for abrupt transition without AKI-D). In contrast, patients who experienced AKI-D without an abrupt transition pattern (N = 2141 had only a modestly higher risk of early death (adjusted HR 1.19, 95% CI 1.01-1.40). CONCLUSIONS: An abrupt decline in kidney function within 1 year prior to ESKD occurred in nearly 1 in 5 incident hemodialysis patients (18%) in this national cohort of Veterans and was strongly associated with higher early mortality after ESKD onset.

Visit and Between-Visit Interaction Frequency Before and After COVID-19 Telehealth Implementation.

Importance: Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient-clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions. Objective: To evaluate rates of change over time in visits (in-person, telehealth) and between-visit interactions (telephone calls, patient portal messages) overall and by key patient characteristics. Design, Setting, and Participants: This retrospective cohort study included adults with diabetes receiving primary care at urban academic (University of California San Francisco [UCSF]) and safety-net (San Francisco Health Network [SFHN]) health care systems. Encounters from April 2019 to March 2021 were analyzed. Exposure: Telehealth implementation over 3 periods: pre-PHE (April 2019 to March 2020), strict shelter-in-place (April to June 2020), and hybrid-PHE (July 2020 to March 2021). Main Outcomes and Measures: The main outcomes were rates of change in monthly mean number of total encounters, visits with any health care team member, visits with billing clinicians, and between-visit interactions. Key patient-level characteristics were age, race and ethnicity, language, and neighborhood socioeconomic status (nSES). Results: Of 15 148 patients (4976 UCSF; 8975 SFHN) included, 2464 (16%) were 75 years or older, 7734 (51%) were female patients, 9823 (65%) self-identified as racially or ethnically minoritized, 6223 (41%) had a non-English language preference, and 4618 (31%) lived in the lowest nSES quintile. After accounting for changes to care delivery through an interrupted time-series analysis, total encounters increased in the hybrid-PHE period (UCSF: 2.3% per patient/mo; 95% CI, 1.6%-2.9% per patient/mo; SFHN: 1.8% per patient/mo, 95% CI, 1.3%-2.2% per patient/mo), associated primarily with growth in between-visit interactions (UCSF: 3.1% per patient/mo, 95% CI, 2.3%-3.8% per patient/mo; SFHN: 2.9% per patient/mo, 95% CI, 2.3%-3.4% per patient/mo). In contrast, rates of visits were stable during the hybrid-PHE period. Although there were fewer differences in visit use by key patient-level characteristics during the hybrid-PHE period, pre-PHE differences in between-visit interactions persisted during the hybrid-PHE period at SFHN. Asian and Chinese-speaking patients at SFHN had fewer monthly mean between-visit interactions compared with White patients (0.46 [95% CI, 0.42-0.50] vs 0.59 [95% CI, 0.53-0.66] between-visit interactions/patient/mo; P < .001) and English-speaking patients (0.52 [95% CI, 0.47-0.58] vs 0.61 [95% CI, 0.56-0.66] between-visit interactions/patient/mo; P = .03). Conclusions and Relevance: In this study, pre-PHE growth in overall patient-clinician encounters persisted after PHE-related telehealth implementation, driven in both periods by between-visit interactions. Differential utilization based on patient characteristics was observed, which may indicate disparities. The implications for health care team workload and patient outcomes are unknown, particularly regarding between-visit interactions. Therefore, to comprehensively understand care utilization for patients with chronic diseases, research should expand beyond billed visits.

Social Determinants of Health Documentation in Structured and Unstructured Clinical Data of Patients With Diabetes: Comparative Analysis.

Background: Electronic health records (EHRs) have yet to fully capture social determinants of health (SDOH) due to challenges such as nonexistent or inconsistent data capture tools across clinics, lack of time, and the burden of extra steps for the clinician. However, patient clinical notes (unstructured data) may be a better source of patient-related SDOH information. Objective: It is unclear how accurately EHR data reflect patients' lived experience of SDOH. The manual process of retrieving SDOH information from clinical notes is time-consuming and not feasible. We leveraged two high-throughput tools to identify SDOH mappings to structured and unstructured patient data: PatientExploreR and Electronic Medical Record Search Engine (EMERSE). Methods: We included adult patients (≥18 years of age) receiving primary care for their diabetes at the University of California, San Francisco (UCSF), from January 1, 2018, to December 31, 2019. We used expert raters to develop a corpus using SDOH in the compendium as a knowledge base as targets for the natural language processing (NLP) text string mapping to find string stems, roots, and syntactic similarities in the clinical notes of patients with diabetes. We applied advanced built-in EMERSE NLP query parsers implemented with JavaCC. Results: We included 4283 adult patients receiving primary care for diabetes at UCSF. Our study revealed that SDOH may be more significant in the lives of patients with diabetes than is evident from structured data recorded on EHRs. With the application of EMERSE NLP rules, we uncovered additional information from patient clinical notes on problems related to social connectionsisolation, employment, financial insecurity, housing insecurity, food insecurity, education, and stress. Conclusions: We discovered more patient information related to SDOH in unstructured data than in structured data. The application of this technique and further investment in similar user-friendly tools and infrastructure to extract SDOH information from unstructured data may help to identify the range of social conditions that influence patients' disease experiences and inform clinical decision-making.

Serious Mental Illness, Glycemic Control, and Neighborhood Factors within an Urban Diabetes Cohort.

BACKGROUND AND HYPOTHESIS: Serious mental illness (SMI) may compromise diabetes self-management. This study assessed the association between SMI and glycemic control, and explored sociodemographic predictors and geographic clustering of this outcome among patients with and without SMI. STUDY DESIGN: We used electronic health record data for adult primary care patients with diabetes from 2 San Francisco health care delivery systems. The primary outcome was poor glycemic control (hemoglobin A1c >9.0%), which was modeled on SMI diagnosis status and sociodemographics. Geospatial analyses examined hotspots of poor glycemic control and neighborhood characteristics. STUDY RESULTS: The study included 11 694 participants with diabetes, 21% with comorbid SMI, of whom 22% had a schizophrenia spectrum or bipolar disorder. Median age was 62 years; 52% were female and 79% were Asian, Black, or Hispanic. In adjusted models, having schizophrenia spectrum disorder or bipolar disorder was associated with greater risk for poor glycemic control (vs participants without SMI, adjusted relative risk [aRR] = 1.24; 95% confidence interval, 1.02, 1.49), but having broadly defined SMI was not. People with and without SMI had similar sociodemographic correlates of poor glycemic control including younger versus older age, Hispanic versus non-Hispanic White race/ethnicity, and English versus Chinese language preference. Hotspots for poor glycemic control were found in neighborhoods with more lower-income, Hispanic, and Black residents. CONCLUSIONS: Poor diabetes control was significantly related to having a schizophrenia spectrum or bipolar disorder, and to sociodemographic factors and neighborhood. Community-based mental health clinics in hotspots could be targets for implementation of diabetes management services.

Impacts of Individual Patient Language and Neighborhood Ethnic Enclave on COVID-19 Test Positivity Among Hispanic/Latinx Patients in San Francisco.

BACKGROUND: Given the known disparities in COVID-19 within the Hispanic/Latinx community, we sought to examine the interaction between individual-level and neighborhood-level social determinants of health using linked electronic health record data. METHODS: We examined electronic health record data linked to neighborhood data among Hispanic/Latinx patients tested for COVID-19 between March 1, 2020, and February 28, 2021, from 2 large health care systems in San Francisco. Hispanic/Latinx ethnic enclave is measured using an index of census-tract level indicators of ethnicity, nativity, and language. Multilevel logistic regression models examined associations between ethnic enclave and COVID-19 positivity (COVID-19+), adjusting for patient-level sociodemographic and clinical characteristics and health system. Cross-level interactions were used to test whether associations between ethnic enclave and COVID-19+ differed by patient language preference. RESULTS: Among 26,871 patients, mean age was 37 years, 56% had Spanish-language preference, and 21% were COVID-19+. In unadjusted models, patients living in the highest versus lowest Hispanic/Latinx enclave had 3.2 higher odds of COVID-19+ (95% CI, 2.45-4.24). Adjusted, the relationship between ethnic enclave and COVID-19+ was attenuated, but not eliminated (odds ratio: 1.4; 95% CI, 1.13-1.17). Our results demonstrated a significant cross-level interaction, such that the influence of ethnic enclave was modified by patient language preference. For individuals with Spanish-language preference, risk of COVID-19+ was high regardless of neighborhood context, whereas for those with English preference, neighborhood ethnic enclave more than doubled the odds of infection. CONCLUSIONS: Findings suggest that a multilevel and intersectional approach to the study of COVID-19 inequities may illuminate dimensions of health inequity that affect marginalized communities and offer insights for targeted clinical and community-based interventions.

Neighborhood Disadvantage, Patterns of Unhealthy Alcohol Use, and Differential Associations by Gender, Race/Ethnicity, and Rurality: A Study of Veterans Health Administration Patients.

OBJECTIVE: Stressful conditions within disadvantaged neighborhoods may shape unhealthy alcohol use and related harms. Yet, associations between neighborhood disadvantage and more severe unhealthy alcohol use are underexplored, particularly for subpopulations. Among national Veterans Health Administration (VA) patients (2013-2017), we assessed associations between neighborhood disadvantage and multiple alcohol-related outcomes and examined moderation by sociodemographic factors. METHOD: Electronic health record data were extracted for VA patients with a routine Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen. Patient addresses were linked by census block group to the Area Deprivation Index (ADI), dichotomized at the 85th percentile, and examined in quintiles for sensitivity analyses. Using modified Poisson generalized estimating equations models, we estimated associations between neighborhood disadvantage and five outcomes: unhealthy alcohol use (AUDIT-C ≥ 5), any past-year heavy episodic drinking (HED), severe unhealthy alcohol use (AUDIT-C ≥ 8), alcohol use disorder (AUD) diagnosis, and alcohol-specific conditions diagnoses. Moderation by gender, race/ethnicity, and rurality was tested using multiplicative interaction. RESULTS: Among 6,381,033 patients, residence in a highly disadvantaged neighborhood (ADI ≥ 85th percentile) was associated with a higher likelihood of unhealthy alcohol use (prevalence ratio [PR] = 1.06, 95% CI [1.05, 1.07]), severe unhealthy alcohol use (PR = 1.14, 95% CI [1.12, 1.15]), HED (PR = 1.04, 95% CI [1.03, 1.05]), AUD (PR = 1.14, 95% CI [1.13, 1.15]), and alcohol-specific conditions (PR = 1.21, 95% CI [1.18, 1.24]). Associations were larger for Black and American Indian/Alaska Native patients compared with White patients and for urban compared with rural patients. There was mixed evidence of moderation by gender. CONCLUSIONS: Neighborhood disadvantage may play a role in unhealthy alcohol use in VA patients, particularly those of marginalized racialized groups and those residing in urban areas.

Prevalence of social and economic stressors among transgender veterans with alcohol and other drug use disorders.

Transgender persons have high rates of alcohol and other drug use disorders (AUD and DUD, respectively) and commonly experience social and economic stressors that may compound risk for adverse substance-related outcomes. National VA electronic health record data were extracted for all outpatients in each facility with documented alcohol screening 10/1/09-7/31/17. We describe the prevalence of eight individual-level social and economic stressors (barriers to accessing care, economic hardship, housing instability, homelessness, social and family problems, legal problems, military sexual trauma, and other victimization) among transgender patients with and without AUD and DUD (alone and in combination), overall and compared to cisgender patients in a national sample of VA outpatients. Among 8,872,793 patients, 8619 (0.1%) were transgender; the prevalence of AUD, DUD, and both was 8.6%, 7.2%, and 3.1% among transgender patients and 6.1%, 3.9%, and 1.7% among cisgender patients, respectively. Among all patients, prevalence of stressors was higher among those with AUD, DUD, or both, relative to those with neither. Within each of these groups, prevalence was 2-3 times higher among transgender compared to cisgender patients. For instance, prevalence of housing instability for transgender vs. cisgender patients with AUD, DUD, and both was: 40.8% vs 24.1%, 45.8% vs. 36.6%, and 57.4% vs. 47.0%, respectively. (all p-values <0.001). Social and economic stressors were prevalent among patients with AUD, DUD, or both, and the experience of these disorders and social and economic stressors was more common among transgender than cisgender patients in all groups. Further research regarding experiences of transgender persons and influences of stressors on risk of AUD and DUD, substance-related outcomes, and treatment uptake are needed. Routine screening for social and economic stressors among patients with substance use disorders (SUDs) could improve equitable substance-related care and outcomes. Treatment of SUDs among all persons should consider social and economic risk factors.

Influence of a national transgender health care directive on receipt of alcohol-related care among transgender Veteran Health Administration patients with unhealthy alcohol use.

INTRODUCTION: Transgender persons are vulnerable to under-receipt of recommended health care due to chronic exposure to systemic stressors (e.g., discriminatory laws and health system practices). Scant information exists on receipt of alcohol-related care for transgender populations, and whether structural interventions to reduce transgender discrimination in health care improve receipt of recommended treatment. This study evaluated the effect of the Veteran Health Administration (VA) Transgender Healthcare Directive-a national policy to reduce structural discrimination-on receipt of evidence-based alcohol-related care for transgender VA patients with unhealthy alcohol use. METHODS: The study used an interrupted time series with control design to compare monthly receipt of alcohol-related care among transgender patients with unhealthy alcohol use (Alcohol Use Disorders Identification Test Consumption ≥5) documented in their electronic health record before (10/1/2009-5/31/2011) and after (7/1/2011-7/31/2017) implementation of VA's Transgender Healthcare Directive. A propensity-score matched sample of non-transgender patients with unhealthy alcohol use served as a comparison group to control for concurrent secular trends. Mixed effects segmented logistic regression models estimated changes in level and slope (i.e., rate of change) in receipt of any evidence-based alcohol-related care, including brief intervention, specialty addictions treatment, and alcohol use disorder medications. RESULTS: The matched sample (mean age = 47.5 [SD = 15.0]; 75% non-Hispanic White race/ethnicity) included 2074 positive alcohol screens completed by 1377 transgender patients and 6,l99 positive alcohol screens completed by 6185 non-transgender patients. Receipt of alcohol-related care increased for transgender patients from 78.5% (95% CI: 71.3%-85.6%) at the start of study to 83.0% (75.9%-90.1%) immediately before the directive and decreased slightly from 81.6% (77.4%-85.9%) immediately after the directive to 80.1% (76.8-85.4) at the end of the study. Changes in level and slope comparing periods before and after the directive were not statistically significant, nor were they statistically significantly different from the matched sample of non-transgender patients. CONCLUSIONS: Health systems must urgently employ and evaluate policies to address structural stigma that produces and reproduces disparities in health and health care. Although VA's directive was not associated with increased receipt of alcohol-related care, that receipt of alcohol-related care among transgender patients is comparable to non-transgender patients is promising.

Examining Neighborhood Socioeconomic Status as a Mediator of Racial/Ethnic Disparities in Hypertension Control Across Two San Francisco Health Systems.

BACKGROUND: A contextual understanding of hypertension control can inform population health management strategies to mitigate cardiovascular disease events. This retrospective cohort study links neighborhood-level data with patients' health records to describe racial/ethnic differences in uncontrolled hypertension and determine if and to what extent these differences are mediated by neighborhood socioeconomic status (nSES). METHODS: We conducted a mediation analysis using a sample of patients with hypertension from 2 health care delivery systems in San Francisco over 2 years (n=47 031). We used generalized structural equation modeling, adjusted for age, sex, and health care system, to estimate the contribution of nSES to disparities in uncontrolled hypertension between White patients and Black, Hispanic/Latino, and Asian patients, respectively. Sensitivity analysis removed adjustment for health care system. RESULTS: Over half the cohort (62%) experienced uncontrolled hypertension during the study period. Racial/ethnic groups showed substantial differences in prevalence of uncontrolled hypertension and distribution of nSES quintiles. Compared with White patients, Black, and Hispanic/Latino patients had higher adjusted odds of uncontrolled hypertension: odds ratio, 1.79 [95% CI, 1.67-1.91] and odds ratio, 1.38 [95% CI, 1.29-1.47], respectively and nSES accounted for 7% of the disparity in both comparisons. Asian patients had slightly lower adjusted odds of uncontrolled hypertension when compared with White patients: odds ratio, 0.95 [95% CI, 0.89-0.99] and the mediating effect of nSES did not change the direction of the relationship. Sensitivity analysis increased the proportion mediated by nSES to 11% between Black and White patients and 13% between Hispanic/Latino and White patients, but did not influence differences between Asian and White patients. CONCLUSIONS: Among patients with hypertension in this study, nSES mediated a small proportion of racial/ethnic disparities in uncontrolled hypertension. Population health management strategies may be most effective by focusing on additional structural and interpersonal pathways such as racism and discrimination in health care settings.

Exploring the Dynamics of Week-to-Week Blood Pressure in Nursing Home Residents Before Death.

BACKGROUND: Aging is accompanied by an overall dysregulation of many dynamic physiologic processes including those related to blood pressure (BP). While year-to-year BP variability is associated with cardiovascular events and mortality, no studies have examined this trend with more frequent BP assessments. Our study objective is to take the next step to examine week-to-week BP dynamics-pattern, variability, and complexity-before death. METHODS: Using a retrospective study design, we assessed BP dynamics in the 6 months before death in long-term nursing home residents between 1 October 2006 and 30 September 2017. Variability was characterized using SD and mean squared error after adjusting for diurnal variations. Complexity (i.e., amount of novel information in a trend) was examined using Shannon's entropy (bits). Generalized linear models were used to examine factors associated with overall BP variability. RESULTS: We identified 17,953 nursing home residents (98.0% male, 82.5% White, mean age 80.2 years, and mean BP 125.7/68.6 mm Hg). Despite a slight trend of decreasing systolic week-to-week BP over time (delta = 7.2 mm Hg), week-to-week complexity did not change in the 6 months before death (delta = 0.02 bits). Average weekly BP variability was stable until the last 3-4 weeks of life, at which point variability increased by 30% for both systolic and diastolic BP. Factors associated with BP variability include average weekly systolic/diastolic BP, days in the nursing home, days in the hospital, and changes to antihypertensive medications. CONCLUSIONS: Week-to-week BP variability increases substantially in the last month of life, but complexity does not change. Changes in care patterns may drive the increase in BP variability as one approaches death.

The incidence of and risk factors for hospitalized acute kidney injury among people living with HIV on antiretroviral treatment.

OBJECTIVES: The epidemiology of hospitalized acute kidney injury (AKI) among people living with HIV (PLWH) in the era of modern antiretroviral therapy (ART) for all PLWH is not well characterized. We evaluated the incidence of and risk factors for hospitalized AKI from 2005 to 2015 among PLWH on ART. METHODS: We conducted a retrospective analysis of PLWH from the Johns Hopkins HIV Clinical Cohort. We defined hospitalized AKI as a rise of ≥ 0.3 mg/dL in serum creatinine (SCr) within any 48-h period or a 50% increase in SCr from baseline and assessed associations of risk factors with incident AKI using multivariate Cox regression models. RESULTS: Most participants (75%) were black, 34% were female, and the mean age was 43 years. The incidence of AKI fluctuated annually, peaking at 40 per 1000 person-years (PY) [95% confidence interval (CI) 22-69 per 1000 PY] in 2007, and reached a nadir of 20 per 1000 PY (95% CI 11-34 per 1000 PY) in 2010. There was no significant temporal trend (-3.3% change per year; 95% CI -8.6 to 2.3%; P = 0.24). After multivariable adjustment, characteristics independently associated with AKI included black race [hazard ratio (HR) 2.44; 95% CI 1.42-4.20], hypertension (HR 1.62; 95% CI 1.09-2.38), dipstick proteinuria > 1 (HR 1.86; 95% CI 1.07-3.23), a history of AIDS (HR 1.82; 95% CI 1.29-2.56), CD4 count < 200 cells/µL (HR 1.46; 95% CI 1.02-2.07), and lower serum albumin (HR 1.73 per 1 g/dL decrease; 95% CI 1.02-2.07). CONCLUSIONS: In this contemporary cohort of PLWH, the annual incidence of first AKI fluctuated during the study period. Attention to modifiable AKI risk factors and social determinants of health may further reduce AKI incidence among PLWH.

Associations Among Military Sexual Trauma, Opioid Use Disorder, and Gender.

INTRODUCTION: Opioid use disorder and high-risk opioid prescription increase the risks for overdose and death. In Veterans, military sexual trauma is associated with increased risk for assorted health conditions. This study evaluates the association of military sexual trauma with opioid use disorder and high-risk opioid prescription and potential moderation by gender. METHODS: In a national sample of Veterans Health Administration outpatients receiving care from October 1, 2009 to August 1, 2017, logistic regression models were fit to evaluate the associations between military sexual trauma and opioid use disorder and high-risk opioid prescription, adjusting for demographic and clinical covariates. A second set of models included a gender X military sexual trauma interaction. Analyses were conducted in 2020-2021. RESULTS: Patients with history of military sexual trauma (n=327,193) had 50% higher odds of opioid use disorder diagnosis (AOR=1.50, 95% CI=1.45, 1.54, p<0.001) and 5% higher odds of high-risk opioid prescription (AOR=1.05, 95% CI=1.04, 1.07, p<0.001) than those without history of military sexual trauma (n=7,738,665). The effect of military sexual trauma on opioid use disorder was stronger in men than in women . The predicted probability of opioid use disorder among men with history of military sexual trauma (1.5%) was nearly double that of women with history of military sexual trauma (0.8%). CONCLUSIONS: Military sexual trauma was a significant risk factor for opioid use disorder and high-risk opioid prescription, with the former association particularly strong in men. Clinical care for Veterans with military sexual trauma should consider elevated risk of opioid use disorder and high-risk opioid prescription.

Google Street View-Derived Neighborhood Characteristics in California Associated with Coronary Heart Disease, Hypertension, Diabetes.

Characteristics of the neighborhood built environment influence health and health behavior. Google Street View (GSV) images may facilitate measures of the neighborhood environment that are meaningful, practical, and adaptable to any geographic boundary. We used GSV images and computer vision to characterize neighborhood environments (green streets, visible utility wires, and dilapidated buildings) and examined cross-sectional associations with chronic health outcomes among patients from the University of California, San Francisco Health system with outpatient visits from 2015 to 2017. Logistic regression models were adjusted for patient age, sex, marital status, race/ethnicity, insurance status, English as preferred language, assignment of a primary care provider, and neighborhood socioeconomic status of the census tract in which the patient resided. Among 214,163 patients residing in California, those living in communities in the highest tertile of green streets had 16-29% lower prevalence of coronary artery disease, hypertension, and diabetes compared to those living in communities in the lowest tertile. Conversely, a higher presence of visible utility wires overhead was associated with 10-26% more coronary artery disease and hypertension, and a higher presence of dilapidated buildings was associated with 12-20% greater prevalence of coronary artery disease, hypertension, and diabetes. GSV images and computer vision models can be used to understand contextual factors influencing patient health outcomes and inform structural and place-based interventions to promote population health.

Deprescribing Blood Pressure Treatment in Long-Term Care Residents.

OBJECTIVES: To evaluate the incidence of deprescribing of antihypertensive medication among older adults residing in Veterans Affairs (VA) nursing homes for long-term care and rates of deprescribing after potentially triggering events. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Long-term care residents aged 65 years and older admitted to a VA nursing home from 2006 to 2019 and using blood pressure medication at admission. METHODS: Data were extracted from the VA electronic health record, and Centers for Medicare & Medicaid Services Minimum Data Set and Bar Code Medication Administration. Deprescribing was defined on a rolling basis as a reduction in the number or dose of antihypertensive medications, sustained for ≥2 weeks. We examined potentially triggering events for deprescribing, including low blood pressure (<90/60 mmHg), acute renal impairment (creatinine increase of 50%), electrolyte imbalance (potassium below 3.5 mEq/L, sodium decrease by 5 mEq/L), and falls. RESULTS: Among 31,499 VA nursing home residents on antihypertensive medication, 70.4% had ≥1 deprescribing event (median length of stay = 6 months), and 48.7% had a net reduction in antihypertensive medications over their stay. Deprescribing events were most common in the first 4 weeks after admission and the last 4 weeks of life. Among potentially triggering events, a 50% increase in serum creatinine was associated with the greatest increase in the likelihood of deprescribing over the subsequent 4 weeks: residents with this event had a 41.7% chance of being deprescribed compared with 11.5% in those who did not (risk difference = 30.3%, P < .001). A fall in the past 30 days was associated with the smallest magnitude increased risk of deprescribing (risk difference = 3.8%, P < .001) of the events considered. CONCLUSIONS AND IMPLICATIONS: Deprescribing of antihypertensive medications is common among VA nursing home residents, especially after a potential renal adverse event.

Receipt of evidence-based alcohol-related care in a national sample of transgender patients with unhealthy alcohol use: Overall and relative to non-transgender patients.

BACKGROUND/OBJECTIVE: Evidence-based alcohol-related care-brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)-should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use. METHODS: We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥ 5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0-14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0-365 days following screening), and filled prescriptions for medications to treat AUD (documented 0-365 days following screening) for transgender patients, and compared to that of non-transgender patients. RESULTS: Among transgender Veterans with unhealthy alcohol use (N = 1392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2-78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7-17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1-20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98-1.04, p = 0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12-1.37, p < 0.001) and pharmacotherapy (PR 1.16, 95% CI 1.06-1.28, p = 0.002). CONCLUSIONS: Findings suggest the majority of transgender VHA patients with unhealthy alcohol use receive brief intervention, though a quarter still do not. Nonetheless, rates of specialty addictions treatment and pharmacotherapy are low overall, although transgender patients may be receiving this care at greater rates than non-transgender patients. Further research is needed to investigate these findings and to increase receipt of evidence-based care overall.

Patterns of Alcohol Use Among Transgender Patients Receiving Care at the Veterans Health Administration: Overall and Relative to Nontransgender Patients.

OBJECTIVE: Alcohol use is understudied among transgender persons--persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients. METHOD: National VA electronic health record data were used to identify all patients' last documented Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screen (October 1, 2009-July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined. RESULTS: Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization. CONCLUSIONS: This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.

Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence?

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p < 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.

RESUMEN: El consumo de alcohol aumenta el no-cumplimiento a la terapia antirretroviral (TARV) entre las personas que viven con VIH. No se han estudiado lo suficiente las dinámicas asociaciones longitudinales. Los datos del Estudio de la Envejecimiento de Cohorte de Veteranos (EECV) (1/2/2008­31/7/2016) fueron usados para encajar modelos de regresión lineal estimando los cambios en cumplimiento (% de días con medicaciones TARV surtidas) asociados con los cambios en el consumo de alcohol basado en los resultados anuales de las evaluaciones AUDIT-C, determinadas clínicamente, (una gama de -12 a + 12, 0 = cero cambio) adaptándose a las estadísticas demográficas y cumplimiento inicial. Entre 21,275 personas que viven con VIH (67,330 observaciones), la mayoría reportó ningún (48%) o bajos niveles del (39%) consumo de alcohol inicialmente, con ningún (55%) o muy pequeño (39% ≤ 3 puntos) cambio anual. la media inicial de cumplimiento fue 86% (DE 21%). La media de cambio anual fue -3.1% (DE 21%). Se observó una asociación de forma V invertida: tanto los aumentos como las disminuciones en AUDIT-C fueron asociados con mayor disminuciones de cumplimiento en comparación con resultados estables (p < 0.001, F (4, 21,274)). Personas que viven con VIH con el consumo dinámico de alcohol (potencialmente indicativo de un trastorno por consumo de alcohol) deben ser considerados por intervenciones de cumplimiento.

Disparities in Documented Drug Use Disorders Between Transgender and Cisgender U.S. Veterans Health Administration Patients.

OBJECTIVES: Transgender people-those whose gender identity differs from their sex assigned at birth-are at risk for health disparities resulting from stressors such as discrimination and violence. Transgender people report more drug use than cisgender people; however, it is unclear whether they have higher likelihood of drug use disorders. We examined whether transgender patients have increased likelihood of documented drug use disorders relative to cisgender patients in the national Veterans Health Administration (VA). METHODS: Electronic health record data were extracted for VA outpatients from 10/1/09 to 7/31/17. Transgender status and past-year documentation of drug use disorders (any, opioid, amphetamine, cocaine, cannabis, sedative, hallucinogen) were measured using diagnostic codes. Logistic regression models estimated odds ratios for drug use disorders among transgender compared to cisgender patients, adjusted for age, race/ethnicity and year. Effect modification by presence of ≥1 mental health condition was tested using multiplicative interaction. RESULTS: Among 8,872,793 patients, 8619 (0.1%) were transgender. Transgender patients were more likely than cisgender patients to have any drug use disorder (Adjusted Odds Ratio [aOR] 1.67, 95% confidence interval [CI] 1.53-1.83), amphetamine (aOR 2.22, 95% CI 1.82-2.70), cocaine (aOR 1.59, 95% CI 1.29-1.95), and cannabis (aOR 1.82, 95% CI 1.62-2.05) use disorders. There was no significant interaction by presence of ≥1 mental health condition. CONCLUSIONS: Transgender VA patients may have higher likelihood of certain drug use disorders than cisgender VA patients, particularly amphetamine use disorder. Future research should explore mechanisms underlying disparities and potential barriers to accessing treatment and harm reduction services faced by transgender people.

Evaluation of Neighborhood Socioeconomic Characteristics and Advance Care Planning Among Older Adults.

Importance: Advance care planning (ACP) is low among older adults with socioeconomic disadvantage. There is a need for tailored community-based approaches to increase ACP, but community patterns of ACP are poorly understood. Objective: To examine the association between neighborhood socioeconomic status (nSES) and ACP and to identify communities with both low nSES and low rates of ACP. Design, Setting, and Participants: This cross-sectional study examined University of California San Francisco electronic health record (EHR) data and place-based data from 9 San Francisco Bay Area counties. Participants were primary care patients aged 65 years or older and living in the San Francisco Bay Area in July 2017. Statistical analysis was performed from May to June 2020. Exposures: Patients' home addresses were geocoded and assigned to US Census tracts. The primary factor, nSES, an index combining area-level measures of income, education, poverty, employment, occupation, and housing or rent values, was divided into quintiles scaled to the distribution of all US Census tracts in the Bay Area (Q1 = lowest nSES). Covariates were from the EHR and included health care use (primary care, outpatient specialty, emergency department, and inpatient encounters in the prior year). Main Outcomes and Measures: ACP was defined as a scanned document (eg, advance directive), ACP Current Procedural Terminology code, or ACP note type in the EHR. Results: There were 13 104 patients included in the cohort-mean (SD) age was 75 (8) years, with 7622 female patients (58.2%), 897 patients (6.8%) identified as Black, 913 (7.0%) as Latinx, 3788 (28.9%) as Asian/Pacific Islander, and 748 (5.7%) as other minority race/ethnicity, and 2393 (18.3%) self-reported that they preferred to speak a non-English language. Of these, 3827 patients (29.2%) had documented ACP. The cohort was distributed across all 5 quintiles of nSES (Q1: 1426 patients [10.9%]; Q2: 1792 patients [13.7%]; Q3: 2408 patients [18.4%]; Q4: 3330 patients [25.4%]; Q5: 4148 patients [31.7%]). Compared with Q5 and after adjusting for health care use, all lower nSES quintiles showed a lower odds of ACP in a graded fashion (Q1: adjusted odds ratio [aOR] = 0.71 [95% CI, 0.61-0.84], Q2: aOR = 0.74 [95% CI, 0.64-0.86], Q3: aOR = 0.81 [95% CI, 0.71-0.93], Q4: aOR = 0.82 [95% CI, 0.72-0.93]. A bivariable map of ACP by nSES allowed identification of 5 neighborhoods with both low nSES and ACP. Conclusions and Relevance: In this study, lower nSES was associated with lower ACP documentation after adjusting for health care use. Using EHR and place-based data, communities of older adults with both low nSES and low ACP were identified. This is a first step in partnering with communities to develop targeted, community-based interventions to meaningfully increase ACP.