From Screening to the Receipt of Services: A Qualitative Examination.

INTRODUCTION: Research has focused on developing methods to facilitate screening and tracking data on social risk factors in healthcare settings. Less is known about the multiple factors that shape patients' acceptance of healthcare-based social risk programs. This qualitative study sought to elucidate the multilevel (individual, interpersonal, family/community, system, policy) factors that influence patients' acceptance of a healthcare-based social risk program within a Federally Qualified Health Center in New York City. METHODS: Participants included 5 patients receiving care at the Federally Qualified Health Center who screened positive for social risks, 4 nurses who are responsible for conducting social risk screenings, and 5 Family Support Services counselors who conduct outreach to patients who screened positive. Interviews were conducted from March to June 2021 and analyzed from July to September 2021 using the constant comparative method. RESULTS: Analyses of the transcripts identified the following 3 themes: (1) Patients appreciated being asked about social risk factors, but there was a mismatch between their understanding of the screening process, their desire for assistance, and the support received. Although nurses and counselors described relationship-centered approaches to involve patients in the process, patients reported feeling initial discomfort and confusion; (2) Multilevel barriers inhibit patients' acceptance of assistance; and (3) Patient trust in the physician and healthcare organization serves as facilitators to acceptance. CONCLUSIONS: Patients' views about the purpose of a healthcare-based social risk program differed from nurses' and counselors' perspectives of the process. Although patients face multilevel challenges, strong trust in the physician and Family Health Centers served as facilitators to accepting healthcare-based assistance.

The National Heart Lung and Blood Institute Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Alliance.

OBJECTIVE: To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) Alliance to support late-stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease. STUDY SETTING: NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high-risk diverse populations including racial and ethnic minorities, urban, rural, and low-income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma. STUDY DESIGN: The initial phase supports planning activities for sustainable uptake of evidence-based interventions in targeted communities. The second phase tests late-stage evidence-based implementation strategies. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross-center partnership and collaboration. CONCLUSIONS: The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.

Racialized economic segregation and health outcomes: A systematic review of studies that use the Index of Concentration at the Extremes for race, income, and their interaction.

Extensive research shows that residential segregation has severe health consequences for racial and ethnic minorities. Most research to date has operationalized segregation in terms of either poverty or race/ethnicity rather than a synergy of these factors. A novel version of the Index of Concentration at the Extremes (ICERace-Income) specifically assesses racialized economic segregation in terms of spatial concentrations of racial and economic privilege (e.g., wealthy white people) versus disadvantage (e.g., poor Black people) within a given area. This multidimensional measure advances a more comprehensive understanding of residential segregation and its consequences for racial and ethnic minorities. The aim of this paper is to critically review the evidence on the association between ICERace-Income and health outcomes. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to conduct a rigorous search of academic databases for papers linking ICERace-Income with health. Twenty articles were included in the review. Studies focused on the association of ICERace-Income with adverse birth outcomes, cancer, premature and all-cause mortality, and communicable diseases. Most of the evidence indicates a strong association between ICERace-Income and each health outcome, underscoring income as a key mechanism by which segregation produces health inequality along racial and ethnic lines. Two of the reviewed studies examined racial disparities in comorbidities and health care access as potential explanatory factors underlying this relationship. We discuss our findings in the context of the extant literature on segregation and health and propose new directions for future research and applications of the ICERace-Income measure.

Adaptation and Evaluation of a Symptom-Monitoring Digital Health Intervention for Patients With Relapsed and Refractory Multiple Myeloma: Pilot Mixed-Methods Implementation Study.

BACKGROUND: Relapsed and refractory multiple myeloma (RRMM) is a bone marrow cancer that requires systemic treatment, which often results in severe symptom burden. Recent studies have found that electronic patient-reported outcome (ePRO) interventions implemented in the clinic setting have had positive outcomes for other oncology populations. Evidence of the efficacy of a similar approach is lacking for patients with RRMM. OBJECTIVE: Recent recommendations for digital health interventions call for the publication of descriptions of iterative development processes in order to improve reproducibility and comparability. This study is an implementation pilot aiming to evaluate the acceptability and appropriateness of an ePRO intervention for patients with RRMM and to explore its impact on clinic workflow. METHODS: A total of 11 patients with RRMM were recruited from the John Theurer Cancer Center in Hackensack, New Jersey. Patients used a mobile app to report on 17 symptoms at 4 sessions, each a week apart. Patients could also report symptoms ad hoc. When reports met predefined thresholds, the clinic was alerted and patients received automated guidance. Study end points were assessed using qualitative and quantitative methods. RESULTS: A total of 9 patients (mean age 69.7 years) completed the study. Overall, 83% (30/36) of weekly sessions were completed. Patients found the frequency and time required to complete reporting acceptable. All patients agreed that the app was easy to use and understand. Providers felt the alerts they received required refinement. Patients and providers agreed it would be beneficial for patients to report for longer than 4 weeks. Patients felt that the training they received was adequate but contained too much information for a single session. All patients found the symptoms tracked to be appropriate; providers suggested shortening the list. All patients understood how to use the app for weekly reporting but had confusion about using it ad hoc. Providers felt the ad hoc feature could be removed. Neither patients nor providers viewed the in-app data reports but agreed on their potential value. Patients reported benefitting from symptom reporting through increased awareness of their symptoms. Clinic staff reported that app alerts were too numerous and redundant. They had difficulty responding to alerts within their existing workflow, partially because the data were not integrated into the electronic medical record system. CONCLUSIONS: Overall, the intervention was found to be acceptable and appropriate for patients with RRMM. Points of friction integrating the intervention into the clinic workflow were identified. Clinic staff provided recommendations for addressing these issues. Once such modifications are implemented, ePRO data from patients with RRMM could be used to inform and improve clinical research and care. This study underlines the importance of an iterative approach to implementation that includes all stakeholders in order to ensure successful adoption.

Comprehensive examination of the multilevel adverse risk and protective factors for cardiovascular disease among hypertensive African Americans.

This paper describes the multilevel factors that contribute to hypertension disparities in 2052 hypertensive African Americans (mean age 52.9 ± 9.9 years; 66.3% female) who participated in a clinical trial. At the family level, participants reported average levels of life chaos and high social support. However, at the individual level, participants exhibited several adverse clinical and behavioral factors including poor blood pressure control (45% of population), obesity (61%), medication non-adherence (48%), smoking (32%), physical inactivity (45%), and poor diet (71%). While participants rated their provider as trustworthy, they reported high levels of discrimination in the health care system. Finally, community-level data indicate that participants reside in areas characterized by poor socio-economic and neighborhood conditions (eg, segregation). In the context of our trial, hypertensive African Americans exhibited several adverse risks and protective factors at multiple levels of influence. Future research should evaluate the impact of these factors on cardiovascular outcomes using a longitudinal design.

Combining Text Messaging and Telephone Counseling to Increase Varenicline Adherence and Smoking Abstinence Among Cigarette Smokers Living with HIV: A Randomized Controlled Study.

Smoking represents an important health risk for people living with HIV (PLHIV). Low adherence to smoking cessation pharmacotherapy may limit treatment effectiveness. In this study, 158 participants recruited from three HIV care centers in New York City were randomized to receive 12-weeks of varenicline (Chantix) either alone as standard care (SC) or in combination with text message (TM) support or TM plus cell phone-delivered adherence-focused motivational and behavioral therapy (ABT). Generalized linear mixed-effect models found a significant decline in varenicline adherence from week 1-12 across treatment groups. At 12-weeks, the probability of smoking abstinence was significantly higher in SC+TM+ABT than in SC. The study demonstrates the feasibility of delivering adherence-focused interventions to PLHIV who smoke. Findings suggest intensive behavioral support is an important component of an effective smoking cessation intervention for this population, and a focus on improving adherence self-efficacy may lead to more consistent adherence and higher smoking abstinence.

Rates and Predictors of Uncontrolled Hypertension Among Hypertensive Homeless Adults Using New York City Shelter-Based Clinics.

PURPOSE: We undertook a study to determine the rates, predictors, and barriers to blood pressure control among homeless and nonhomeless hypertensive adult patients from 10 New York City shelter-based clinics. METHODS: The study was a retrospective chart review of blood pressure measurements, sociodemographic characteristics, and factors associated with homelessness and hypertension extracted from the medical records of a random sample of hypertensive patients (N = 210) in 2014. RESULTS: Most patients were African American or Hispanic; 24.8% were female, and 84.3% were homeless for a mean duration of 3.07 years (SD = 5.04 years). Homeless adult patients were younger, had less insurance, and were more likely to be a current smoker and alcohol abuser. Of the 210 hypertensive patients, 40.1% of homeless and 33.3% of nonhomeless patients had uncontrolled blood pressure (P = .29) when compared with US rates for hypertensive adults, which range between 19.6% and 24.8%, respectively; 15.8% of homeless patients had stage 2 hypertension (P = .27). Homeless hypertensive patients with diabetes or multiple chronic diseases had better blood pressure control (P <.01). In logistic regression, lack of insurance was associated with inadequate blood pressure control (P <.05). CONCLUSIONS: The high rate of uncontrolled hypertension among hypertensive homeless adults is alarming. We propose comprehensive approaches to improve social support, access to medical insurance, and medication adherence, the lack of which complicate blood pressure control, targeted health education, and life style modifications using mobile health strategies for this mobile population.

The FAITH Trial: Baseline Characteristics of a Church-based Trial to Improve Blood Pressure Control in Blacks.

OBJECTIVE: To describe the baseline characteristics of participants in the Faith-based Approaches in the Treatment of Hypertension (FAITH) Trial. DESIGN: FAITH evaluates the effectiveness of a faith-based lifestyle intervention vs health education control on blood pressure (BP) reduction among hypertensive Black adults. SETTING PARTICIPANTS AND MAIN MEASURES: Participants included 373 members of 32 Black churches in New York City. Baseline data collected included participant demographic characteristics, clinical measures (eg, blood pressure), behaviors (eg, diet, physical activity), and psychosocial factors (eg, self-efficacy, depressive symptoms). RESULTS: Participants had a mean age of 63.4 ± 11.9 years and 76% were female. About half completed at least some college (53%), 66% had an income ≥$20,000, and 42.2% were retired or on disability. Participants had a mean systolic and diastolic BP of 152.1 ± 16.8 mm Hg and 86.2 ± 12.2 mm Hg, respectively, and a mean BMI of 32 kg/m2. Hypertension (HTN) medications were taken by 95% of participants, but most (79.1%) reported non-adherence to their regimen. Participants reported consuming 3.4 ± 2.6 servings of fruits and vegetables and received 30.9% of their energy from fat. About one-third (35.9%) reported a low activity level. CONCLUSIONS: Participants in the FAITH trial exhibited several adverse clinical and behavioral characteristics at baseline. Future analyses will evaluate the effectiveness of the faith-based lifestyle intervention on changes in BP and lifestyle behaviors among hypertensive Black adults.

Rationale and design of the Investigation of Motivational Interviewing and Prevention Consults to Achieve Cardiovascular Targets (IMPACT) trial.

BACKGROUND: Patients undergoing cardiovascular procedures remain at increased risk for myocardial infarction, stroke, and cardiovascular death. Risk factor control in this patient population remains suboptimal and would likely benefit from strategies targeting education, lifestyle, and healthy behaviors. DESIGN: The IMPACT trial is a 400-subject prospective randomized trial designed to compare different cardiovascular prevention strategies in subjects following a cardiovascular intervention. The trial began enrollment in the Spring of 2012 and is randomizing subjects in a 1:1:1 manner to usual care, a one-time cardiovascular prevention consult, or a one-time cardiovascular prevention consult plus behavioral intervention program (telephone-based motivational interviewing and tailored text messages) over a 6-month period. The primary end point is non-high-density lipoprotein cholesterol. Secondary end points include other plasma lipid values, metabolic risk, smoking cessation, physical activity, dietary intake, medication use and adherence, and quality of life. CONCLUSIONS: The IMPACT trial provides data on different management strategies for risk factor optimization in subjects following cardiovascular procedures. The results will provide a platform for the continued development of novel multidisciplinary interventions in this high-risk population.

Correlates of Adherence to Varenicline Among HIV+ Smokers.

INTRODUCTION: Low rates of adherence to smoking cessation pharmacotherapy may limit the effectiveness of treatment. However, few studies have examined adherence in smoking cessation trials thus, there is a limited understanding of factors that influence adherence behaviors. This brief report analyzes correlates of adherence to varenicline among people living with HIV/AIDS. METHODS: Study participants were recruited from three HIV care centers in New York City and enrolled in a three-arm randomized controlled pilot study in which all subjects received varenicline. At the 1-month study visit, there were no significant differences in adherence by study condition, therefore we combined treatment arms to examine correlates of adherence (n = 127). We used pill counts to assess varenicline adherence, defined as taking at least 80% of the prescribed dose. We conducted a multivariate path analysis to assess factors proposed by the information-motivation-behavioral skills model to predict adherence. RESULTS: Only 56% of smokers were at least 80% adherent to varenicline at 1 month. Adherence-related information, self-efficacy, a college degree, and non-Hispanic white race/ethnicity were associated with increased varenicline adherence. In path analysis, information and motivation were associated with increased adherence self-efficacy, and adherence self-efficacy was associated with increased adherence, but with marginal significance. These associations with adherence were no longer significant after controlling for race/ethnicity and education. CONCLUSIONS: Further exploration of the role of a modifiable correlates of adherence, such as adherence-related information, motivation and self-efficacy is warranted. Interventions are needed that can address disparities in these and other psychosocial factors that may mediate poor medication adherence.

Panel Management to Improve Smoking and Hypertension Outcomes by VA Primary Care Teams: A Cluster-Randomized Controlled Trial.

BACKGROUND: Panel Management can expand prevention and chronic illness management beyond the office visit, but there is limited evidence for its effectiveness or guidance on how best to incorporate it into practice. OBJECTIVE: We aimed to test the effectiveness of incorporating panel management into clinical practice by incorporating Panel Management Assistants (PMAs) into primary care teams with and without panel management education. DESIGN: We conducted an 8-month cluster-randomized controlled trial of panel management for improving hypertension and smoking cessation outcomes among veterans. PATRICIPANTS: Twenty primary care teams from the Veterans Affairs New York Harbor were randomized to control, panel management support, or panel management support plus education groups. Teams included 69 clinical staff serving 8,153 hypertensive and/or smoking veterans. INTERVENTIONS: Teams assigned to the intervention groups worked with non-clinical Panel Management Assistants (PMAs) who monitored care gaps and conducted proactive patient outreach, including referrals, mail reminders and motivational interviewing by telephone. MAIN MEASURES: Measurements included mean systolic and diastolic blood pressure, proportion of patients with controlled blood pressure, self-reported quit attempts, nicotine replacement therapy (NRT) prescriptions, and referrals to disease management services. KEY RESULTS: Change in mean blood pressure, blood pressure control, and smoking quit rates were similar across study groups. Patients on intervention teams were more likely to receive NRT (OR = 1.4; 95% CI 1.2-1.6) and enroll in the disease management services MOVE! (OR = 1.2; 95% CI 1.1-1.6) and Telehealth (OR = 1.7, 95% CI 1.4-2.1) than patients on control teams. CONCLUSIONS: Panel Management support for primary care teams improved process, but not outcome variables among veterans with hypertension and smoking. Incorporating PMAs into teams was feasible and highly valued by the clinical staff, but clinical impact may require a longer intervention.

Community-based settings and sampling strategies: implications for reducing racial health disparities among black men, New York City, 2010-2013.

INTRODUCTION: Rates of screening colonoscopies, an effective method of preventing colorectal cancer, have increased in New York City over the past decade, and racial disparities in screening have declined. However, vulnerable subsets of the population may not be reached by traditional surveillance and intervention efforts to improve colorectal cancer screening rates. METHODS: We compared rates of screening colonoscopies among black men aged 50 or older from a citywide random-digit-dial sample and a location-based sample focused on hard-to-reach populations to evaluate the representativeness of the random-digit-dial sample. The location-based sample (N = 5,568) was recruited from 2010 through 2013 from community-based organizations in New York City. Descriptive statistics were used to compare these data with data for all black men aged 50 or older from the 2011 cohort of the Community Health Survey (weighted, N = 334) and to compare rates by community-based setting. RESULTS: Significant differences in screening colonoscopy history were observed between the location-based and random-digit-dial samples (49.1% vs 62.8%, P < .001). We observed significant differences between participants with and without a working telephone among the location-based sample and between community-based settings. CONCLUSIONS: Vulnerable subsets of the population such as those with inconsistent telephone access are excluded from random-digit-dial samples. Practitioners and researchers should consider the target population of proposed interventions to address disparities, and whether the type of setting reaches those most in need of services.

Rationale and design of Faith-based Approaches in the Treatment of Hypertension (FAITH), a lifestyle intervention targeting blood pressure control among black church members.

BACKGROUND: Uncontrolled hypertension (HTN) is a significant public health problem among blacks in the United States. Despite the proven efficacy of therapeutic lifestyle change (TLC) on blood pressure (BP) reduction in clinical trials, few studies have examined their effectiveness in church-based settings-an influential institution for health promotion in black communities. METHODS: Using a cluster-randomized, 2-arm trial design, this study evaluates the effectiveness of a faith-based TLC intervention vs health education (HE) control on BP reduction among hypertensive black adults. The intervention is delivered by trained lay health advisors through group TLC sessions plus motivational interviewing in 32 black churches. Participants in the intervention group receive 11 weekly TLC sessions targeting weight loss, increasing physical activity, fruit, vegetable and low-fat dairy intake, and decreasing fat and sodium intake, plus 3 monthly individual motivational interviewing sessions. Participants in the control group attend 11 weekly classes on HTN and other health topics delivered by health care experts. The primary outcome is change in BP from baseline to 6 months. Secondary outcomes include level of physical activity, percent change in weight, and fruit and vegetable consumption at 6 months, and BP control at 9 months. CONCLUSION: If successful, this trial will provide an alternative and culturally appropriate model for HTN control through evidence-based lifestyle modification delivered in churches by lay health advisors.

Perceived racial discrimination and adoption of health behaviors in hypertensive Black Americans: the CAATCH trial.

BACKGROUND: Few studies examine psychosocial factors influencing the adoption of healthy behaviors among hypertensive patients. The effect of discrimination on health behaviors remains untested. PURPOSE: To examine the influence of discrimination on adoption of healthy behaviors among low-income Black hypertensive patients. METHODS: Black patients (N = 930) in community-based primary care practices enrolled in the CAATCH trial. Mixed effects regressions examined associations between perceived discrimination and change in medication adherence, diet, and physical activity from baseline to 12 months, controlling for intervention, gender, age, income, and education. RESULTS: Patients were low-income, high-school-educated, with a mean age of 57 years. Greater discrimination was associated with worse diet and lower medication adherence at baseline. Discrimination was associated with greater improvement in healthy eating behaviors over the course of the 12-month trial. CONCLUSIONS: Prior exposure to discrimination was associated with unhealthy behaviors at baseline, but did not negatively influence the adoption of health behaviors over time.

Developing a toolkit for panel management: improving hypertension and smoking cessation outcomes in primary care at the VA.

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