Use of a Single-Item Ecological Momentary Assessment to Measure Daily Exercise: Agreement with Accelerometer-Measured Exercise.

Accelerometers have been used to objectively quantify physical activity, but they can pose a high burden. This study was conducted to determine the feasibility of using a single-item smartphone-based ecological momentary assessment (EMA) in lieu of accelerometers in long-term assessment of daily exercise. Data were collected from a randomized controlled trial of intermittently exercising, otherwise healthy adults (N = 79; 57% female, mean age: 31.9 ± 9.5 years) over 365 days. Smartphone-based EMA self-reports of exercise entailed daily end-of-day responses about physical activity; the participants also wore a Fitbit device to measure physical activity. The Kappa statistic was used to quantify the agreement between accelerometer-determined (24 min of moderate-to-vigorous physical activity [MVPA] within 30 min) and self-reported exercise. Possible demographic predictors of agreement were assessed. Participants provided an average of 164 ± 87 days of complete data. The average within-person Kappa was κ = 0.30 ± 0.22 (range: -0.15-0.73). Mean Kappa ranged from 0.16 to 0.30 when the accelerometer-based definition of an exercise bout varied in duration from 15 to 30 min of MVPA within any 30 min period. Among the correlates examined, sex was significantly associated with agreement; mean agreement was higher among women (κ = 0.37) than men (κ = 0.20). Agreement between EMA self-reported and accelerometer-measured exercise was fair, suggesting that long-term exercise monitoring through a single-item EMA may be acceptable.

Maternal Mortality: A National Institutes of Health Pathways to Prevention Panel Report.

The National Institutes of Health's (NIH) Pathways to Prevention panel on postpartum health provides a consensus statement on the evidence, research gaps, and future priorities to prevent maternal morbidity and mortality. The panel reviewed an NIH-commissioned evidence review and workshop that included epidemiologic studies, demonstration interventions, and other maternal morbidity and mortality research to create these national recommendations. The panel concludes that a maternal morbidity and mortality crisis reflects a systemic failure of current U.S. health care, research efforts, and social policies. The panel recommends improving maternal health through a "maternal morbidity and mortality prevention moonshot" that adopts a comprehensive, multilevel life course conceptual framework; strengthens the research methods used within the science of maternal health; establishes and conducts national prevention, treatment, and policy interventions; and reimburses evidence-informed clinical approaches to improve maternal health across the life course. Without a national focus on fundamentally transformative interventions and other initiatives aimed at redressing structural racism and inequities in health care, current interventions and clinical advances in maternal morbidity and mortality prevention will remain tragically insufficient.

Putting Evidence Into Practice: An Update on the US Preventive Services Task Force Methods for Developing Recommendations for Preventive Services.

PURPOSE: The US Preventive Services Task Force (USPSTF) is an independent body that makes evidence-based recommendations regarding preventive services to improve health for people nationwide. Here, we summarize current USPSTF methods, describe how methods are evolving to address preventive health equity, and define evidence gaps for future research. METHODS: We summarize current USPSTF methods as well as ongoing methods development. RESULTS: The USPSTF prioritizes topics on the basis of disease burden, extent of new evidence, and whether the service can be provided in primary care and going forward will increasingly consider health equity. Analytic frameworks specify the key questions and linkages connecting the preventive service to health outcomes. Contextual questions provide information on natural history, current practice, health outcomes in high-risk groups, and health equity. The USPSTF assigns a level of certainty to the estimate of net benefit of a preventive service (high, moderate, or low). The magnitude of net benefit is also judged (substantial, moderate, small, or zero/negative). The USPSTF uses these assessments to assign a letter grade from A (recommend) to D (recommend against). I statements are issued when evidence is insufficient. CONCLUSIONS: The USPSTF will continue to evolve its methods for simulation modeling and to use evidence to address conditions for which there are limited data for population groups who bear a disproportionate burden of disease. Additional pilot work is underway to better understand the relations of the social constructs of race, ethnicity, and gender with health outcomes to inform the development of a USPSTF health equity framework.

Addressing Gaps in Research to Reduce Disparities and Advance Health Equity: The USPSTF Incorporation of the NASEM Taxonomy on Closing Evidence Gaps in Clinical Prevention.

This Viewpoint reviews the evidence gaps reported to Congress by the US Preventive Services Task Force (USPSTF) in 2021 on improving health inequities in prevention and uses the 3 taxonomies provided by National Academies of Sciences, Engineering, and Medicine (NASEM) to classify these gaps.

Association of race/ethnicity with mortality in patients hospitalized with COVID-19.

OBJECTIVE: To evaluate racial and ethnic differences in mortality among patients hospitalized with coronavirus disease 2019 (COVID-19) after adjusting for baseline characteristics and comorbidities. METHODS: This retrospective cohort study at 13 acute care facilities in the New York City metropolitan area included sequentially hospitalized patients between March 1, 2020, and April 27, 2020. Last day of follow up was July 31, 2020. Patient demographic information, including race/ethnicity and comorbidities, were collected. The primary outcome was in-hospital mortality. RESULTS: A total of 10 869 patients were included in the study (median age, 65 years [interquartile range (IQR) 54-77; range, 18-107 years]; 40.5% female). In adjusted time-to-event analysis, increased age, male sex, insurance type (Medicare and Self-Pay), unknown smoking status, and a higher score on the Charlson Comorbidity Index were significantly associated with higher in-hospital mortality. Adjusted risk of hospital mortality for Black, Asian, Hispanic, multiracial/other, and unknown race/ethnicity patients were similar to risk for White patients. CONCLUSIONS: In a large diverse cohort of patients hospitalized with COVID-19, patients from racial/ethnic minorities experienced similar mortality risk as White patients.

Social Determinants of Health, Race, and Diabetes Population Health Improvement: Black/African Americans as a Population Exemplar.

PURPOSE OF REVIEW: To summarize evidence of impact of social determinants of health (SDOH) on diabetes risk, morbidity, and mortality and to illustrate this impact in a population context. RECENT FINDINGS: Key findings from the American Diabetes Association's scientific review of five SDOH domains (socioeconomic status, neighborhood and physical environment, food environment, health care, social context) are highlighted. Population-based data on Black/African American adults illustrate persisting diabetes disparities and inequities in the SDOH conditions in which this population is born, grows, lives, and ages, with historical contributors. SDOH recommendations from US national committees largely address a health sector response, including health professional education, SDOH measurement, and patient referral to services for social needs. Fewer recommendations address solutions for systemic racism and socioeconomic discrimination as root causes. SDOH are systemic, population-based, cyclical, and intergenerational, requiring extension beyond health care solutions to multi-sector and multi-policy approaches to achieve future population health improvement.

Actions to Transform US Preventive Services Task Force Methods to Mitigate Systemic Racism in Clinical Preventive Services.

Importance: US life expectancy and health outcomes for preventable causes of disease have continued to lag in many populations that experience racism. Objective: To propose iterative changes to US Preventive Services Task Force (USPSTF) processes, methods, and recommendations and enact a commitment to eliminate health inequities for people affected by systemic racism. Design and Evidence: In February 2021, the USPSTF began operational steps in its work to create preventive care recommendations to address the harmful effects of racism. A commissioned methods report was conducted to inform this process. Key findings of the report informed proposed updates to the USPSTF methods to address populations adversely affected by systemic racism and proposed pilots on implementation of the proposed changes. Findings: The USPSTF proposes to consider the opportunity to reduce health inequities when selecting new preventive care topics and prioritizing current topics; seek evidence about the effects of systemic racism and health inequities in all research plans and public comments requested, and integrate available evidence into evidence reviews; and summarize the likely effects of systemic racism and health inequities on clinical preventive services in USPSTF recommendations. The USPSTF will elicit feedback from its partners and experts and proposed changes will be piloted on selected USPSTF topics. Conclusions and Relevance: The USPSTF has developed strategies intended to mitigate the influence of systemic racism in its recommendations. The USPSTF seeks to reduce health inequities and other effects of systemic racism through iterative changes in methods of developing evidence-based recommendations, with partner and public input in the activities to implement the advancements.

Incorporation of Social Risk in US Preventive Services Task Force Recommendations and Identification of Key Challenges for Primary Care.

IMPORTANCE: In its mission to improve health, the US Preventive Services Task Force (USPSTF) recognizes the strong relationship between a person's health and social and economic circumstances as well as persistent inequities in health care delivery. OBJECTIVE: To assess how social risks have been considered in USPSTF recommendation statements and identify current gaps in evidence needed to expand the systematic inclusion of social risks in future recommendations. EVIDENCE: The USPSTF commissioned a technical brief that reviewed existing literature on screening and interventions for social risk factors and also audited the 85 USPSTF recommendation statements active as of December 2019 to determine how social risks were addressed in clinical preventive services recommendations. FINDINGS: Among the 85 USPSTF recommendation statements reviewed, 14 were focused on preventive services that considered health-related social risks. Social risks were commonly referenced in parts of USPSTF recommendations, with 57 of 85 recommendations including some comment on social risks within the recommendation statement, although many comments were not separate prevention services. Social risks were commented on in USPSTF recommendations as part of risk assessment, as a marker of worse health outcomes from the condition of focus, as a consideration for clinicians when implementing the preventive service, and as a research need or gap on the topic. CONCLUSIONS AND RELEVANCE: This report identified how social risks have been considered in the USPSTF recommendation statements. It serves as a benchmark and foundation for ongoing work to advance the goal of ensuring that health equity and social risks are incorporated in USPSTF methods and recommendations.

Introducing the MAVEN Leadership Training Initiative to diversify the scientific workforce.

Addressing gender and racial-ethnic disparities at all career stages is a priority for the research community. In this article, we focus on efforts to encourage mid-career women, particularly women of color, to move into leadership positions in science and science policy. We highlight the need to strengthen leadership skills for the critical period immediately following promotion to associate/tenured professor - when formal career development efforts taper off while institutional demands escalate - and describe a program called MAVEN that has been designed to teach leadership skills to mid-career women scientists, particularly those from underrepresented groups.

Economic outcomes of depression screening after acute coronary syndromes: The CODIACS-QoL randomized clinical trial.

OBJECTIVE: To evaluate the cost-effectiveness of screening for depression in patients with acute coronary syndrome (ACS) and no history of depression. METHODS: Cost-effectiveness analysis of a randomized trial enrolling 1500 patients with ACS between 2013 and 2017. Patients were randomized to no screening, screening and notifying the primary care provider (PCP), and screening, notifying the PCP, and providing enhanced depression treatment. Outcomes measured were Healthcare utilization, costs, and incremental cost-effectiveness ratios. RESULTS: 7.1% of patients screened positive for depressive symptoms. There was no significant difference in usage of mental health services, cardiovascular tests and procedures, and medications. Mean total costs in No Screen group ($7440), in Screen, Notify, and Treat group ($6745), and in Screen and Notify group ($6204). The difference was only significant in the Screen and Notify group versus the No Screen group (-$1236, 95% confidence interval -$2388 to -$96). Because mean QALYs were higher (+0.003 QALY in Screen and Notify; +0.004 QALYs in Screen, Notify, and Treat) and mean total costs were lower in both intervention groups, these interventions were cost-effective. There was substantial uncertainty because confidence intervals around cost differences were wide and QALY effects were small. CONCLUSION: Depression screening strategies for patients with ACS may be modestly cost-effective.

The Association of Structural Inequities and Race With Out-of-Hospital Sudden Death During the COVID-19 Pandemic.

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Examination of patient characteristics and hydroxychloroquine use based on the US Food and Drug Administration's recommendation: a cross-sectional analysis in New York.

OBJECTIVE: To describe the pattern of hydroxychloroquine use and examine the association between hydroxychloroquine use and clinical outcomes arising from changes in the US Food and Drug Administration (FDA)'s recommendation during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A retrospective cross-sectional analysis. SETTING AND PARTICIPANTS: We included hospitalised adult patients at Northwell Health hospitals with confirmed COVID-19 infections between 1 March 2020 and 11 May 2020. We categorised changes in the FDA's recommendation as pre-FDA approval (1 March 2020-27 March 2020), FDA approval (28 March 2020-23 April 2020), and FDA warning (24 April 2020-11 May 2020). The hydroxychloroquine-treated group received at least one dose within 48 hours of hospital admission. PRIMARY OUTCOME: A composite of intubation and inpatient death. RESULTS: The percentages of patients who were treated with hydroxychloroquine were 192/2202 (8.7%) pre-FDA approval, 2902/6741 (43.0%) FDA approval, and 176/1066 (16.5%) FDA warning period (p<0.001). Using propensity score matching, there was a higher rate of the composite outcome among patients treated with hydroxychloroquine (49/192, 25.5%) compared with no hydroxychloroquine (66/384, 17.2%) in the pre-FDA approval period (p=0.03) but not in the FDA approval period (25.5% vs 22.6%, p=0.08) or the FDA warning (21.0% vs 15.1%, p=0.11) periods. Coincidently, there was an increase in number of patients with COVID-19 and disease severity during the FDA approval period (24.1% during FDA approval vs 21.4% during pre-FDA approval period had the composite outcome). Hydroxychloroquine use was associated with increased odds of the composite outcome during the pre-FDA approval period (OR=1.65 (95% CI 1.09 to 2.51)) but not during the FDA approval (OR=1.17 (95% CI 0.99 to 1.39)) and FDA warning (OR=1.50 (95% CI 0.94 to 2.39)) periods. CONCLUSIONS: Hydroxychloroquine use was associated with adverse clinical outcomes only during the pre-FDA approval period but not during the FDA approval and warning periods, even after adjusting for concurrent changes in the percentage of patients with COVID-19 treated with hydroxychloroquine and the number (and disease severity) of hospitalised patients with COVID-19 infections.

Developing Primary Care-Based Recommendations for Social Determinants of Health: Methods of the U.S. Preventive Services Task Force.

The purpose of the U.S. Preventive Services Task Force (USPSTF) is to provide evidence-based recommendations on primary care screening, behavioral counseling, and preventive medications. A person's health is strongly influenced by social determinants of health, such as economic and social conditions; therefore, preventive recommendations that address these determinants would be ideal. However, differing social determinants have been proposed by a wide range of agencies and organizations, little prevention evidence is available, and responsible parties are in competition, all of which make the creation of evidence-based prevention recommendations for social determinants of health challenging. This article highlights social determinants already included in USPSTF recommendations and proposes a process by which others may be considered for primary care preventive recommendations. In many ways, incorporating social determinants of health into evidence-based recommendations is an evolving area. By reviewing the evidence on the effects of screening and interventions on social determinants relevant to primary care, the USPSTF will continue to provide recommendations on clinical preventive services to improve the health of all Americans.

Health behaviour change in cardiovascular disease prevention and management: meta-review of behaviour change techniques to affect self-regulation.

Self-regulation processes assume a major role in health behaviour theory and are postulated as important mechanisms of action in behavioural interventions to improve health prevention and management. The need to better understand mechanisms of behaviour change interventions for cardiovascular diseases (CVD) called for conducting a meta-review of meta-analyses for interventions targeting self-regulation processes. The protocol, preregistered on Open Science Framework (OSF), found 15 eligible meta-analyses, published between 2006 and August 2019, which quantitatively assessed the role of self-regulatory mechanisms and behaviour change techniques (BCTs). Quality of the meta-analyses varied widely according to AMSTAR-2 criteria. Several BCTs, assumed to engage self-regulatory mechanisms, were unevenly represented in CVD meta-analytic reviews. Self-monitoring, the most frequently studied self-regulatory BCT, seemed to improve health behaviour change and health outcomes but these results merit cautious interpretation. Findings for other self-regulatory BCTs were less promising. No studies in the CVD domain directly tested engagement of self-regulation processes. A general challenge for this area stems from reliance on post-hoc tests of the effects of BCTs in multiple-component interventions. Recent advances in BCT taxonomies and the experimental medicine approach to engaging self-regulation mechanisms, however, provide opportunities to improve CVD prevention and management behavioural interventions.

Social Determinants as a Preventive Service: U.S. Preventive Services Task Force Methods Considerations for Research.

The body of research on social determinants of health is rapidly accumulating. The U.S. Preventive Services Task Force is conducting evaluations to consider the inclusion of screening and counseling for social risks as a clinical preventive service. Yet, for many social risks, evidence is still likely needed before the U.S. Preventive Services Task Force can recommend universal screening or counseling. This manuscript offers a brief review of the social determinants of health that may be germane to the U.S. Preventive Services Task Force, the methods the U.S. Preventive Services Task Force uses to evaluate relevant evidence, and current evidence gaps for social risks. Key methods for making clinical preventive service recommendations are applied for considering the integration of social and clinical care. These methods include determining the certainty of the evidence, assessing the net benefit, defining appropriate prevention frameworks, defining health outcomes versus intermediate outcomes, fully assessing the harms, and defining to what populations and care contexts the evidence applies. This road map for research is intended to spark ingenuity and purpose in the next generation of research studies, thereby ensuring that future recommendations to address and prevent social risks in primary care are informed by high-quality evidence. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Identifying and Intervening on Social Needs in Clinical Settings: Evidence and Evidence Gaps, which is sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services, Kaiser Permanente, and the Robert Wood Johnson Foundation.

Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer: US Preventive Services Task Force Recommendation Statement.

Importance: Potentially harmful mutations of the breast cancer susceptibility 1 and 2 genes (BRCA1/2) are associated with increased risk for breast, ovarian, fallopian tube, and peritoneal cancer. For women in the United States, breast cancer is the most common cancer after nonmelanoma skin cancer and the second leading cause of cancer death. In the general population, BRCA1/2 mutations occur in an estimated 1 in 300 to 500 women and account for 5% to 10% of breast cancer cases and 15% of ovarian cancer cases. Objective: To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer. Evidence Review: The USPSTF reviewed the evidence on risk assessment, genetic counseling, and genetic testing for potentially harmful BRCA1/2 mutations in asymptomatic women who have never been diagnosed with BRCA-related cancer, as well as those with a previous diagnosis of breast, ovarian, tubal, or peritoneal cancer who have completed treatment and are considered cancer free. In addition, the USPSTF reviewed interventions to reduce the risk for breast, ovarian, tubal, or peritoneal cancer in women with potentially harmful BRCA1/2 mutations, including intensive cancer screening, medications, and risk-reducing surgery. Findings: For women whose family or personal history is associated with an increased risk for harmful mutations in the BRCA1/2 genes, or who have an ancestry associated with BRCA1/2 gene mutations, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are moderate. For women whose personal or family history or ancestry is not associated with an increased risk for harmful mutations in the BRCA1/2 genes, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are small to none. Regardless of family or personal history, the USPSTF found adequate evidence that the overall harms of risk assessment, genetic counseling, genetic testing, and interventions are small to moderate. Conclusions and Recommendation: The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. (B recommendation) The USPSTF recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 gene mutations. (D recommendation).

Rationale, design, and baseline data for a multicenter randomized clinical trial comparing depression screening strategies after acute coronary syndrome: The comparison of depression identification after acute Coronary Syndromes-Quality of Life and Cost Outcomes (CODIACS-QOL) trial.

BACKGROUND: Elevated depressive symptoms among survivors of acute coronary syndromes (ACS) confer recurrent cardiovascular events and mortality, worse quality of life, and higher healthcare costs. While multiple scientific groups advise routine depression screening for ACS survivors, no randomized trials exist to inform this screening recommendation. We aimed to assess the effect of screening for depression on change in quality of life over 18 months among ACS patients. METHODS: The Comparison of Depression Identification after Acute Coronary Syndrome on Quality of Life and Cost Outcomes (CODIACS-QoL) trial is a pragmatic, 3-arm trial that randomized ACS patients to 1) systematic depression screening using the 8-item Patient Health Questionnaire (PHQ-8) and if positive screen (PHQ-8 ≥ 10), notification of primary care providers (PCPs) and invitation to participate in centralized, patient-preference, stepped depression care (Screen, Notify, and Treat, N = 499); 2) systematic depression screening and PCP notification only (Screen and Notify, N = 501); and 3) usual care (No Screen, N = 500). Adults hospitalized for ACS in the previous 2-12 months without prior history of depression were eligible for participation. Key outcomes will be quality-adjusted life years (primary), cost of health care utilization, and depression-free days across 18 months. RESULTS: A total of 1500 patients were randomized in the CODIACS-QOL trial (28.3% women; 16.3% Hispanic; mean age 65.9 (11.5) years). Only 7% of ACS survivors had elevated depressive symptoms. CONCLUSIONS: Using a novel randomization schema and pragmatic design principles, the CODIACS-QoL trial achieved its enrollment target. Eventual results of this trial will inform future depression screening recommendations in cardiac patients. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01993017).