E-cigarette Use Among Young Adult Patients: The Opportunity to Intervene on Risky Lifestyle Behaviors to Reduce Cancer Risk.

Use of e-cigarettes and other electronic nicotine delivery systems (ENDS) is on the rise. We administered a health needs survey via email to 804 adult primary care and oncology patients at a large urban academic medical center in 2019. We examined differences in e-cigarette use by smoking status, personal history of cancer, alcohol use, and second-hand tobacco smoke exposure. Of the 804 participants, 90 (11.2%) reported ever using e-cigarettes. E-cigarette use was more prevalent in young adults (risk ratio [RR] for 18-24 years: 4.58, 95% confidence interval [95% CI] 2.05, 10.26), current smoking (RR 4.64, 95% CI 1.94, 11.07), very often/often binge drinking (RR 3.04, 96% CI 1.38, 6.73), and ≥ 1 smokers in the home (RR 3.90, 95% CI 2.10, 7.23). Binge alcohol consumption and tobacco smoking are associated with increased risk cancer. Inquiries about e-cigarette use among adults 25-40 years present providers the opportunity to also counsel young adult about reducing cancer risk.

Hospital Readmissions After Implementation of a Discharge Care Program for Patients with COVID-19 Illness.

BACKGROUND: The surge of coronavirus 2019 (COVID-19) hospitalizations in New York City required rapid discharges to maintain hospital capacity. OBJECTIVE: To determine whether lenient provisional discharge guidelines with remote monitoring after discharge resulted in safe discharges home for patients hospitalized with COVID-19 illness. DESIGN: Retrospective case series SETTING: Tertiary care medical center PATIENTS: Consecutive adult patients hospitalized with COVID-19 illness between March 26, 2020, and April 8, 2020, with a subset discharged home INTERVENTIONS: COVID-19 Discharge Care Program consisting of lenient provisional inpatient discharge criteria and option for daily telephone monitoring for up to 14 days after discharge MEASUREMENTS: Fourteen-day emergency department (ED) visits and hospital readmissions RESULTS: Among 812 patients with COVID-19 illness hospitalized during the study time period, 15.5% died prior to discharge, 24.1% remained hospitalized, 10.0% were discharged to another facility, and 50.4% were discharged home. Characteristics of the 409 patients discharged home were mean (SD) age 57.3 (16.6) years; 245 (59.9%) male; 27 (6.6%) with temperature ≥ 100.4 °F; and 154 (37.7%) with oxygen saturation < 95% on day of discharge. Over 14 days of follow-up, 45 patients (11.0%) returned to the ED, of whom 31 patients (7.6%) were readmitted. Compared to patients not referred, patients referred for remote monitoring had fewer ED visits (8.3% vs 14.1%; OR 0.60, 95% CI 0.31-1.15, p = 0.12) and readmissions (6.9% vs 8.3%; OR 1.15, 95% CI 0.52-2.52, p = 0.73). LIMITATIONS: Single-center study; assignment to remote monitoring was not randomized. CONCLUSIONS: During the COVID-19 surge in New York City, lenient discharge criteria in conjunction with remote monitoring after discharge were associated with a rate of early readmissions after COVID-related hospitalizations that was comparable to the rate of readmissions after other reasons for hospitalization before the COVID pandemic.

Interest in genetic testing and risk-reducing behavioral changes: results from a community health assessment in New York City.

Risk-based genetic tests are often used to determine cancer risk, when to initiate screening, and frequency of screening, but rely on interest in genetic testing. We examined overall interest in genetic testing for cancer risk assessment and willingness to change behavior, and whether these are affected by demographic or socioeconomic factors.We conducted a community needs health survey in 2019 among primary care and cancer patients, family members and community members in New York City. We used univariable analysis and relative risk regression to examine interest in genetic cancer risk testing and willingness to modify lifestyle behaviors in response to an informative genetic test.Of the 1225 participants, 74.0% (n = 906) expressed interest in having a genetic test to assess cancer risk. Interest in genetic testing was high across all demographic and socioeconomic groups; reported interest in genetic testing by group ranged from 65.0 (participants aged 65 years and older) to 83.6% (participants below federal poverty level). Among the 906 participants that reported interest in genetic testing, 79.6% were willing to change eating habits, 66.5% to change exercise habits, and 49.5% to lose weight in response to an informative genetic test result.Our study reveals that interest in genetic testing for cancer risk is high among patients and community members and is high across demographic and socioeconomic groups, as is the reported willingness to change behavior. Based on these results, we recommend that population-based genetic testing may result in greater reduction cancer risk, particularly among minoritized groups.

Patient and Clinician Decision Support to Increase Genetic Counseling for Hereditary Breast and Ovarian Cancer Syndrome in Primary Care: A Cluster Randomized Clinical Trial.

Importance: To promote the identification of women carrying BRCA1/2 variants, the US Preventive Services Task Force recommends that primary care clinicians screen asymptomatic women for an increased risk of carrying a BRCA1/2 variant risk. Objective: To examine the effects of patient and clinician decision support about BRCA1/2 genetic testing compared with standard education alone. Design, Setting, and Participants: This clustered randomized clinical trial was conducted at an academic medical center including 67 clinicians (unit of randomization) and 187 patients. Patient eligibility criteria included women aged 21 to 75 years with no history of breast or ovarian cancer, no prior genetic counseling or testing for hereditary breast and ovarian cancer syndrome (HBOC), and meeting family history criteria for BRCA1/2 genetic testing. Interventions: RealRisks decision aid for patients and the Breast Cancer Risk Navigation Tool decision support for clinicians. Patients scheduled a visit with their clinician within 6 months of enrollment. Main Outcomes and Measures: The primary end point was genetic counseling uptake at 6 months. Secondary outcomes were genetic testing uptake at 6 and 24 months, decision-making measures (perceived breast cancer risk, breast cancer worry, genetic testing knowledge, decision conflict) based upon patient surveys administered at baseline, 1 month, postclinic visit, and 6 months. Results: From December 2018 to February 2020, 187 evaluable patients (101 in the intervention group, 86 in the control group) were enrolled (mean [SD] age: 40.7 [13.2] years; 88 Hispanic patients [46.6%]; 15 non-Hispanic Black patients [8.1%]; 72 non-Hispanic White patients [38.9%]; 35 patients [18.9%] with high school education or less) and 164 (87.8%) completed the trial. There was no significant difference in genetic counseling uptake at 6 months between the intervention group (20 patients [19.8%]) and control group (10 patients [11.6%]; difference, 8.2 percentage points; OR, 1.88 [95% CI, 0.82-4.30]; P = .14). Genetic testing uptake within 6 months was also statistically nonsignificant (13 patients [12.9%] in the intervention group vs 7 patients [8.1%] in the control group; P = .31). At 24 months, genetic testing uptake was 31 patients (30.7%) in intervention vs 18 patients (20.9%) in control (P = .14). Comparing decision-making measures between groups at baseline to 6 months, there were significant decreases in perceived breast cancer risk and in breast cancer worry (standard mean differences = -0.48 and -0.40, respectively). Conclusions and Relevance: This randomized clinical trial did not find a significant increase in genetic counseling uptake among patients who received patient and clinician decision support vs those who received standard education, although more than one-third of the ethnically diverse women enrolled in the intervention underwent genetic counseling. These findings suggest that the main advantage for these high-risk women is the ability to opt for screening and preventive services to decrease their cancer risk. Trial Registration: ClinicalTrials.gov Identifier: NCT03470402.

Field-deployable, rapid diagnostic testing of saliva for SARS-CoV-2.

To safely re-open economies and prevent future outbreaks, rapid, frequent, point-of-need, SARS-CoV-2 diagnostic testing is necessary. However, existing field-deployable COVID-19 testing methods require the use of uncomfortable swabs and trained providers in PPE, while saliva-based methods must be transported to high complexity laboratories for testing. Here, we report the development and clinical validation of High-Performance Loop-mediated isothermal Amplification (HP-LAMP), a rapid, saliva-based, SARS-CoV-2 test with a limit of detection of 1.4 copies of virus per µl of saliva and a sensitivity and specificity with clinical samples of > 96%, on par with traditional RT-PCR based methods using swabs, but can deliver results using only a single fluid transfer step and simple heat block. Testing of 120 patient samples in 40 pools comprised of 5 patient samples each with either all negative or a single positive patient sample was 100% accurate. Thus, HP-LAMP may enable rapid and accurate results in the field using saliva, without need of a high-complexity laboratory.

Time-Varying Depressive Symptoms and Cardiovascular and All-Cause Mortality: Does the Risk Vary by Age or Sex?

Background Depressive symptoms are associated with mortality. Data regarding moderation of this effect by age and sex are inconsistent, however. We aimed to identify whether age and sex modify the association between depressive symptoms and all-cause and cardiovascular disease (CVD) mortality. Methods and Results The REGARDS (Reasons for Geographic and Racial Differences in Stroke) study is a prospective cohort of Black and White individuals recruited between 2003 and 2007. Associations between time-varying depressive symptoms (Center for Epidemiologic Studies Depression scale score ≥4 versus <4) and all-cause and CVD mortality were measured using Cox proportional hazard models adjusting for demographic and clinical risk factors. All results were stratified by age or sex and by self-reported health status. Of 29 491 participants, 3253 (11%) had baseline elevated depressive symptoms. Mean age was 65 (9.4) years, with 55.1% of participants female, 41.1% Black, and 46.4% had excellent/very good health. Depressive symptoms were measured at baseline, on average 4.9 (SD, 1.5), then 2.1 (SD, 0.4) years later. Neither age nor sex moderated the association between elevated time-varying depressive symptoms and all-cause or CVD mortality (all-cause: age 45-64 years adjusted hazard ratio [aHR], 1.38; 95% CI, 1.18-1.61 versus age ≥65 years aHR,1.36; 95% CI, 1.23-1.50; P=0.05; CVD: age 45-64 years aHR, 1.17; 95% CI, 0.90-1.53 versus age ≥65 years aHR, 1.26; 95% CI, 1.06-1.50; P=0.54; all-cause: males aHR, 1.46; 95% CI, 1.29-1.64 versus female aHR, 1.34; 95% CI, 1.19-1.50; P=0.35; CVD: male aHR, 1.32; 95% CI, 1.08-1.62 versus female aHR, 1.22; 95% CI, 1.00-1.47; P=0.64). Similar results were observed when stratified by self-reported health status. Conclusions Depressive symptoms confer mortality risk regardless of age and sex, including individuals who report excellent/very good health.

Field-deployable, rapid diagnostic testing of saliva samples for SARS-CoV-2.

Rapid, scalable, point-of-need, COVID-19 diagnostic testing is necessary to safely re-open economies and prevent future outbreaks. We developed an assay that detects single copies of SARS-CoV-2 virus directly from saliva and swab samples in 30 min using a simple, one-step protocol that utilizes only a heat block and microcentrifuge tube prefilled with a mixture containing the necessary reagents and has a sensitivity and specificity of 97% and 100%, respectively.

Primary Care Providers' Perspectives on Errors of Omission.

BACKGROUND: Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions. METHODS: A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview. RESULTS: PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices. DISCUSSION: Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs. CONCLUSIONS: Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm.

Identifying the Complexity of Multiple Risk Factors for Obesity Among Urban Latinas.

The prevalence of obesity is rising rapidly among Hispanics/Latinas. We evaluated the prevalence of being obese or overweight and associated risk factors among 630 low-income, Latina women from ambulatory care clinics in Upper Manhattan. Overall, 37 % of the sample was overweight and 41 % of the sample was obese, and yet, almost half of women who are overweight considered their weight "just about right." After adjusting for socio-demographic, behavioral, and biological risk factors, being obese was strongly associated with having hypertension [relative risk ratio (RRR) 3.93, 1.75-8.82], pre-hypertension (RRR 2.59, 1.43-4.67), diabetes (RRR 2.50, 1.21-5.14) and moderate/moderately severe/severe depression (RRR 2.09, 1.03-4.26). Women who reported that finding time was a barrier to physical activity were also more likely to be obese (RRR 1.78, 1.04-3.02). Chronic financial stress was associated with lower risk of being overweight (RRR 0.47, 0.28-0.79) or obese (RRR 0.51, 0.31-0.86), as well as eating out at restaurants (RRR 0.75, 0.62-0.89). Opportunities for intervention relate to understanding cultural factors around perceptions of weight and helping women find the time for physical activity.

Preliminary Findings of the Delivery of the National Diabetes Prevention Program via a Mobile Application.

NewYork-Presbyterian Hospital partnered with Noom Health to pilot the virtual delivery of the proven National Diabetes Prevention Program (NDPP) to prediabetic patients. Goals were to understand if the patients can use a mobile device to receive the NDPP content, perform tasks and communicate with a virtual health coach. This poster describes our preliminary findings and responses from patients and staff.

Results of the northern Manhattan diabetes community outreach project: a randomized trial studying a community health worker intervention to improve diabetes care in Hispanic adults.

OBJECTIVE The Northern Manhattan Diabetes Community Outreach Project evaluated whether a community health worker (CHW) intervention improved clinically relevant markers of diabetes care in adult Hispanics. RESEARCH DESIGN AND METHODS Participants were adult Hispanics, ages 35-70 years, with recent hemoglobin A1c (A1C) ≥8% (≥64 mmol/mol), from a university-affiliated network of primary care practices in northern Manhattan (New York City, NY). They were randomized to a 12-month CHW intervention (n = 181), or enhanced usual care (educational materials mailed at 4-month intervals, preceded by phone calls, n = 179). The primary outcome was A1C at 12 months; the secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure, and LDL-cholesterol levels. RESULTS There was a nonsignificant trend toward improvement in A1C levels in the intervention group (from unadjusted mean A1C of 8.77 to 8.40%), as compared with usual care (from 8.58 to 8.53%) (P = 0.131). There was also a nonsignificant trend toward an increase in SBP and LDL cholesterol in the intervention arm. Intervention fidelity, measured as the number of contacts in the intervention arm (visits, phone contacts, group support, and nutritional education), showed a borderline association with greater A1C reduction (P = 0.054). When assessed separately, phone contacts were associated with greater A1C reduction (P = 0.04). CONCLUSIONS The trend toward A1C reduction with the CHW intervention failed to achieve statistical significance. Greater intervention fidelity may achieve better glycemic control, and more accessible treatment models, such as phone-based interventions, may be more efficacious in socioeconomically disadvantaged populations.

A regional health collaborative formed By NewYork-Presbyterian aims to improve the health of a largely Hispanic community.

Communities of poor, low-income immigrants with limited English proficiency and disproportionate health burdens pose unique challenges to health providers and policy makers. NewYork-Presbyterian Hospital developed the Regional Health Collaborative, a population-based health care model to improve the health of the residents of Washington Heights-Inwood. This area is a predominantly Hispanic community in New York City with high rates of asthma, diabetes, heart disease, and depression. NewYork-Presbyterian created an integrated network of patient-centered medical homes to form a "medical village" linked to other providers and community-based resources. The initiative set out to document the priority health needs of the community, target high-prevalence conditions, improve cultural competence among providers, and introduce integrated information systems across care sites. The first six months of the program demonstrated a significant 9.2 percent decline in emergency department visits for ambulatory care-sensitive conditions and a 5.8 percent decrease in hospitalizations that was not statistically significant. This initiative offers a model for other urban academic medical centers to better serve populations facing social and cultural barriers to care.

Physical activity participation among Caribbean Hispanic women living in New York: relation to education, income, and age.

BACKGROUND: Inadequate participation in physical activity is a serious public health issue in the United States, with significant disparities among population groups. In particular, there is a scarcity of information about physical activity among Caribbean Hispanics, a group on the rise. METHODS: Our goal was to accumulate data on physical activity among Caribbean Hispanic women living in New York and determine the relation between physical activity and age, marital status, education, income, primary language, and children in the household. To this end, a survey adapted from the National Health Interview Survey of the National Center for Health Statistics assessing type, frequency, and duration of physical activity was administered. RESULTS: There were 318 self-identified Hispanic women who participated. Total activity time, mean 385 +/- 26 minutes, and education (r = 0.14, p < 0.01) were significantly related. Women who had attended some college had greater total activity time than those with some high school education (p = 0.046) or < 8th grade education (p = 0.022). Walking as a form of transportation was the most frequent pursuit, 285 +/- 21 minutes. Age (r = -0.34, p < 0.001) and education (r = 0.25, p < 0.001) correlated with nonwalking activity time (leisure time). Nonwalking activity times were greater in younger, that is, 18-29 years (p < 0.001) and college-educated women (p < 0.001). Physical activity recommendations were met by 11%; and 17% reported no physical activity. CONCLUSIONS: Among Caribbean Hispanic women living in New York City, the current recommendations for physical activity are met by 11%, and physical activity and education are significantly related. Our observation that education is a critical factor related to physical activity suggests that programs to address the promotion of a physically active lifestyle are needed.

Metabolic syndrome and the burden of cardiovascular disease in Caribbean Hispanic women living in northern Manhattan: a red flag for education.

BACKGROUND: Metabolic syndrome has the highest prevalence among Mexican-American women. Little information is available for Caribbean Hispanics, the largest and fastest growing ethnic minority in the United States. We sought to evaluate the frequency of metabolic syndrome and its relationship with race/ethnicity, socioeconomic position, and education in women of largely Caribbean Hispanic origin. METHODS: There were 204 women enrolled in a cross-sectional study who had demographics, fasting glucose, lipid profile, waist circumference, and blood pressure determined. Metabolic syndrome (defined by the National Cholesterol Education Program/Adult Treatment Panel III [NCEP/ATP III]) was analyzed using univariate and multivariate logistic regression to test age, race/ethnicity, education, health insurance, and residence on the risk of metabolic syndrome. A P value <0.05 was considered significant. RESULTS: Mean age was 58 +/- 11 years, Hispanic 44.1% (93% Caribbean), non-Hispanic white (NHW) 38.7%, and non-Hispanic black 9.8%. Education was some high school (