Impact of Telemedicine Modality on Quality Metrics in Diverse Settings: Implementation Science-Informed Retrospective Cohort Study.

BACKGROUND: Video-based telemedicine (vs audio only) is less frequently used in diverse, low socioeconomic status settings. Few prior studies have evaluated the impact of telemedicine modality (ie, video vs audio-only visits) on clinical quality metrics. OBJECTIVE: The aim of this study was to assess telemedicine uptake and impact of visit modality (in-person vs video and phone visits) on primary care quality metrics in diverse, low socioeconomic status settings through an implementation science lens. METHODS: Informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, we evaluated telemedicine uptake, assessed targeted primary care quality metrics by visit modality, and described provider-level qualitative feedback on barriers and facilitators to telemedicine implementation. RESULTS: We found marginally better quality metrics (ie, blood pressure and depression screening) for in-person care versus video and phone visits; de-adoption of telemedicine was marked within 2 years in our population. CONCLUSIONS: Following the widespread implementation of telemedicine during the COVID-19 pandemic, the impact of visit modality on quality outcomes, provider and patient preferences, as well as technological barriers in historically marginalized settings should be considered.

Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy.

BACKGROUND: Depression leads to poor health outcomes in patients with coronary heart disease (CHD). Despite guidelines recommending screening and treatment of depressed patients with CHD, few patients receive optimal care. We applied behavioral and implementation science methods to (1) identify generalizable, multilevel barriers to depression screening and treatment in patients with CHD and (2) develop a theory-informed, multilevel implementation strategy for promoting guideline adoption. METHODS: We conducted a narrative review of barriers to depression screening and treatment in patients with CHD (ie, medications, exercise, cardiac rehabilitation, or therapy) comprising data from 748 study participants. Informed by the behavior change wheel framework and Expert Recommendations for Implementing Change, we defined multilevel target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multilevel implementation strategy, targeting health care systems/providers and patients. RESULTS: We identified implementation barriers at the system/provider level (eg, Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (eg, Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. Expert Recommendations for Implementing Change strategies included learning collaborative, audit, feedback, and educational materials. The final multicomponent strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (electronic shared decision-making) tool with several functions for patients, for example, patient activation, patient treatment selection support. CONCLUSIONS: We applied implementation and behavioral science methods to identify implementation barriers and to develop a multilevel implementation strategy for increasing uptake of depression screening and treatment in patients with CHD as a use case. The multilevel implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

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.

Transforming the study of organisms: Phenomic data models and knowledge bases.

The rapidly decreasing cost of gene sequencing has resulted in a deluge of genomic data from across the tree of life; however, outside a few model organism databases, genomic data are limited in their scientific impact because they are not accompanied by computable phenomic data. The majority of phenomic data are contained in countless small, heterogeneous phenotypic data sets that are very difficult or impossible to integrate at scale because of variable formats, lack of digitization, and linguistic problems. One powerful solution is to represent phenotypic data using data models with precise, computable semantics, but adoption of semantic standards for representing phenotypic data has been slow, especially in biodiversity and ecology. Some phenotypic and trait data are available in a semantic language from knowledge bases, but these are often not interoperable. In this review, we will compare and contrast existing ontology and data models, focusing on nonhuman phenotypes and traits. We discuss barriers to integration of phenotypic data and make recommendations for developing an operationally useful, semantically interoperable phenotypic data ecosystem.

Regeneration of the cementum and periodontal ligament using local BDNF delivery in class II furcation defects.

Periodontal furcation defects are usually addressed by the placement of a physical barrier which may limit the regenerative potential of periodontal wounds. This study morphometrically quantified the regenerative effect of brain-derived neurotrophic factor (BDNF) in furcation defects in a non-human primate model. Grade II furcation defects (with and without induced inflammation prior to surgery) were created on the first and second molars of eight non-human primates. Defects were treated with open flap debridement and subsequently filled with either: Group A; BDNF (500 µg mL-1 ) in high-molecular weight-hyaluronic acid (HMW-HA), Group B; BDNF (50 µg mL-1 ) in HMW-HA, Group C; HMW-HA acid only, Group D; unfilled defect, or Group E; BDNF (500 µg mL-1 ) in saline. Periodontal wound healing was observed every 2 weeks by computed-tomography. At 11 weeks all animals were sacrificed and maxillary and mandibular block biopsies were referred for nondecalcified histology. Linear measurements of new cementum (cellular and acellular) and periodontal ligament (PDL) formation were performed. Computerized-tomography reconstruction and software quantification demonstrated successful bone fill for all groups. However, histometric assessment demonstrated significantly higher level of total periodontal regeneration for the 500 µg mL-1 BDNF HMW-HA relative to all other groups. No significant differences in cementogenesis were observed among groups. Significantly higher acellular cementum formation was observed for sites where inflammation was not induced prior to surgical procedures. While all groups experienced similar bone fill and cementogenesis, the 500 µg mL-1 BDNF HMW-HA appeared to most effectively repair PDL (minimum increase of ∼22% relative to all groups; over 200% relative to unfilled defects). © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 1611-1617, 2018.

Plasma metabolite profiles, cellular cholesterol efflux, and non-traditional cardiovascular risk in patients with CKD.

BACKGROUND: Patients with chronic kidney disease (CKD) experience high rates of atherosclerotic cardiovascular disease and death that are not fully explained by traditional risk factors. In animal studies, defective cellular cholesterol efflux pathways which are mediated by the ATP binding cassette transporters ABCA1 and ABCG1 are associated with accelerated atherosclerosis. We hypothesized that cholesterol efflux in humans would vary in terms of cellular components, with potential implications for cardiovascular disease. METHODS: We recruited 120 CKD patients (eGFR<30mL/min/1.73m2) and 120 control subjects (eGFR ≥60mL/min/1.73m2) in order to measure cholesterol efflux using either patients' HDL and THP-1 macrophages or patients' monocytes and a flow cytometry based cholesterol efflux assay. We also measured cell-surface levels of the common ß subunit of the IL-3/GM-CSF receptor (IL-3Rß) which has been linked to defective cholesterol homeostasis and may promote monocytosis. In addition, we measured plasma inflammatory cytokines and plasma metabolite profiles. RESULTS: There was a strong positive correlation between cell-surface IL-3Rß levels and monocyte counts in CKD (P<0.001). ABCA1 mRNA was reduced in CKD vs. control monocytes (P<0.05), across various etiologies of CKD. Cholesterol efflux to apolipoprotein A1 was impaired in monocytes from CKD patients with diabetic nephropathy (P<0.05), but we found no evidence for a circulating HDL-mediated defect in cholesterol efflux in CKD. Profiling of plasma metabolites showed that medium-chain acylcarnitines were both independently associated with lower levels of cholesterol transporter mRNA in CKD monocytes at baseline (P<0.05), and with cardiovascular events in CKD patients after median 2.6years of follow-up. CONCLUSIONS: Cholesterol efflux in humans varies in terms of cellular components. We report a cellular defect in ABCA1-mediated cholesterol efflux in monocytes from CKD patients with diabetic nephropathy. Unlike several traditional risk factors for atherosclerotic cardiovascular disease, plasma metabolites inversely associated with endogenous cholesterol transporters predicted cardiovascular events in CKD patients. (Funded by the National Institute of Diabetes and Digestive and Kidney DiseasesK23DK097288 and others.).

Adiponectin and all-cause mortality in elderly people with type 2 diabetes.

OBJECTIVE: To assess the association between serum adiponectin level and all-cause mortality in people with type 2 diabetes. Because of the insulin-sensitizing, anti-inflammatory, and antiatherogenic effects of adiponectin, we hypothesized that higher adiponectin level would be associated with lower all-cause mortality. RESEARCH DESIGN AND METHODS: A total of 609 men and women aged 72 ± 6.3 years with type 2 diabetes and information on total and high molecular weight adiponectin were followed for a median of 5 years. The longitudinal association between adiponectin and all-cause mortality was analyzed with Cox proportional hazards models with time from adiponectin measurement to death as the time-to-event variable. Analyses were adjusted for demographic variables and significant diabetes parameters, significant cardiovascular parameters, and significant diabetes medications. RESULTS: Total and high molecular weight adiponectin were highly correlated. The highest adiponectin quartile was strongly associated with higher all-cause mortality compared with the lowest quartile (hazard ratio = 4.0 [95% CI: 1.7-9.2]) in the fully adjusted model. These results did not change in analyses stratified by sex and thiazolidinedione use, after exclusion of people who died within one year of adiponectin measurement, or when change in weight before adiponectin measurement was considered. CONCLUSIONS: Contrary to our hypothesis, higher adiponectin level was related to higher all-cause mortality. This association was not explained by confounding by other characteristics, including medications or preceding weight loss.