Population and Quantitative Health Sciences Publications

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https://hdl.handle.net/20.500.14038/192

ABOUT THIS COLLECTION

The vision of the Department of Population and Quantitative Health Sciences (PQHS) is the best health and well-being for all through science, community engagement, and education. Our mission is to advance science and improve population health. This collection showcases selected journal articles and other publications written by faculty and researchers of the Department of Population and Quantitative Health Sciences.

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Association of Systemic Thromboxane Generation With Risk of Developing Heart Failure
(2025-01-07) Rade, Jeffrey J; Kronsberg, Shari S; Kickler, Thomas S; Vasan, Ramachandran S; Xanthakis, Vanessa; Nayor, Matthew G; Barton, Bruce A; Population and Quantitative Health Sciences; Medicine; Biostatistics and Health Services Research
Background: Systemic thromboxane A2 generation, which is readily assessed by quantifying thromboxane B2 metabolites (TXB2-M) in the urine, is associated with impaired cardiac performance and mortality in aspirin (ASA) users with heart failure (HF). Objectives: This study sought to determine the association of urinary TXB2-M with the risk of developing HF in individuals without prior history of HF and with normal left ventricular function irrespective of ASA use. Methods: Urine TXB2-M were measured by immunoassay and adjusted to urine concentration and renal function (TXB2-MGFR) in 2,611 Framingham Heart Study participants (54.9% women, mean age 65 ± 9 years, 43.8% ASA users) without prior history of HF and with left ventricular ejection fraction (LVEF) ≥55%. The association of TXB2-MGFR with HF risk over a median observation period of 14.8 years (Q1-Q3: 12.6-15.7 years) was modeled using Cox regression. Results: HF occurred in 189 participants (7.2%), with 104 of the first events (55.0%) classified as HF with preserved LVEF, 56 (29.6%) as HF with reduced LVEF, and 29 (15.3%) were unclassifiable. TXB2-MGFR levels, above compared to below, of 16.6 and 62.1 filtered prostanoid units for ASA users and nonusers, respectively, were associated with increased risk of developing HF (HR: 1.81; 95% CI: 1.38-2.64; P < 0.0001, adjusted for age, sex, ASA use, and HF risk factors), including both HF subtypes (HF with preserved LVEF: HR: 1.81; 95% CI: 1.17-2.80; P = 0.0081, and HF with reduced LVEF: HR: 2.63; 95% CI: 1.48-4.68; P = 0.0010, adjusted for age, sex, ASA use, and cardiovascular disease). Neither ASA use nor evidence of platelet activation, as measured by plasma P-selectin, were independently associated with HF risk. Conclusions: Systemic thromboxane A2 generation as measured by urinary TXB2-MGFR was significantly associated with HF risk and remained so after accounting for traditional risk factors. Urinary TXB2-MGFR is therefore a potentially useful novel biomarker to identify at-risk individuals who might benefit from aggressive primary prevention.
Organization Theory for Implementation Science (OTIS): reflections and recommendations
(2024-12-13) Birken, Sarah A; Baloh, Jure; Kegler, Michelle C; Huang, Terry T-K; Lee, Matthew; Adsul, Prajakta; Ryan, Grace; Peluso, Alexandra; Wagi, Cheyenne; Randazzo, Aliza; Mullins, Megan A; Morrill, Kristin E; Ko, Linda K; Population and Quantitative Health Sciences; Prevention Research Center
Organizations exert influence on the implementation of evidence-based practices and other innovations that are independent of the influence of organizations' individual constituents. Despite their influence, nuanced explanations of organizations' influence remain limited in implementation science. Organization theories are uniquely suited to offer insights and explain organizational influences on implementation. In this paper, we describe the efforts of the Cancer Prevention and Control Research Network's (CPCRN) Organization Theory for Implementation Science (OTIS) workgroup to equip implementation scientists with theory-guided understanding of organizational influences on implementation. We provide a set of recommendations for future efforts to enhance implementation through the use of organization theories and OTIS tools.
Baseline Smartphone App Survey Return in the Electronic Framingham Heart Study Offspring and Omni 1 Study: eCohort Study
(2024-12-31) Rong, Jian; Pathiravasan, Chathurangi H; Zhang, Yuankai; Faro, Jamie M; Wang, Xuzhi; Schramm, Eric; Borrelli, Belinda; Benjamin, Emelia J; Liu, Chunyu; Murabito, Joanne M; Population and Quantitative Health Sciences
Background: Smartphone apps can be used to monitor chronic conditions and offer opportunities for self-assessment conveniently at home. However, few digital studies include older adults. Objective: We aim to describe a new electronic cohort of older adults embedded in the Framingham Heart Study including baseline smartphone survey return rates and survey completion rates by smartphone type (iPhone [Apple Inc] and Android [Google LLC] users). We also aim to report survey results for selected baseline surveys and participant experience with this study's app. Methods: Framingham Heart Study Offspring and Omni (multiethnic cohort) participants who owned a smartphone were invited to download this study's app that contained a range of survey types to report on different aspects of health including self-reported measures from the Patient-Reported Outcomes Measurement Information System (PROMIS). iPhone users also completed 4 tasks including 2 cognitive and 2 physical function testing tasks. Baseline survey return and completion rates were calculated for 12 surveys and compared between iPhone and Android users. We calculated standardized scores for the PROMIS surveys. The Mobile App Rating Scale (MARS) was deployed 30 days after enrollment to obtain participant feedback on app functionality and aesthetics. Results: We enrolled 611 smartphone users (average age 73.6, SD 6.3 y; n=346, 56.6% women; n=88, 14.4% Omni participants; 478, 78.2% iPhone users) and 596 (97.5%) returned at least 1 baseline survey. iPhone users had higher app survey return rates than Android users for each survey (range 85.5% to 98.3% vs 73.8% to 95.2%, respectively), but survey completion rates did not differ in the 2 smartphone groups. The return rate for the 4 iPhone tasks ranged from 80.9% (380/470) for the gait task to 88.9% (418/470) for the Trail Making Test task. The Electronic Framingham Heart Study participants had better standardized t scores in 6 of 7 PROMIS surveys compared to the general population mean (t score=50) including higher cognitive function (n=55.6) and lower fatigue (n=45.5). Among 469 participants who returned the MARS survey, app functionality and aesthetics was rated high (total MARS score=8.6 on a 1-10 scale). Conclusions: We effectively engaged community-dwelling older adults to use a smartphone app designed to collect health information relevant to older adults. High app survey return rates and very high app survey completion rates were observed along with high participant rating of this study's app.
Plasma fibronectin is a prognostic biomarker of disability in Parkinson's disease: a prospective, multicenter cohort study
(2025-01-02) Zhu, Shuzhen; Li, Hualin; Huang, Zifeng; Zeng, Yiheng; Huang, Jianmin; Li, Guixia; Yang, Shujuan; Zhou, Hang; Chang, Zihan; Xie, Zhenchao; Que, Rongfang; Wei, Xiaobo; Li, Minzi; Liang, Yanran; Xian, Wenbiao; Li, Mengyan; Pan, Ying; Huang, Fanheng; Shi, Lin; Yang, Chengwu; Deng, Chao; Batzu, Lucia; Poplawska-Domaszewicz, Karolina; Chen, Shuhan; Chan, Ling-Ling; Ray Chaudhuri, K; Tan, Eng-King; Wang, Qing; Population and Quantitative Health Sciences; Biostatistics and Health Services Research
In a prospective longitudinal study with 218 Parkinson's disease (PD) patients in the discovery cohort and 84 in the validation cohort, we aimed to identify novel blood biomarkers predicting disability milestones in PD. Through Least Absolute Shrinkage and Selection Operator-Cox (Lasso-Cox) regression, developed nomogram predictive model and Linear mixed-effects models, we identified low level of plasma fibronectin (pFN) as one of the best-performing risk markers in predicting disability milestones. A low level of pFN was associated with a short milestone-free survival period in PD. Longitudinal analysis showed an annual decline in the rate of pFN was significantly associated with the annual elevation rate in the Hoehn-Yahr stage. Moreover, pFN level was negatively correlated with phosphorylated α-synuclein, and a low level of pFN was associated with BBB disruption in the striatum on neuroimaging, providing evidence for pFN's role in PD progression. We finally identified pFN as a novel blood biomarker that predicted first-milestone disability in PD.
Cost and activity analysis for a citywide patient navigation intervention to engage underserved patients in breast cancer treatment: Findings from the Translating Research Into Practice study
(2025-01-01) Rajabiun, Serena; Cabral, Howard J; Chen, Clara A; Lloyd-Travaglini, Christine; Dugas, Julianne N; Amburgey, Deborah; Fitzgerald, Madyson; Lemon, Stephenie C; Haas, Jennifer S; Freund, Karen M; Battaglia, Tracy; Population and Quantitative Health Sciences; Prevention Research Center
Background: Patient navigation is an evidence-based intervention for reducing delays in cancer care for underserved populations. There are limited economic evaluations of patient navigation in the US health care system and few have considered costs at various phases along the implementation spectrum. Having economic data, including costs and cost savings, can support sustainability of patient navigation programs. This study presents findings from a cost and activity analysis of a citywide hospital-based patient navigation program to engage women in timely breast cancer treatment post-diagnosis. Methods: This study was conducted as part of Translating Research Into Practice (TRIP), a citywide patient navigation hybrid effectiveness-implementation research study conducted at five cancer care hospitals in Boston, Massachusetts. The authors surveyed participating patient navigators and supervisors about their tasks and level of effort over consecutive 10-day periods from 2019 to 2021. Patient navigators documented the time spent on activities in accordance with an 11-step protocol across five sites. Cost data were collected from annual fiscal year end expenditure hospital administrative databases at concurrent time frames. Descriptive analyses were used to calculate average time on tasks, cost per activity and cost per outcome. Cost savings were estimated by calculating the additional persons engaged in timely entry to treatment compared to a matched control group with respect to hospitalization and emergency room costs averted. Results: Average time spent per day on TRIP-specific navigation activities was approximately 3 hours (range, 0-8 hours) and the average time per patient per day was 25 minutes (n = 7 navigators). Total costs for clinical site interventions were $218,394 for startup and $392,407 for maintenance costs over the study period. A total of 223 patients were served during the intervention period with an average cost per patient of $979 for startup and $1759 for maintenance. Potential costs savings with the TRIP navigation program from averted hospitalization and emergency room visits for 63 additional patients who received timely treatment is estimated at $21,798-$30,429 and $2536-$5692 per patient, respectively, compared to treatment as usual. Conclusions: The economic evaluation in this study provides insight into startup and implementation costs for uptake and scalability of navigation programs across a citywide system. The information may be useful for payors in reimbursing navigation activities and health systems in planning for high quality navigation programs to ensure patient-centered and timely treatment for women diagnosed with breast cancer.
Multiclass arrhythmia classification using multimodal smartwatch photoplethysmography signals collected in real-life settings [preprint]
(2024-12-13) Han, Dong; Moon, Jihye; Díaz, Luís Roberto Mercado; Chen, Darren; Williams, Devan; Mohagheghian, Fahimeh; Ghetia, Om; Peitzsch, Andrew G; Kong, Youngsun; Nishita, Nishat; Ghutadaria, Ohm; Orwig, Taylor A; Otabil, Edith Mensah; Noorishirazi, Kamran; Hamel, Alexander; Dickson, Emily L; DiMezza, Danielle; Lessard, Darleen; Wang, Ziyue; Mehawej, Jordy; Filippaios, Andreas; Naeem, Syed; Gottbrecht, Matthew F; Fitzgibbons, Timothy P; Saczynski, Jane S; Barton, Bruce; Ding, Eric Y; Tran, Khanh-Van; McManus, David D; Chon, Ki H; Medicine; Population and Quantitative Health Sciences; Biostatistics and Health Services Research
In the early stages of atrial fibrillation (AF), most cases are paroxysmal (pAF), making identification only possible with continuous and prolonged monitoring. With the advent of wearables, smartwatches equipped with photoplethysmographic (PPG) sensors are an ideal approach for continuous monitoring of pAF. There have been numerous studies demonstrating successful capture of pAF events, especially using deep learning. However, deep learning requires a large amount of data and independent testing on diverse datasets, to ensure the generalizability of the model, and most prior studies did not meet these requirements. Moreover, most prior studies using wearable-based PPG sensor data collection were limited either to controlled environments, to minimize motion artifacts, or to short duration data collection. Most importantly, frequent premature atrial and ventricular contractions (PAC/PVC) can confound most AF detection algorithms. This has not been well studied, largely due to limited datasets containing these rhythms. Note that the recent deep learning models show 97% AF detection accuracy, and the sensitivity of the current state-of-the-art technique for PAC/PVC detection is only 75% on minimally motion artifact corrupted PPG data. Our study aims to address the above limitations using a recently completed NIH-funded Pulsewatch clinical trial which collected smartwatch PPG data over two weeks from 106 subjects. For our approach, we used multi-modal data which included 1D PPG, accelerometer, and heart rate data. We used a computationally efficient 1D bi-directional Gated Recurrent Unit (1D-Bi-GRU) deep learning model to detect three classes: normal sinus rhythm, AF, and PAC/PVC. Our proposed 1D-Bi-GRU model's performance was compared with two other deep learning models that have reported some of the highest performance metrics, in prior work. For three-arrhythmia-classification, testing data for all deep learning models consisted of using independent data and subjects from the training data, and further evaluations were performed using two independent datasets that were not part of the training dataset. Our multimodal model achieved an unprecedented 83% sensitivity for PAC/PVC detection while maintaining a high accuracy of 97.31% for AF detection. Our model was computationally more efficient (14 times more efficient and 2.7 times faster) and outperformed the best state-of-the-art model by 20.81% for PAC/PVC sensitivity and 2.55% for AF accuracy. We also tested our models on two independent PPG datasets collected with a different smartwatch and a fingertip PPG sensor. Our three-arrhythmia-classification results show high macro-averaged area under the receiver operating characteristic curve values of 96.22%, and 94.17% for two independent datasets, demonstrating better generalizability of the proposed model.
Advancing Equitable Participation in Pediatric Clinical Trials Through Cognitive Interviewing
(2025-01-01) Ryan, Grace W; Goulding, Melissa; Mejia Agudelo, Deicy; Simms, Stephanie; Spano, Michelle; Arenas, Juliana; Becker, Sarah; Radu, Sonia; Lemon, Stephenie C; Rosal, Milagros; Pbert, Lori; Trivedi, Michelle; Population and Quantitative Health Sciences; Prevention Research Center; Pediatrics
Shared Medication Planning In Home Hospice to Address Medication Regimen Complexity and Family Caregiver Burden: A Brief Report
(2024-10-28) Tjia, Jennifer; Clayton, Margaret F; Puerto, Geraldine; Duodu, Vennesa; Troiani, Francesca; Tanikella, Sruthi; DeSanto-Madeya, Susan; Population and Quantitative Health Sciences
Medication management in home hospice is challenging for family caregivers (FCGs). We tested a patient-centered medication review and FCG support program delivered by hospice staff called "Shared Medication PLanning In (SiMPLIfy) Home Hospice." A pilot cluster-randomized trial at two U.S. home hospice agencies measured the primary outcome of reduction in Medication Regimen Complexity Index (MRCI) (range 0 [no medications]-no upper limit) and secondary outcome of Family Caregiver Medication Administration Hassle Scale (FCMAHS) (range 0 [no hassle-120 [greatest hassle]). Twenty-two patient-FCG dyads enrolled. Mean baseline MRCI in the intervention group = 39 (95% CI: 30.9, 47.1) and control group = 25.5 (95% CI: 21.0-30.1). Half of intervention patients (3 of 6) had reduced MRCI compared with 26.7% (4 of 15) control patients ( = 0.07). MRCI was not significantly associated with caregiver burden. FCMAHS differed between spousal and nonspousal FCGs ( = 0.12). A clinician-FCG-patient communication program in home hospice is feasible and may reduce medication complexity. SiMPLIfy has the potential to reduce polypharmacy.
School Nurse Practices Related to Blood Pressure Screening, and Identification and Monitoring of High Blood Pressures in Youth
(2024-12-16) Goulding, Melissa; Branley, Claire; O'Brien, Mary Jane; Hayman, Laura L; Lemon, Stephenie C; Population and Quantitative Health Sciences; Prevention Research Center
Despite rising prevalence of high blood pressure among youth, literature on school nurses' practices related to youth blood pressure is limited. We aimed to describe school nurses' current practices related to blood pressure screening and identification and monitoring of high blood pressures. We conducted a web-based national survey of currently practicing school nurses and received 195 responses across 37 states. All participants reported having a blood pressure cuff, nearly all (98%) reported confidence measuring children's blood pressure, and 82% reported interest in doing more to support children's cardiovascular health. Blood pressure measurement by school nurses was common (73% reported "sometimes" or "often" and 25% reported "seldomly"). However, only 32% stated hypertension impacts their students and only 19% endorsed having enough time to complete all their necessary tasks. In describing school nurse's current practices related to youth blood pressure, we highlight opportunities for expanding this role and considerations for doing so.
Incorporating systems-level stakeholder perspectives into the Design of Mobile Integrated Health Programs
(2024-12-17) O'Connor, Laurel; Behar, Stephanie; Refuerzo, Jade; Mele, Xhenifer; Rowe, Joel; Ulintz, Alexander; Faro, Jamie M; Soni, Apurv; Lindenauer, Peter K; Population and Quantitative Health Sciences; Emergency Medicine; Medicine
Objectives: Despite early evidence of effectiveness, cost-savings, and resource optimization, mobile integrated health (MIH) programs have not been widely implemented in the United States. System, community, and organizational-level barriers often hinder evidence-based public health interventions, such as MIH programs, from being broadly adopted into real-world clinical practice. The objective of this study is to identify solutions to the barriers impeding the implementation of MIH through interviews with multilevel stakeholders. Methods: Using the CENTERing multi-level partner voices in Implementation Theory methodology, the study team recruited stakeholders to participate in semi-structured interviews that were recorded, transcribed, and open-coded. Stakeholders were asked to explore and propose solutions to established barriers to the implementation of MIH programs including poor understanding of the role of MIH, the absence of sustainable reimbursement for MIH programs, and its disruption of existing clinical workflows. The study team used the Consolidated Framework for Implementation Research to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes related to pragmatic solutions for overcoming barriers to the adoption of MIH. Results: Interviews with Department of Public Health officials, medical directors of MIH programs, non-physician MIH program leaders, community paramedics, health insurance officials, ambulatory physicians, hospital administrators, and hospital contract specialists (n = 18) elicited solutions to address barriers including 1) Developing a consistent identity for the MIH paradigm, 2) adopting an interdisciplinary approach to the development of efficient MIH workflows that utilize informatics to mimic existing clinical work, and 3) implementing capitated fee schedules that are cost-effective by targeting high-risk populations that are already a priority for payors. Conclusions: An investigation of solutions to barriers that impede the translation of MIH models into sustainable practice elicited several unifying themes including the establishment of a cohesive identity for MIH to improve engagement and dissemination, the use of a strategic approach to program design that aligns with existing healthcare delivery workflows and collaboration with payors to promote a robust reimbursement structure. These findings may help accelerate the implementation of MIH programs into real clinical practice.
Medications for opioid use disorders among incarcerated persons and those in the community supervision setting: exploration of implementation issues with key stakeholders
(2024-12-18) Kang, Augustine W; Bailey, Amelia; Surace, Anthony; Stein, Lynda; Rohsenow, Damaris; Martin, Rosemarie A; Population and Quantitative Health Sciences
Introduction: Receipt of medications for opioid use disorder (MOUD) critically reduces opioid-related mortality during the post-incarceration period. Optimal provision of this care to individuals on community supervision (i.e., probation) requires an understanding of this unique and complex system at the local level. Methods: We conducted in-depth individual interviews with key treatment providers and probation staff (n = 10) involved with the provision of MOUD to individuals on community supervision in the Northeast. Interviews explored perspectives on the provision of MOUD and support services during the community supervision period. Thematic analysis was conducted to describe inductive and deductive codes, subcodes, and themes. Results: Stakeholders shared diverse attitudes about the benefits and drawbacks of MOUD utilization. The provision of MOUD during the community supervision period was perceived to be influenced by both treatment and probation organizational characteristics, including the structures and values of the agencies. As such, the specific context of the community supervision setting facilitated and impeded MOUD delivery. Persistent challenges to enhancing MOUD delivery to this population remain including widespread MOUD stigma, inter-agency communication issues, and structural barriers to healthcare (i.e., transportation, finances). Conclusions: There are opportunities to enhance access to evidence-based OUD treatment for persons on community supervision by engaging probation agencies and community treatment staff in systems change.
Diet and Physical Activity Behaviors of Breast Cancer Survivors: A Scoping Review
(2024-12-09) Phothikul, Jittrarath; Chung, Joohyun; Faro, Jamie; Seven, Memnun; Population and Quantitative Health Sciences
Objectives: This scoping review explored insight into the current evidence on adherence to health behavior guidelines, specifically diet and physical activity among breast cancer survivors. Methods: A scoping review was conducted through databases including PubMed, CINAHL, Scopus, Web of Science, and SPORTDiscus with Full Text in November 2022, following the JBI methodology. The search strategy combined the keywords i) diet OR nutrition OR eating OR exercise OR physical activity OR fitness and ii) breast cancer survivors OR patients with breast cancer. Results: Twelve original research studies were included; most were conducted in the United States (50%), followed by the European countries (33.34%). Most studies exclusively focused on physical activity (83.33%) and assessed adherence to the physical activity guidelines for Americans (30%), along with the American Cancer Society (20%) and American College of Sports Medicine (20%) guidelines. Overweight or obesity, comorbidity, race, and quality of life were reported as factors associated with physical activity. Independence of disease status was significantly associated with fruit and vegetable intake. Conclusion: Studies reported a wide range of prevalence of adherence to dietary and physical activity recommendations among breast cancer survivors. Further studies are needed to explore diet and physical activity in the context of factors affecting these behaviors among cancer survivors to support the development of healthy behavior, improve health outcomes, and reduce the disease burden among this population. Implication for nursing practice: Nurses have a key role in educating and coordinating multidiscipline teams to initiate and provide cancer survivorship care. These findings indicate that nurses should consider developing targeted strategies and education to promote dietary patterns and physical activity adherence among breast cancer survivors.
Vitiligo is associated with lower body mass index: a retrospective case-control study
(2024-12-09) Sharifzadeh, Afsheen; Wetstone, Rachel; Chen, Li-Chi; Guilarte-Walker, Yurima; Flahive, Julie; Harris, John E; Dermatology; Population and Quantitative Health Sciences; Biostatistics and Health Services Research
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Exploring the Experience of Pain and Pain Management for Pregnant and Postpartum Veterans with Chronic Musculoskeletal Pain
(2024-09-05) Kroll-Desrosiers, Aimee; Wallace, Kate F; Higgins, Diana M; Martino, Steve; Marteeny, Valerie; Walker, Lorrie; Mattocks, Kristin M; Population and Quantitative Health Sciences
Background: To examine how veterans experience and treat pain during the perinatal period, we conducted a qualitative study to explore the experiences of pain, pain management, and facilitators and barriers to treatment among perinatal veterans. Methods: We identified veterans who received care at any of the 15 Veterans Health Administration (VHA) facilities across the United States and were enrolled in an ongoing cohort study. All participants gave birth to a newborn between March 2016 and June 2021 and met the inclusion criteria for having a prepregnancy pain-related musculoskeletal condition. We completed interviews with 30 veterans between November 2021 and January 2022. We used a framework approach to our qualitative analysis. Results: Veterans in our sample were, on average, 31 years of age, married (80%), and white (47%). The most common type of pain diagnoses were back pain (93%) and joint disorders (73%). We identified the following major themes: 1) veteran experiences of pain during pregnancy, 2) challenges to pain care during the perinatal period, and 3) veteran recommendations for VHA perinatal pain care. Experiences of pain during pregnancy varied and several barriers to pain care were identified. Veterans suggested several ways the VHA could improve pain care during the perinatal period, including more training for VHA providers on perinatal pain care and greater complementary and integrative health coverage. Conclusions: Understanding the unique needs of pregnant veterans with chronic pain is important to provide high-quality care during the perinatal period. Veterans who participated in this study highlighted several areas where the VHA could improve pain management during pregnancy and postpartum.
Medication for Opioid Use Disorders (MOUD) Providers' Experiences with Recovery Courts: Qualitative Study of Individual and Systemic Factors Impacting Interagency Collaboration
(2024-12-04) Pivovarova, Ekaterina; Taxman, Faye S; Boland, Alexandra K; Andraka-Christou, Barbara; De La Cruz, Barbara A; Smelson, David; Lemon, Stephenie C; Friedmann, Peter D; Prevention Research Center; Population and Quantitative Health Sciences; Family Medicine and Community Health; Medicine
Background: Recovery courts mandate substance use disorder treatment as an alternative to prosecution or incarceration but lack internal resources to offer treatment. Hence, recovery courts must rely on community-based providers to ensure access to care. Interagency collaborations between recovery courts and providers of medications for opioid use disorders (MOUD) are often challenging. This qualitative study aimed to understand community-based MOUD providers' perspectives on collaboration with recovery courts. Methods: Semi-structured, hourlong interviews were conducted with 24 providers from 11 community agencies about their experiences and perceptions of working with recovery courts. Consolidated Framework for Implementation Research informed study design, coding, and analysis. Results: At the individual-level domain, lack of knowledge about recovery courts and overall negative impressions of the criminal legal system were impediments to collaboration. Inner setting factors such as staffing shortages and provider roles in establishing therapeutic relationships limited active engagement in interagency collaboration. Outer setting domains such as communication barriers (eg, requirement of multiple release forms, lack of knowledge about who needed what information and when) and nonresponse from the courts were frequently referenced. Providers, however, also noted that direct experience with recovery court staff, especially in person, and recognition of mutual agency goals to ensure individuals receive proper care and remain in the community served as facilitators. Discussion: While interagency collaboration is essential to ensuring that individuals in recovery courts can access MOUD, providers identify individual- and system-level barriers that impact collaboration with recovery courts. Results from providers mirror findings from recovery court staff that note communication barriers, distrust toward external agencies, and limited resources for active collaboration. Findings highlight areas where implementation strategies to improve collaboration can be targeted to ensure that individuals in recovery courts can access and remain in MOUD treatment.
Digital Health Tools and Behavioral Strategies to Increase Engagement With Diabetes Self-Management Education and Support: Design and Feasibility of DM-BOOST
(2024-10-14) Amante, Daniel J; Shenette, Lisa; Wainaina, Stacey; Balakrishnan, Kavitha; Bhatia, Shina; Lee, Jung Ae; Lemon, Stephenie C; McManus, David; Harlan, David M; Malkani, Samir; Gerber, Ben S; Population and Quantitative Health Sciences; Medicine; Diabetes Center of Excellence; Biostatistics and Health Services Research
Purpose: The purpose of the study was to describe the development and feasibility of implementing the DM-BOOST program in support of an established diabetes self-management education and support (DSMES) program. Methods: A patient panel of 4 adults with type 2 diabetes (T2DM) codesigned DM-BOOST. DM-BOOST is a patient-focused program that includes peer-written text messages about diabetes self-management behaviors and digital health training to improve patient portal use and initiate goal setting prior to a scheduled DSMES appointment. Adults with T2DM and A1C ≥8.0% participated in a 6-month feasibility pilot. Participants were randomly assigned (1:1) to receive either DM-BOOST or usual care. Outcomes included DSMES engagement (scheduled and attended DSMES appointments) and changes in diabetes self-efficacy and treatment satisfaction. Results: Pilot participants (n = 60) were 60.0% female with mean age 45.5 years (SD 8.3) and A1C 10.1% (SD 1.8%). All DM-BOOST participants (30/30, 100%) had DSMES appointments scheduled compared to 86.7% of usual care (26/30). DM-BOOST participants had fewer DSMES appointment no-shows/cancellations (3/30, 10%) compared to usual care (10/26, 35%). There was greater improvement in diabetes self-efficacy in the DM-BOOST group compared to usual care and no difference in treatment satisfaction. Conclusions: DM-BOOST, leveraging peer-written text messaging and digital health training, increased DSMES engagement. Implementation of DM-BOOST was determined to be feasible, with several system-level barriers identified, including obtaining provider referrals and scheduling appointments. An effectiveness trial of DM-BOOST is needed to evaluate the impact on clinical outcomes.
Healthy at Home for COPD: An Integrated Digital Monitoring, Treatment, and Pulmonary Rehabilitation Intervention [preprint]
(2024-11-15) O'Connor, Laurel; Behar, Stephanie; Tarrant, Seanan; Stamegna, Pamela; Pretz, Caitlin; Shirshac, Jeanne; Scornavacca, Thomas; Wilkie, Tracey; Fisher, Kimberly; Tigas, Emil; Mullen, Marie; Hyder, Michael; Wong, Steven; Savage, Brendon; Toomey, Shaun; Wang, Biqi; Zai, Adrian; Alper, Eric; Lindenauer, Peter; Dickson, Eric; Broach, John; McManus, David; Kheterpal, Vik; Soni, Apurv; Population and Quantitative Health Sciences; Emergency Medicine
Background: Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality in the United States. Frequent exacerbations result in higher use of emergency services and hospitalizations, leading to poor patient outcomes and high costs. Objective: Demonstrate the feasibility of a multimodal, digitally enhanced remote monitoring, treatment, and tele-pulmonary rehabilitation intervention among patients with COPD. Methods: In this pilot clinical trial, community-dwelling adults with moderate-severe COPD were enrolled in a multimodal digital monitoring and treatment program including a Fitbit wearable device, study app that tracked COPD-related symptoms, on-demand mobile integrated health (MIH) services for acute home-based treatment, and tele-pulmonary-rehabilitation. Participants were enrolled in the program for six months. COPD severity and health-related quality of life assessments were performed at baseline, 3 months, and 6 months. Primary feasibility outcomes include recruitment and retention rate, and participant protocol fidelity, which were reported descriptively. Exploratory clinical outcomes included patient-reported quality of life, activation, and intervention satisfaction. Results: Over 18 months, 1,333 patients were approached and 100 (7.5%) were enrolled (mean age 66, 52% female). Ninety-six participants (96%) remained in the study for the full enrollment period. Fifty-five (55%) participated in tele-pulmonary-rehabilitation. Participants wore the Fitbit for a median of 114 days (IQR 183.6) and 16.85 hours/day (4.05), resulting in a median of 1133 minutes (243) per day. Completion rates for scheduled instruments ranged from 78-93%. Nearly all participants (85%) performed COPD ecological momentary assessment at least once with a median of 4.85 recordings. On average, a 2.48-point improvement (p=0.03) in COPD Assessment Test Score was observed from baseline to study completion. The adherence and symptom improvement metrics were not associated with baseline patient activation measures. Conclusions: A multimodal intervention combining preventative care, symptom and biometric monitoring, and home treatment was feasible in adults living with COPD. Participants demonstrated high protocol fidelity and engagement and reported improved quality of life.
Rationale and design of healthy at home for COPD: an integrated remote patient monitoring and virtual pulmonary rehabilitation pilot study
(2024-10-28) O'Connor, Laurel; Behar, Stephanie; Tarrant, Seanan; Stamegna, Pamela; Pretz, Caitlin; Wang, Biqi; Savage, Brandon; Scornavacca, Thomas Thomas; Shirshac, Jeanne; Wilkie, Tracey; Hyder, Michael; Zai, Adrian; Toomey, Shaun; Mullen, Marie; Fisher, Kimberly; Tigas, Emil; Wong, Steven; McManus, David D; Alper, Eric; Lindenauer, Peter K; Dickson, Eric; Broach, John; Kheterpal, Vik; Soni, Apurv; Population and Quantitative Health Sciences; Emergency Medicine; Family Medicine and Community Health; Medicine
Chronic obstructive pulmonary disease (COPD) is a common, costly, and morbid condition. Pulmonary rehabilitation, close monitoring, and early intervention during acute exacerbations of symptoms represent a comprehensive approach to improve outcomes, but the optimal means of delivering these services is uncertain. Logistical, financial, and social barriers to providing healthcare through face-to-face encounters, paired with recent developments in technology, have stimulated interest in exploring alternative models of care. The Healthy at Home study seeks to determine the feasibility of a multimodal, digitally enhanced intervention provided to participants with COPD longitudinally over 6 months. This paper details the recruitment, methods, and analysis plan for the study, which is recruiting 100 participants in its pilot phase. Participants were provided with several integrated services including a smartwatch to track physiological data, a study app to track symptoms and study instruments, access to a mobile integrated health program for acute clinical needs, and a virtual comprehensive pulmonary support service. Participants shared physiologic, demographic, and symptom reports, electronic health records, and claims data with the study team, facilitating a better understanding of their symptoms and potential care needs longitudinally. The Healthy at Home study seeks to develop a comprehensive digital phenotype of COPD by tracking and responding to multiple indices of disease behavior and facilitating early and nuanced responses to changes in participants' health status. This study is registered at Clinicaltrials.gov (NCT06000696).
Repetitive transcranial magnetic stimulation alleviates motor impairment in Parkinson's disease: association with peripheral inflammatory regulatory T-cells and SYT6
(2024-10-25) Xie, Fen; Shen, Bibiao; Luo, Yuqi; Zhou, Hang; Xie, Zhenchao; Zhu, Shuzhen; Wei, Xiaobo; Chang, Zihan; Zhu, Zhaohua; Ding, Changhai; Jin, Kunlin; Yang, Chengwu; Batzu, Lucia; Chaudhuri, K Ray; Chan, Ling-Ling; Tan, Eng-King; Wang, Qing; Biostatistics and Health Services Research; Population and Quantitative Health Sciences
Background: Repetitive transcranial magnetic stimulation (rTMS) has been used to treat various neurological disorders. However, the molecular mechanism underlying the therapeutic effect of rTMS on Parkinson's disease (PD) has not been fully elucidated. Neuroinflammation like regulatory T-cells (Tregs) appears to be a key modulator of disease progression in PD. If rTMS affects the peripheral Tregs in PD remains unknown. Methods: Here, we conducted a prospective clinical study (Chinese ClinicalTrials. gov: ChiCTR 2100051140) involving 54 PD patients who received 10-day rTMS (10 Hz) stimulation on the primary motor cortex (M1) region or sham treatment. Clinical and function assessment as well as flow cytology study were undertaken in 54 PD patients who were consecutively recruited from the department of neurology at Zhujiang hospital between September 2021 and January 2022. Subsequently, we implemented flow cytometry analysis to examine the Tregs population in spleen of MPTP-induced PD mice that received rTMS or sham treatment, along with quantitative proteomic approach reveal novel molecular targets for Parkinson's disease, and finally, the RNA interference method verifies the role of these new molecular targets in the treatment of PD. Results: We demonstrated that a 10-day rTMS treatment on the M1 motor cortex significantly improved motor dysfunction in PD patients. The beneficial effects persisted for up to 40 days, and were associated with an increase in peripheral Tregs. There was a positive correlation between Tregs and motor improvements in PD cases. Similarly, a 10-day rTMS treatment on the brains of MPTP-induced PD mice significantly ameliorated motor symptoms. rTMS reversed the downregulation of circulating Tregs and tyrosine hydroxylase neurons in these mice. It also increased anti-inflammatory mediators, deactivated microglia, and decreased inflammatory cytokines. These effects were blocked by administration of a Treg inhibitor anti-CD25 antibody in MPTP-induced PD mice. Quantitative proteomic analysis identified TLR4, TH, Slc6a3 and especially Syt6 as the hub node proteins related to Tregs and rTMS therapy. Lastly, we validated the role of Treg and rTMS-related protein syt6 in MPTP mice using the virus interference method. Conclusions: Our clinical and experimental studies suggest that rTMS improves motor function by modulating the function of Tregs and suppressing toxic neuroinflammation. Hub node proteins (especially Syt6) may be potential therapeutic targets. Trial registration: Chinese ClinicalTrials, ChiCTR2100051140. Registered 15 December 2021, https://www.chictr.org.cn/bin/project/edit?pid=133691.
Health Care Workers' Perspectives on Collecting Sexual Orientation and Gender Identity in the Adult Primary Care Setting
(2024-10-02) LeClair, Amy M; Rose, Raviv; Barker, Olivia; Carpenter, Eilish; Concannon, Thomas W; Boehmer, Ulrike; Blazey-Martin, Deborah; Bird, Chloe E; Freund, Karen M; Lemon, Stephenie C; Population and Quantitative Health Sciences; Prevention Research Center
Background: Despite numerous calls for standardized collection of sexual orientation and gender identity (SOGI) data in clinical settings, uptake of this practice still lags. Objectives: This study conducted a preimplementation assessment of staff attitudes toward SOGI data collection within an adult primary care practice in an urban academic medical center in the northeastern United States. Research design: We created a process map of the flow of patient data from the point of registration to the clinical encounter to identify all staff roles associated with registration and patient demographic data collection. We purposively sampled staff members across these roles and conducted semistructured virtual interviews between November 2021 and February 2022. The research team used deductive and inductive coding and conducted a thematic analysis to identify barriers and facilitators to implementation. Subjects: Nine clinical staff and eleven nonclinical staff were interviewed. Measures: Participants were asked about their general experiences with lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients, their perspectives on collecting this data, and potential barriers and facilitators to incorporating this into the workflow. Results: The main themes that emerged were the relevance of SOGI data to the clinical practice; concerns about patient acceptability; the prevalence of cis-gender, heteronormative assumptions; and concerns about linguistic, cultural, and generational differences. Differences were noted between clinical and nonclinical staff. Conclusions: Greater education is needed to help both clinical and nonclinical staff understand how patients' SOGI demographics can be used to provide affirming, patient-centered care. Implementation strategies can be tailored to address specific barriers at the individual, organizational, and social levels.

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