Publications

PURPOSE: Fear of cancer recurrence (FCR) is highly common and, if poorly managed, can be distressing and impairing. We developed a virtual, mind-body resiliency intervention for fear of cancer recurrence in survivorship (IN FOCUS), which was shown to be feasible and improved FCR post-intervention. This report aimed to describe coping processes associated with FCR and effects of IN FOCUS on coping over time.

METHOD: A single-blinded, 2-arm, randomized controlled trial was conducted from July 2021 to March 2022 comparing IN FOCUS (8 weekly, 90-minute, synchronous virtual group classes teaching cognitive behavioral techniques, relaxation training, meditation, adaptive health behaviors, and positive psychology skills) to usual care (synchronous virtual community group support referral) among cancer survivors with non-metastatic disease and clinically elevated FCR (FCR Inventory severity ≥16). Measures included coping styles (Brief COPE) and perceived coping skills (Measure of Current Status-Part A). Intent-to-treat analyses with separate general linear mixed models were used to identify group-by-time effects (Cohen's d; 0.5 a medium effect, 0.8 a large effect) from baseline through 2 months and 5 months.

RESULTS: Sixty-four survivors enrolled (age M = 52 years, time since completing primary cancer treatment M = 5 years). By 5 months, survivors randomized to IN FOCUS (vs usual care) demonstrated multiple effects on coping in the medium to large range. Compared to usual care, IN FOCUS increased problem-focused coping, such as using instrumental support (d = 0.60), planning (d = 0.60), positive reframing (d = 0.48), and active coping (d = 0.45). Similarly, IN FOCUS improved emotion-focused coping, specifically venting (d = 0.70), acceptance (d = 0.58), humor (d = 0.50), and religion (d = 0.48). IN FOCUS also enhanced survivors' coping confidence (d = 0.79), relaxation skills (d = 0.57), and assertiveness (d = 0.46). Avoidance-focused coping and awareness of physical tension exhibited less robust changes by 5 months.

CONCLUSIONS: Cancer survivors can enhance multiple aspects of coping with FCR through interventions such as IN FOCUS that teach mind-body resiliency techniques.

BACKGROUND: Frailty is a proxy for biologic aging that confers risk independently of chronologic age. Most frailty indices correlate strongly with chronologic age, making independent features of biologic aging challenging to identify.

METHODS: We aimed to create a novel Age Less-Dependent Frailty (AGELESS) Score less-associated with chronologic age than the Fried frailty phenotype. Among Cardiovascular Health Study participants with available echocardiographic data, we identified demographic, clinical, serologic, and echocardiographic variables more correlated with a continuous version of the Fried frailty phenotype than age, then used LASSO regression for variable selection. In a 25% leave-out sample, we internally validated the score's association with age-adjusted all-cause and cardiovascular mortality and compared model characteristics with the Fried frailty phenotype.

RESULTS: In 4,029 individuals (mean age 72 ± 5.0 years, 59.6% female), serum cystatin C, depression, diabetes, educational attainment, forced expiratory volume in 1 s, and income were more associated with frailty than age and selected for inclusion in the AGELESS Score. Adjusted for age, individuals in the highest vs. lowest quartiles of the AGELESS Score had a higher risk of all-cause (HR: 1.44, 95% CI: 1.17-1.79, p < 0.001) and CV death (HR: 1.64, 95% CI: 1.43-1.87, p = 0.002). The AGELESS Score was less correlated with age (AGELESS r = 0.23, 95% CI: 0.16-0.30; Fried r = 0.28, 95% CI: 0.21-0.34; p-value for comparison of correlations < 0.001) and more closely associated with all-cause and CV mortality within each age quartile than the Fried frailty phenotype.

CONCLUSIONS: We derived and internally validated a novel frailty score that is less associated with chronologic age than existing indices and predicts mortality within age strata better than the existing reference standard for phenotypic frailty. This score could help identify high-risk patients with frailty across the age spectrum and may provide insights into mechanisms of biologic aging.

BACKGROUND: ED disposition decisions for older adults are complex and often uncertain, yet studies rarely capture emergency physicians' real-time perspectives.

OBJECTIVE: To assess patient outcomes based on emergency physician-perceived need for admission.

DESIGN: Single-site prospective cohort study conducted between July and November 2024.

SETTING: A Boston-area academic tertiary care ED.

PARTICIPANTS: Patients aged 65 and older dispositioned by attending physicians, excluding patients who were handed off, left without being seen, or eloped.

MEASUREMENTS: Physicians rated admission need using a 5-point Likert scale (2-4 considered marginal). Primary outcome was ED disposition stratified by rating. Secondary outcomes were hospital length-of-stay (LOS), 7-day ED return, and 30-day mortality.

RESULTS: Of the 489 patients (mean age 76.9 years [SD 7.5], 51.1% female), 55.8% were non-marginal admissions, 26.0% were non-marginal discharges, and 18.2% were marginal dispositions. Patients with marginal dispositions had longer workup times than non-marginal admissions or discharges (3.3 vs. 2.8 vs. 2.4 h, p < 0.05). Thirty-day mortality was greater for non-marginal admissions (8.8%) than non-marginal discharges (1.6%, p = 0.01), but not significantly different than marginal dispositions (3.4%). Marginal admissions had shorter median LOS (3.1 vs. 5 days, p < 0.01) and higher early discharge rates (27.8% vs. 13.2%, p = 0.01) than non-marginal admissions. Marginal discharges had fewer 7-day returns than non-marginal discharges (0% vs. 11.7%, p = 0.04). For marginal cases, physicians discussed admission benefits more than risks (70.1% vs. 43.3%, p < 0.01) for marginal cases.

LIMITATIONS: Single-site and need for admission were reported contemporaneous with disposition decision.

CONCLUSIONS: One in six older adult ED dispositions was identified as marginal. These patients are potential targets for shared decision-making and alternative care pathways.

BACKGROUND: Limited access to primary care may disproportionately affect older adults, who often have greater chronic disease management and care coordination needs. However, little is known about the effect of having a primary care practitioner (PCP) on longevity in the aging population.

OBJECTIVE: To examine the association of having a usual source of primary care with mortality and life expectancy among US adults aged 65 and older.

DESIGN: Retrospective cohort study, using nationally representative data from the 2000 and 2005 cohorts of the National Health Interview Survey linked with National Death Index records through 2019.

PARTICIPANTS: All respondents aged 65 to 84 (n = 10,873, weighted n = 16,484,914).

INTERVENTIONS/EXPOSURES: Having a usual source of primary care.

MAIN MEASURES: Using a Cox proportional hazards model, we examined the association between exposure to primary care and 15-year mortality, adjusting for sociodemographic factors and respondent life expectancy (using a validated index). We also used this model to generate survival curves by exposure to primary care and computed median survival times for each group.

KEY RESULTS: Overall, 60.3% of respondents were female, 83.6% were non-Hispanic White, and 6.4% (n = 739, weighted n = 1,056,554) did not have a usual source of primary care. Use of primary care was associated with a lower 15-year mortality risk (aHR: 0.84, 95% CI: 0.72-0.98). Median survival time was also at least 2.1 years longer among those who used primary care (> 15 years) compared to those who did not (12.9 years).

CONCLUSIONS: We found that primary care use is associated with greater survival among older adults. As the population of adults aged 65 + is growing rapidly, investing in primary care is essential for the health of US older adults.

BACKGROUND: Hypertension, a major contributor to cardiovascular mortality, requires multimodal monitoring and management strategies for optimal blood pressure (BP) control. Patients are turning toward mobile health (mHealth) applications to manage hypertension which vary widely in design and regulation. This study examines the landscape of hypertension mHealth applications on Apple's App Store and Google's Play Store and qualitatively evaluates their functionality and security features from patient and clinician perspectives.

METHODS: Publicly available applications were identified using keyword "hypertension" on the Apple App Store and Google Play Store or in a recent meta-analysis that met specific review criteria. Applications with <1,000 reviews (Apple Store) or < 10,000 reviews (Google Play Store) were excluded to capture the top 5% of applications with high public use. Of > 700 applications, 43 underwent full application screening and eighteen were reviewed for general information, storage, revenue models, security, patient/clinician interfaces, and associated research. Discrepancies were resolved through consensus and available manufacturer confirmation.

RESULTS: Clinician interfaces were largely absent, with limited EMR integration and alert systems. Revenue models ranged from free to subscription-based. Security and data privacy policies varied with applications lacking clear opt-out options for data collection. Patient interfaces offered BP tracking and reminders, and accessibility features. Sentiment analysis showed an overall positive view of frequently reviewed Google Play Store applications.

CONCLUSIONS: Current mHealth applications lack several features for optimal hypertension monitoring and management. Based on the range of qualitative application features assessed, we formulate a framework for developing an ideal mHealth application for optimal hypertension management.

OBJECTIVES: To evaluate the impact of a phased, multifaceted intervention on reducing central line-associated bloodstream infection (CLABSI) rates in a large pediatric referral hospital in Vietnam.

METHODS: A multi-year quality improvement study conducted in six intensive care units at the Vietnam National Children's Hospital. The intervention was implemented in three phases: baseline surveillance (2018-2019), CLABSI prevention bundle implementation (2020-2021), and compliance monitoring with data-driven quality improvement (2021-2024). Primary outcome was CLABSI incidence per 1,000 central line-days. Bundle compliance was assessed using structured checklists. Descriptive methods were used to examine trends in CLABSI and compliance rates. Associations between bundle compliance and CLABSI rates were explored.

RESULTS: The pooled CLABSI rate declined from 5.8 per 1,000 central line-days at baseline to 0.9 per 1,000 in 2024, representing an 84.5% reduction. Among 12,189 observed central line insertions, compliance with all prevention bundle elements was 89.7%, increasing from 84.6% in 2021 to 93.1% in 2024 (p<0.001). Higher quarterly compliance correlated with lower quarterly CLABSI rates (r=-0.555; p=0.039).

CONCLUSIONS: A sustained reduction in CLABSI rates was achieved through a multifaceted approach integrating standardized surveillance, evidence-based bundles, and continuous audit-and-feedback. This study demonstrates the feasibility of adapting and sustaining infection prevention strategies in a pediatric low- and middle-income country setting.

Conventional cuff-based blood pressure (BP) monitoring has several limitations, including patient discomfort with arm cuff inflation, inconvenience, and limited frequency of readings. Cuffless BP devices, which are increasingly available for purchase on the international market, have the potential to remove barriers to BP measurement in both research and clinical care. However, there are unanswered questions on whether, how, and in what settings these devices may be appropriate for use. Gaps include the need to understand whether the somewhat distinctive and often enormous volume of readings obtained by these devices have meaningful relationships with clinical outcomes and are appropriate for determining actionable interventions. Furthermore, international standards for determining the accuracy of some, but not yet all, of these devices only recently became available and do not provide a full assessment of the typical use of the devices. Thus, the devices on the market have not yet been adequately vetted for accuracy and efficacy. Several of these devices, however, have been cleared by the US Food and Drug Administration and are being used clinically. Moreover, many patients use cuffless devices for BP self-monitoring, often without disclosing this information to health care professionals. This scientific statement provides an overview of the existing literature on cuffless BP monitoring technologies and their potential future applications, and stresses the importance of understanding the gaps that need to be filled before these devices can be used clinically, recognizing that currently available devices may be inappropriate for clinical use.

OBJECTIVE: Complicated mild traumatic brain injury (cmTBI) is a common emergency consultation in trauma care at community and tertiary hospitals. While neurosurgical evaluation is typically required, actual neurosurgical intervention is rare. The aim of this study was to evaluate the adoption, safety, and effectiveness of a telemedicine-based neurosurgery consultation program (tele-TBI) in reducing unnecessary interhospital transfers of patients with cmTBI.

METHODS: A multidisciplinary team implemented the tele-TBI program at 4 community hospitals. Patients with cmTBI who were eligible to receive telehealth consultations over the first 2 years of the program were retrospectively analyzed. The program's impact on reducing interhospital transfers, disposition outcomes, and safety were assessed.

RESULTS: Of 179 eligible patients (94 female, mean age 75 years) reviewed, 117 underwent tele-TBI consultation and 62 did not. Among the patients with tele-TBI consultations, 15 (13%) were transferred to tertiary centers, with 2 (1.7%) admitted to the ICU, 10 (8.5%) admitted to the floor, and 3 (2.6%) managed in the emergency department. Most patients (87%) who underwent tele-TBI consultation were effectively managed at community hospitals; 90 (77%) were observed in the emergency department then discharged and 12 (10%) were admitted. In contrast, all 62 patients without tele-TBI consultation were transferred to tertiary hospitals, of whom 10 (16%) were admitted and 52 (84%) were observed in the emergency department and then discharged. Multivariate analysis revealed that subdural hematoma (OR 2.90, 95% CI 1.53-5.51) and age < 80 years (OR 0.25, 95% CI 0.11-0.56) significantly influenced the likelihood of transfer.

CONCLUSIONS: The tele-TBI program reduced unnecessary interhospital transfers. Notably, most patients with tele-TBI consultation were successfully managed in their community hospital. Moreover, nearly 4 of 5 patients without tele-TBI consultation were transferred, only to be discharged directly from the tertiary referral center's emergency department.

Achieving digital health equity and proper use of identity credentials is crucial as reliance on electronic modalities increases. Proxy access-now increasingly referred to as shared access-is a widely available functionality that offers identity credentials to care partners who assist loved ones in navigating the electronic care delivery demands of patients with complex care needs. However, adoption of these tools has been hindered by complicated user interfaces and low awareness.Drawing on frameworks and principles rooted in human-centered design (HCD), we conducted an evaluation of a multisite quality improvement study designed to increase the awareness and adoption of shared access to patient portals for older adults and their care partners. Through feedback gathered from key informants, we identified barriers to the adoption of materials created for the parent quality improvement project, and synthesize additional implementation strategies from informant feedback to improve shared access.We employed the Double Diamond Model (DDM) of HCD to guide our research. The DDM includes engaging a diverse group of community partners-older adults, care partners, health care system leaders, communications professionals-through focus groups and individual interviews. Our process involved identifying pain points related to registration for shared access, then synthesizing these insights through inductive coding and affinity mapping to generate solutions.An analysis of our community partner feedback revealed several themes, including the necessity for simplified patient portal registration, standardized terminology about shared access, and clear messaging strategies. A step-by-step video tutorial was developed as a prototype. The prototype was then implemented at a partner health system and received positive feedback, suggesting its potential for broader use.These findings emphasize the importance of involving "end users" (patients, care partners, health care system leaders, communications professionals) in the evaluation and implementation of digital health tools. Approaching challenges with an HCD mindset helped our team identify barriers to shared access adoption and led to the development of a tangible resource (prototype and video). This project highlights the potential for HCD to drive improvements in digital health equity.This research demonstrates a practical application of HCD methods in developing effective solutions for enhancing shared access for older adults, and all people using patient portals.