Publications

OBJECTIVES: Emergency department (ED) visits offer opportunities for seriously ill patients to formulate future medical care goals, yet ED clinicians lack practical strategies for these conversations. ED GOAL, a behavioral intervention, engages seriously ill yet clinically stable older adults in the ED to address advance care planning (ACP) with their outpatient clinicians. In a randomized trial, goals-of-care documentation was significantly higher in the intervention group compared to controls after three (24.3% vs. 9.9%, p = 0.03) and 6 months (31.4% vs. 12.7%, p < 0.01). This study is a sub-analysis to learn about intervention arm participants' perceived benefits and obstacles of the intervention.

METHODS: We conducted semi-structured interviews between October 2022 and August 2024 (N = 52) with intervention-arm patients aged 50+ years at three hospitals in Boston, Massachusetts. Using rapid qualitative analyses, we identified themes in intervention-arm participants' comments to open-ended questions about the intervention's benefits and obstacles to continue ACP outside the ED.

RESULTS: Of 70 intervention-arm participants, 52 completed interviews, of which two were surrogates. ED GOAL motivated most patients to initiate ACP with outpatient clinicians and loved ones and improved the quality of conversations by clarifying patients' wishes and improving patient-clinician relations. Barriers to continuing ACP were the lack of clinician availability and patient/surrogate readiness. Those with clear care goals found the intervention less useful yet harmless.

CONCLUSIONS: The intervention provided participants with insights into actionable ACP steps. To address the lack of clinician availability, these conversations may be completed by non-physician clinicians or through non-personnel resources. Better tailored ACP interventions may improve patients' readiness.

TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05209880.

Organ transplant listing decisions are made by multidisciplinary selection committees using structured, deliberative processes to evaluate candidate eligibility. Engaging patients in these meetings has been proposed as a strategy to enhance transparency, trust, and patient-centered care. This study assessed patient and professional perspectives via an online survey of 1,349 American Society of Transplantation (AST) and National Kidney Foundation (NKF) members (907 patients, caregivers, family; 442 transplant team members). Among patient respondents, 77% (n=694) supported the option for patients to participate in transplant listing meetings, compared to 27% (n=121) of transplant team members. Additionally, 79% (n=717) of patients agreed that patient involvement would enhance trust, compared to 37% (n=164) of transplant team members. Qualitative analysis revealed four key themes: Patient-Centeredness Requires Inclusion (voice and visibility, addressing information gaps, fostering transparency and trust); Feasibility (open dialogue in patient-inclusive settings, logistics and work flow); Tradeoffs (potential harms, equity); and Seeking Common Ground. This study highlights the perspectives between patients and transplant care team members regarding patient participation in listing committee meetings. The contrasting views highlight an area for further exploration. Bridging this gap may help create a collaborative decision-making framework that equally values and integrates the opinions of both patients and transplant care team.

BACKGROUND: The Dietary Approaches to Stop Hypertension (DASH) Eating Plan is proven to lower blood pressure; however, the original DASH diet involved a set menu of meals prepared in a metabolic kitchen. There is little evidence mapping this dietary pattern to real-world groceries, tailored to a range of cultural preferences and dietary practices.

METHODS: The GoFresh Trial, a parallel-arm randomized, controlled trial, is studying the impact of DASH-patterned, home-delivered groceries on the blood pressure of Black adults living in communities with reduced access to grocery stores. Participants were able to choose DASH-patterned groceries according to their preferences for themselves and up to five family members from local supermarkets. A dietitian assisted participants with grocery selection to ensure that groceries followed a DASH pattern and met potassium/sodium ratio of >2.2 with kilocalories from saturated fat ≤7%. In addition, dietitians provided weekly educational modules on sustainably adopting DASH. Two conceptual frameworks were designed to address five domains related to diet adoption: accessibility and cost, food preparation, social influences, individual beliefs, and cultural adaptations. To support meal preparation, a recipe book and 24 demonstration videos were created in collaboration with Boston chefs to highlight heritage diets like African and Afro-Caribbean.

RESULTS: Compliance assessments include 24-hour urine paired with 24-hour nutrition recalls, seated blood pressure, and surveys collecting information on food preparation and shopping habits.

CONCLUSION: Findings from this study will inform policy related to healthy food access and provide real-world examples of how DASH might be adapted in a real-world context now and in years to come.

BACKGROUND: OBJECTIVE: To characterize hospital phenotypes with respect to trends in observation care use and examine whether patterns differ for people with AD/ADRD.

DESIGN: Retrospective cohort study.

SUBJECTS: Traditional Medicare beneficiaries aged 68 + who visited an emergency department from 2012 to 2019.

MAIN MEASURES: For each beneficiary, we determined visit disposition (e.g., discharge, inpatient admission, or observation stay). We calculated hospital-level slopes for each disposition using linear regression and categorized each hospital as having an increase, decrease, or no change in each disposition category. Cross-tabulations of these trends determined hospital phenotypes (e.g., increasing observation stays along with decreasing admissions). We compared phenotypes by hospital characteristics and repeated these analyses stratified by AD/ADRD diagnosis.

KEY RESULTS: Sample included 22,780,334 ED visits among 5,162,037 beneficiaries at 4835 hospitals. Nationally, the percentage of visits ending in observation increased over time, but there was a substantial decrease in observation stays among 17.5% of hospitals, and 41.4% saw no change. There were 68.8% of hospitals with identifiable phenotypes of observation use trends, the most common of which (N = 788 hospitals, 16.3%) was an increase in the rate of observation stays and a decrease in the rate of admissions. Large, teaching, and urban hospitals saw a disproportionate increase in observation use, while small, non-teaching rural and critical access hospitals saw no meaningful change. A greater share of hospitals saw an increase in observation for beneficiaries with AD/ADRD compared to those without AD/ADRD (49.0% vs. 40.0%).

CONCLUSIONS: While there has been a large national increase in observation use for Medicare beneficiaries, trends among individual hospitals varied substantially, with differential patterns by hospital characteristics and beneficiary AD/ADRD status.

BACKGROUND: Medical cannabis consumption is rising, but limited evidence informs the safety and efficacy of cannabis use in cancer patients. A national survey of oncology trainees found that most fellows felt insufficiently informed to make clinical recommendations about cannabis.

AIM: In this secondary analysis, we aimed to measure how frequently trainees recommend in favor of cannabis and determine factors influencing this clinical practice.

METHODS: In this cross-sectional survey study for fellows enrolled in oncology training programs across the United States, an online survey assessing trainee practices regarding medical cannabis was sent to 155 oncology fellowship program directors from January - March 2021; who were asked to distribute it to their fellows. The primary outcome was the frequency with which oncology fellows recommended cannabis in the prior year.

RESULTS: Nationally, 40 programs from 25 states participated, with 189 of 462 trainees across these programs responding (40.9% response rate). 22% (95% CI: 16.3-29.0%) of participants reported recommending medical cannabis to > 5 patients in the past year. 24% (95% CI: 18.4-30.5%) of participants had prior training in medical cannabis. Regarding participant characteristics, only prior training in medical cannabis was significantly associated with recommending cannabis to > 5 patients (RR: 2.4; 95% CI: 1.4-4.2).

CONCLUSIONS: With increasing cannabis use among patients with cancer and given that a substantial number of oncology fellows recommend its use, it is crucial that fellowship training incorporate evidence-based curricula regarding medical cannabis use to guide informed decision-making between patients and their fellow providers.

BACKGROUND: Stigma is a key barrier to compassionate primary health care delivery and people-centered care (PCC), but is understudied among primary care providers (PCPs). Hepatitis B and C have a significant burden of disease in the Philippines, where there is limited awareness of and access to screening and treatment. Patient-reported stigma has been identified as a significant barrier to hepatitis care in the Philippines, but PCP stigma-related attitudes and behaviors have not been explored in this context.

METHODS: In this study, we assessed primary PCP-reported stigma-related attitudes and behaviors toward patients with hepatitis B and C. We surveyed primary PCPs in Tarlac, Philippines working within a network of healthcare facilities that have been part of an initiative to decentralize hepatitis care to the primary care level and prioritize PCC.

RESULTS: We found that PCPs' self-reported attitudes toward patients with hepatitis B and C reflect a strong sense of responsibility to provide care, and comfort with sensitive history-taking, but also pervasive attitudes of pity and blame. PCPs' self-reported behaviors showed commitment to providing equal care, but variation in infection control practices suggesting misconceptions about transmission risk.

CONCLUSIONS: Our results provide essential insight into PCPs' stigma-related attitudes and behaviors that will serve as a baseline for future comparison with patient-reported experiences. These findings underscore the critical role of primary care in addressing stigma and improving hepatitis care in the Philippines, highlighting the importance of training, resource allocation, and people-centered care strategies.

In their previously published article in the Israel Journal of Health Policy Research, Rose and colleagues describe and advocate for greater use of implementation science in Israel. As a discipline, implementation science seeks to traverse the last steps in bringing new science from research to clinical practice, which are often the most difficult of the entire process. Implementation science in general faces substantial challenges, including the extraordinary heterogeneity of the dissemination process, and the obstacles represented by established practices, singular preferences, and questions about generalizability. In our view, implementation science complements classic epidemiology as part of a continuum of population health research that warrants greater attention and funding. For now, however, implementation science will need to show that it can consistently achieve sizable, durable, and widespread results if it is to traverse its own last mile and establish itself as a successful and permanent component of biomedicine in Israel.

OBJECTIVE: Accidental falls are the leading cause of injury for older adults in the United States. Identifying risk factors for falls is a public health priority. Poor sleep is prevalent among aging adults and has been linked to falls risk. We examined late-life sleep medication use and falls risk in a cohort of older adults.

METHODS: The Atherosclerosis Risk in Communities (ARIC) study is an ongoing community-based cohort study. ARIC participants taking any barbiturates, benzodiazepines, antidepressants, non-benzodiazepine receptor agonists, or other hypnotics in the past 4 weeks (2011-2013) were categorized as taking a medication that affects sleep, regardless of indication. Participant hospital discharge records were reviewed through 2019 for ICD codes indicating incident falls. Propensity score matching was used to match participants who used sleep medications with those who did not (1:2). Cox proportional hazards regression models were used to assess the association of sleep medication use with falls with adjustment for demographics, lifestyle, and health characteristics.

RESULTS: In the matched sample (N = 4794; 70% female; mean age 75.5 ± 5 years), 1200 documented falls occurred over 6.5 years of follow-up. In fully adjusted models, sleep medication use was associated with a 33% greater risk of falls compared to nonuse (HR: 1.33; 95% CI: 1.18-1.51). Results did not differ by age, sex, depressive symptoms, baseline cognitive status, or physical functioning status (interaction p-values >.05).

CONCLUSIONS: Late-life sleep medication use is associated with a higher risk of falls. Further research is needed to clarify the mechanisms linking sleep medications to falls risk.

Albuminuria reflects systemic endothelial dysfunction, but its relationships with subclinical brain abnormalities have not been comprehensively catalogued. The Cardiovascular Health Study recruited older adults from four US communities, beginning in 1989-1990. Systematic measurements of albuminuria were performed in 1996-1997; two brain MRIs, in 1992-1994 and 1997-1999; and serum neurofilament light chain (NfL) measurements from 1996-1997 stored samples. We examined the associations of albuminuria with longitudinal progression of white matter hyperintensities (WMH) and ventricular size, incident infarcts, and cross-sectional quantitative brain volumes and circulating biomarkers of neuronal injury (n = 834-1950). Albuminuria was positively associated with ventricular grade worsening (odds ratio per doubling 1.10, 95% confidence interval (CI) 1.01-1.19) and with circulating NfL levels (2% higher per doubling, 95% CI 1-4%), even after adjustment for vascular risk factors. Albuminuria was also associated with worsening of WMH, incident infarcts, and quantitative WMH and hippocampal volumes, but these latter associations appeared to reflect burden of cardiovascular risk factors. Albuminuria is independently associated with worsening ventricular size and circulating NfL, suggesting a specific role of microvascular dysfunction in brain atrophy. It also reflects cardiovascular risk factor burden on markers of vascular brain injury. These results highlight the diverse associations of albuminuria with common brain abnormalities of aging.