Publications

BACKGROUND: Despite evidence that use of patient portals and telehealth is associated with many health benefits, disparities exist in awareness, adoption, and use. Understanding factors and strategies specific to underserved populations is key to achieving digital equity and better health.

OBJECTIVE: This study assesses portal and telehealth experiences among residents of a minoritized and lower-resource area of Dallas, Texas.

METHODS: Using an explanatory sequential design, we conducted surveys and semistructured interviews with English- and Spanish-speaking adults in 15 ZIP Codes surrounding a community-based clinic. We recruited participants via a patient portal, flyers, emails distributed by clinic and community partners, and in person. Surveys were offered online and on paper. We used Fisher exact tests to identify factors associated with telehealth and/or portal use. We also recruited a subsample of survey participants to expound on survey findings in semistructured interviews. Our thematic analysis assessed convergence in survey and interview findings.

RESULTS: Among 182 survey respondents, most were older (n=109, 66%; age ≥60 years), African American or Black (n=120, 65%), and female (n=142, 79%); a little more than half (n=97, 54%) had completed ≥1 telehealth appointment, and a majority (n=131, 72%) had used a patient portal at least once. Compared with those who used the portal and/or telehealth, those reporting no use of portal or telehealth were more likely to have a high school education or less (P<.001) or be Spanish speakers (P<.011). A majority, regardless of portal or telehealth use, agreed with health promotion activity survey statements like "Using the Internet for health-related activities makes me feel actively involved with my health care" (n=103, 59%) and "I find the Internet useful for monitoring my health" (n=100, 58%). In interviews with 20 individuals, most of whom were older, Black, female, and had digital technology experience, seven factors were key to increased engagement in portals and telehealth: (1) improving patient autonomy, (2) integrating digital health technology into daily life, (3) receiving recommendations from trusted individuals, (4) appreciating the value of digital health technologies, (5) enlisting the support of care partners or peers, (6) managing severe or chronic illness, and (7) accessing test results rapidly.

CONCLUSIONS: This study builds on previous work by confirming and contributing insights about factors key to technology uptake and use among underserved populations. Interventions using digital health technologies should focus on these factors to promote digital and health equity and achieve better health outcomes. Future research should explore which clinical settings and contexts are most conducive to increasing digital technology uptake and use, and implementation should leverage partnerships with community groups.

BACKGROUND: Black adults are underrepresented in cardiovascular disease clinical trials. Individual and social circumstances may limit when they are available to complete trial prescreening requirements. Characterizing preferences related to callback times and the impact of calling during preferred times could inform strategies to improve the recruitment of Black adults into clinical research. Our objectives were to characterize prescreening call preferences and successfully reaching a potential participant among adults inquiring about participation in two trials for Black residents of Boston.

METHODS: The GoFreshRx and GoFresh trials examine the effect of a home-delivered Dietary Approaches to Stop Hypertension (DASH)-patterned grocery intervention on blood pressure among Black adults with or without hypertension treatment in Boston. With the exception of the study population, both trials were identical and used the same recruitment apparatus for outreach. Interested persons completed a common online form for both trials and indicated their preferred callback time. Staff call attempts and participant screening status were logged prospectively. Gender was estimated based on first name, using a published algorithm. Odds ratios (OR) were determined via logistic regression models with adjustment for estimated gender, recruitment source, method of inquiry, and first call during preferred callback time.

RESULTS: Of 2870 inquiries (September 2022-July 2023), 1740 participants were called and 1286 were reached. Out of the 1740 participants, 25% preferred to be called before noon and 22% after 4 pm, yet only 10% of the latter were called after 4 pm. Calling during preferred times significantly increased the odds of reaching participants (OR: 1.44; 95% CI: 1.12, 1.85) and completing a prescreening interview (OR: 1.39; 95% CI: 1.14, 1.71). Staff outreach 8-12 weeks (vs 0-4 weeks) after inquiry submission was significantly associated with lower odds of completing a prescreening interview (OR: 0.41; 95% CI: 0.23, 0.73). Participants who made inquiries via return mail were significantly less likely to be reached outside work hours (OR: 0.49; 95% CI: 0.27, 0.90) and in the afternoon (OR: 0.51; 95% CI: 0.30, 0.88). Participants recruited through community events were more likely to be reached in the afternoon (OR: 2.71; 95% CI: 1.06, 6.97).

CONCLUSION: Contacting participants during their preferred callback time was associated with reaching them and completing a prescreening interview. These data highlight the importance of study teams' flexibility in outreach time to enhance the recruitment of Black adults into cardiovascular clinical trials.

RATIONALE & OBJECTIVE: Chronic kidney disease (CKD) disproportionately affects Black adults and those with lower socioeconomic status in the United States. The aim of this study was to examine the associations between socioeconomic status and CKD, albuminuria/stage 1-2 CKD, and stage 3-5 CKD, and to assess differences between Black and White adults.

STUDY DESIGN: We used data from the 2017-2020 National Health and Nutrition Examination Survey. CKD was defined as an estimated glomerular filtration rate of <60 mL/min/1.73 m2 based on the race-free CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation (stage 3-5 CKD) and/or a urinary albumin-creatinine ratio of >30 mg/g (albuminuria/stage 1-2 CKD).

SETTING & PARTICIPANTS: Respondents to the 2017-2020 National Health and Nutrition Examination Survey with Black or White race.

EXPOSURE: Measures of socioeconomic status (income to poverty ratio, insurance status, education, employment status, and health care access).

ANALYTICAL APPROACH: We examined the relationship between measures of socioeconomic status and CKD, albuminuria/stage 1-2 CKD, and stage 3-5 CKD using survey-weighted Poisson regressions controlling for age, sex, and medical comorbid conditions.

RESULTS: The weighted sample (N = 182,622,525) was 52.2% women and 15.5% Black, with a mean age of 49.1 years. The prevalence of CKD was 15.6% in the overall sample, 20.9% among Black adults, and 14.7% among White adults. Higher income, higher education levels, and having health insurance were associated with a lower prevalence of CKD in the overall sample and among White adults, but not among Black adults. This pattern was consistent for those with albuminuria/stage 1-2 CKD, but not for those with stage 3-5 CKD.

LIMITATIONS: This study is limited by its cross-sectional design. In addition, data were based on single measurements and thus may be less precise in estimating the prevalence of chronic disease.

CONCLUSIONS: Higher socioeconomic status was inversely associated with albuminuria/stage 1-2 CKD and CKD among White but not Black adults. Future work should investigate the mechanisms by which albuminuria/stage 1-2 CKD remains independent of socioeconomic status among Black adults.

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.

OBJECTIVE: Messaging about breast cancer screening cessation may reduce over-screening by raising awareness of the harms of screening, but in a background of strongly positive beliefs about screening among the public, such messaging may be perceived negatively. We aimed to assess whether older women perceived it to be ethically appropriate for clinicians to share a message that encourages breast cancer screening cessation.

METHODS: As part of a large national online survey experiment with women 65+ years, we presented a message (hereafter referred to as primary message) describing the rationales for stopping breast cancer screening (e.g., guideline recommendation, harms of screening) and assessed how ethical women thought it would be for doctors to share this information with patients. We assessed open-ended reactions. We also tested two variations of the primary message with different wordings of the recommendation to consider stopping screening.

RESULTS: Of 683 participants, 75.9 % agreed that the primary message is ethically appropriate for doctors to share with patients., 13.2 % neither agree or disagree, and 10.9 % disagreed. Themes in open-ended responses suggested that the difference in participant response was partly attributed to whether participants perceived the message as informative or persuasive. Comparing across message variations, messages with stronger recommendations to stop screening were perceived to be less ethically appropriate than the primary message.

CONCLUSIONS: Most older women perceived that it was ethically appropriate for doctors to share messages aimed at reducing breast cancer over-screening with patients.

PRACTICE IMPLICATIONS: Interventions should be developed to deliver messages to reduce over-screening among older women in practice settings, with evaluations to monitor their response.

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: 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.

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.