Publications

Abstract

Barriers to following dietary recommendations have been described; however, they remain poorly understood. The purpose of this qualitative study was to explore perceived barriers to adherence to dietary recommendations in a diverse hemodialysis patient population. Participants were eligible to participate in a semi-structured qualitative telephone interview prior to randomization for an ongoing clinical trial to evaluate the efficacy of an intervention designed to reduce dietary sodium intake. Interviews were digitally recorded, transcribed verbatim and coded using an iterative qualitative process. In total, 30 (37% females, 53% Caucasians) participants, 63.2 ± 13.3 years, were interviewed. Time, convenience, and financial constraints hindered dietary adherence. Dietary counseling efforts were rated positively but require individualization. Ability to follow recommended guidelines was challenging. Suggestions for addressing barriers include technology-based interventions that allow patients to improve food choices and real-time decision-making, and permit tailoring to individual barriers and preferences.

Abstract

Middle-aged and older adults with HIV experience double discrimination and cognitive impairment due to both their HIV status and their age. However, the relationship between perceived discrimination and self-reported cognitive ability in middle-aged and older people living with HIV (PLWH) is less clear. We measured self-reported perceived discrimination and cognitive ability using the Expanded Everyday Discrimination Scale and the subscale of the AIDS Health Assessment Questionnaire (AIDS-HAQ). The study sample included 324 middle-aged and older PLWH (over 45 years old) from five designated HIV hospitals in three regions (east coast, middle, and southwest regions) of China. The descriptive analysis showed that 45.37% of the participants reported perceiving discrimination at least once in the past twelve months, and 47.22% reported having at least one type of cognitive impairment. Multiple linear regression results showed that higher levels of perceived discrimination (β = −0.121, P = 0.036) were significantly associated with lower levels of self-reported cognitive ability after controlling for several covariates, including sociodemographic variables, mental health status, health behaviors, and social support. A longer duration of HIV was also related to a lower level of self-reported cognitive ability. Our findings indicate that perceived discrimination is related to self-reported cognitive ability and suggest that counseling services and support systems should be developed to reduce age- and disease-associated discrimination. A reduction in perceived discrimination would improve not only overall wellbeing but also cognitive ability in later life.

Abstract

Background: Patient populations with low socioeconomic status (SES) experience psychological stress because of social determinants of health. Social determinants of health contribute to self-care - especially among patients with heart failure (HF). Objective: We sought to describe the influence of stress and social determinants of health on self-care in patients with HF who have low SES. Methods: In this mixed-methods, concurrent embedded study, participants (N = 35) were recruited from 2 urban hospitals in Chicago if they had low SES and were readmitted within 120 days of an exacerbation of HF. We conducted semistructured interviews to collect qualitative data about stressors associated with patients' living circumstances, strategies patients used to foster self-care, family dynamics, and coping strategies patients used to decrease stress. We measured psychological stress (Perceived Stress Scale [PSS-10]), and self-care (Self-care of Heart Failure Index). Content analysis was used to analyze the qualitative data, and descriptive statistics were used to describe the sample. In the final analytic phase, the qualitative and quantitative data were integrated. Results: Self-care was poor: 91.5% of participants had Self-care of Heart Failure Index subscale scores lower than 70. Perceived stress was high: 34% of participants had PSS-10 scores of 20 or higher. Several social determinants of health emerged as affecting self-care: financial stress, family personal health, past impactful deaths, and a recent stressful event (eg, child's death). Participants lived in areas with high crime and violence, and participants described many stressful events. However, among participants whose PSS-10 scores were lower than 20 (indicating lower stress), there was discordance among the description of factors impacting self-care and their PSS-10 score. Conclusions: Social determinants of health negatively impact the ability of low-SES patients to manage their HF symptoms and adhere to a medication and dietary regimen. It is important that healthcare providers assess patients' stressors so appropriate referral to services can occur.

Abstract

OBJECTIVESDry mouth is a common condition among older adults that negatively influences oral health, general health, and quality of life. The role of psychosocial factors in oral health conditions and diseases remains largely unknown. We conducted a study to examine the relationship between perceived stress and dry mouth among US older Chinese adults and further investigated the potential moderating role of social support and social strain from different sources in the relationship.DESIGNCross‐sectional analysis.SETTINGBaseline of the Population Study of Chinese Elderly in Chicago, a community‐engaged, population‐based longitudinal study of health and well‐being among community‐dwelling US older Chinese adults.PARTICIPANTSIndividuals 60 years or older (N = 3157).MEASUREMENTSPerceived stress was measured by the 10‐item Chinese Perceived Stress Scale to evaluate the degree to which life situations were perceived as stressful during the preceding month on a 5‐point scale, ranging from 0 (“never”) to 4 (“very often”). Dry mouth was a binary self‐reported outcome variable (1 = “dry mouth”). Social support was measured by the Health and Retirement Study's social support and strain scale from sources including spouse, other family members, and friends with a 3‐point response set, ranging from 0 (“hardly ever”) to 2 (“often”). Sociodemographics and disease processes were assessed as covariates. We conducted stepwise logistic regressions with interaction terms.RESULTSHaving higher levels of perceived stress was significantly associated with a higher likelihood of reporting dry mouth (odds ratio = 1.03; 95% confidence interval = 1.02‐1.04). The effect of perceived stress on dry mouth may vary by levels of family and friend support.CONCLUSIONPerceived stress may influence dry mouth either directly or indirectly. To prevent or reduce dry mouth, in addition to disease processes, interventions need to consider psychosocial factors in dry mouth, especially perceived stress and social support, in this growing population. J Am Geriatr Soc 67:S551–S556, 2019.

Abstract

Background and Objectives While there are qualitative studies examining the delirium-related experiences of patients, family caregivers, and nurses separately, little is known about common aspects of delirium burden among all three groups. We describe common delirium burdens from the perspectives of patients, family caregivers, and nurses. Research Design and Methods We conducted semistructured qualitative interviews about delirium burden with 18 patients who had recently experienced a delirium episode, with 16 family caregivers, and with 15 nurses who routinely cared for patients with delirium. We recruited participants from a large, urban teaching hospital in Boston, Massachusetts. Interviews were recorded and transcribed. We used interpretive description as the approach to data analysis. Results We identified three common burden themes of the delirium experience: Symptom Burden (Disorientation, Hallucinations/Delusions, Impaired Communication, Memory Problems, Personality Changes, Sleep Disturbances); Emotional Burden (Anger/Frustration, Emotional Distress, Fear, Guilt, Helplessness); and Situational Burden (Loss of Control, Lack of Attention, Lack of Knowledge, Lack of Resources, Safety Concerns, Unpredictability, Unpreparedness). These burdens arise from different sources among patients, family caregivers, and nurses, with markedly differing perspectives on the burden experience. Discussion and Implications Our findings advance the understanding of common burdens of the delirium experience for all groups and offer structure for instrument development and distinct interventions to address the burden of delirium as an individual or group experience. Our work reinforces that no one group experiences delirium in isolation. Delirium is a shared experience that will respond best to systemwide approaches to reduce associated burden.

Abstract

Background: Engagement in the HIV care continuum combined with office-based opioid treatment remains a cornerstone in addressing the intertwined epidemics of opioid use disorder (OUD) and HIV/AIDS. Factors influencing patient engagement with OUD and HIV care are complex and require further study. Methods: In this qualitative study, in-depth interviews were conducted among 23 adult patients who use drugs (PWUD) in an inpatient detoxification program in New York City. The semi-structured interview guide elicited participant experiences with various phases of the HIV care continuum, including factors influencing access to HIV care, interactions with HIV and primary care providers, preferences around integrated care approaches for OUD and HIV, and barriers experienced beyond clinical settings which affected access to HIV care (e.g., insurance issues, transportation, cost, retrieving prescriptions from their pharmacy). Data collection and thematic analysis took place concurrently using an iterative process-based established qualitative research method. Results: Respondents elicited high acceptability for integrated or co-located care for HIV and OUD in primary care. Factors influencing engagement in HIV care included (1) access to rapid point-of-care HIV testing and counseling services, (2) insurance coverage and costs related to HIV testing and receipt of antiretroviral therapy (ART), (3) primary care providers offering HIV care and buprenorphine, (4) illicit ART sales to pharmacies, (5) disruption in supplies of ART following admissions to inpatient detoxification or residential treatment programs, (6) in-person and telephone contact with peer support networks and clinic staff, (7) stigma, and (8) access to administrative support in primary care to facilitate reengagement with care following relapse, behavioral health services, transportation vouchers, and relocation from subsidized housing exposing patients to actively using peers. Conclusion: These findings suggest expanding clinical and administrative support in primary care for PWUDs with patient navigators, case managers, mobile health interventions, and peer support networks to promote linkage and retention in care.

Abstract

Objective: Enhancing physician resilience has the promise of addressing the problem of burnout, which threatens both doctors and patients and increases in residents with each year of training. Programmes aimed at enhancing physician resilience are heterogeneous and use varied targets to measure efficacy, because there is a lack of clarity regarding this concept. A more robust understanding of how resilience is manifested could enhance efforts to create and measure it in physicians in training. Methods: A qualitative study used grounded theory methodology to analyse semi-structured interviews with a purposive, intensity sample of obstetrics and gynaecology residents in an urban academic health centre. Longitudinal engagement through two sets of interviews 3-6 months apart allowed for variations in season and context. Thematic saturation was achieved after enrollment of 18 residents representing all 4 years of postgraduate training. A three-phase coding process used constant comparison, reflective memos and member checking to support the credibility of the analysis. Results: A conceptual model for resilience as a socio-ecological phenomenon emerged. Resilience was linked to professional identity and purpose served to root the individual and provide a base of support through adversity. Connections to others inside and outside medicine were essential to support developing resilience, as was finding meaning in experiences. The surrounding personal and professional environments had strong influences on the ability of individuals to develop personal resilience. Conclusions: Physician resilience in this context emerged as a developmental phenomenon, influenced by individual response to adversity as well as surrounding culture. This suggests that both programmes teaching individual skills as well as systematic and cultural interventions could improve a physician's capacity to thrive.

Abstract

Objective Evaluate risk of preterm birth (PTB, < 37 completed weeks’ gestation) among a population of women in their second pregnancy with previous full term birth but other adverse pregnancy outcome. Methods The sample included singleton live born infants between 2007 and 2012 in a birth cohort file maintained by the California Office of Statewide Health Planning and Development. The sample was restricted to women with two pregnancies resulting in live born infants and first birth between 39 and 42 weeks’ gestation. Logistic regression was used to calculate the risk of PTB in the second birth for women with previous adverse pregnancy outcome including: small for gestational age (SGA) infant, preeclampsia, placental abruption, or neonatal death (≤ 28 days). Risks were adjusted for maternal factors recorded for second birth. Results The sample included 133,622 women. Of the women with any previous adverse outcome, 4.7% had a PTB while just 3.0% of the women without a previous adverse outcome delivered early (relative risk adjusted for maternal factors known at delivery 1.4, 95% CI 1.3–1.5). History of an SGA infant, placental abruption, or neonatal death increased the adjusted risk of PTB in their second birth by 1.5–3.7-fold. History of preeclampsia did not elevate the risk of a preterm birth in the subsequent birth. Conclusions for Practice The findings indicate that women with previous SGA infant, placental abruption, or neonatal death, despite a term delivery, may be at increased risk of PTB in the subsequent birth. These women may be appropriate participates for future interventions aimed at reduction in PTB.

Abstract

Introduction: Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness. Methods and analysis: This is the protocol for a pragmatic, cluster-randomised stepped wedge trial to test the effectiveness of PRIM-ER in 35 EDs across the USA. The intervention includes four core components: (1) evidence-based, multidisciplinary primary palliative care education; (2) simulation-based workshops; (3) clinical decision support; and (4) audit and feedback. The study is divided into two phases: a pilot phase, to ensure feasibility in two sites, and an implementation and evaluation phase, where we implement the intervention and test the effectiveness in 33 EDs over 2 years. Using Centers for Medicare and Medicaid Services (CMS) data, we will assess the primary outcomes in approximately 300 000 patients: ED disposition to an acute care setting, healthcare utilisation in the 6 months following the ED visit and survival following the index ED visit. Analysis will also determine the site, provider and patient-level characteristics that are associated with variation in impact of PRIM-ER. Ethics and dissemination: Institutional Review Board approval was obtained at New York University School of Medicine to evaluate the CMS data. Oversight will also be provided by the National Institutes of Health, an Independent Monitoring Committee and a Clinical Informatics Advisory Board. Trial results will be submitted for publication in a peer-reviewed journal.

Abstract

Health systems around the world are faced with the challenge of improving the efficiency, effectiveness and responsiveness of service delivery. Pasmore defines organisational technology as consisting of the tools, techniques, devices, artefacts, methods, configurations, procedures and knowledge used to acquire inputs, transform inputs to outputs and provide services to clients. Socio-technical theory provides a framework to examine the adaptation of new technology into the organisational routines for the delivery of clinical care. A recent review conducted by the NHS Research and Development Health Technology Assessment Programme (HTAP) highlights the flaws in the existing research and development model of clinical care technologies. The principle of emergent competition provides the foundation for a new model of process innovation for clinical care technology. The durable technology sector in health care, through a combination of intellectual property rights and regulatory requirements for proof of effectiveness has produced an extraordinary flow of new effective technologies.

Abstract

Objective: The majority of groceries purchased by US households are industrially processed, yet it is unclear how processing level influences diet quality. We sought to determine if processing level is associated with diet quality of grocery purchases. Design: We analysed grocery purchasing data from the National Household Food Acquisition and Purchase Survey 2012-2013. Household grocery purchases were categorized by the NOVA framework as minimally processed, processed culinary ingredients, processed foods or ultra-processed foods. The energy share of each processing level (percentage of energy; %E) and Healthy Eating Index-2015 (HEI-2015) component and total scores were calculated for each household's purchases. The association between %E from processed foods and ultra-processed foods, respectively, and HEI-2015 total score was determined by multivariable linear regression. Foods purchased by households with the highest v. lowest ultra-processed food purchases and HEI-2015 total score <40 v. ≥60 were compared using linear regression. Setting: USA. Participants: Nationally representative sample of 3961 households. Results: Processed foods and ultra-processed foods provided 9·2 (se 0·3) % and 55·8 (se 0·6) % of purchased energy, respectively. Mean HEI-2015 score was 54·7 (se 0·4). Substituting 10 %E from minimally processed foods and processed culinary ingredients for ultra-processed foods decreased total HEI-2015 score by 1·8 points (β = -1·8; 95 % CI -2·0, -1·5). Processed food purchases were not associated with diet quality. Among households with high ultra-processed food purchases, those with HEI-2015 score <40 purchased less minimally processed plant-foods than households with HEI-2015 score ≥60. Conclusions: Increasing purchases of minimally processed foods, decreasing purchases of ultra-processed foods and selecting healthier foods at each processing level may improve diet quality.

Abstract

Chronic diseases have become serious threats to public health in China; the risk is particularly high for internal migrants. Chronic disease education is a key to the prevention and control of chronic diseases for such population. The national population-based Migrants Population Dynamic Monitoring Survey (MPSMA) was used to examine the current status and delivery methods of chronic disease education among internal migrants, from both provincial level and individual’s level. The study population included 402 587 internal migrants. Multilevel logistic regression was used to investigate factors that were related to chronic diseases education. In total, only 33.9% of the participants received chronic disease education. In the final model, parameter estimates on key variables from both individual and provincial level were significant (P < .001). Participants from provinces with higher level of health care resources and lower density of internal migrants were more likely to receive chronic disease education. The percentage and methods of receiving education varied across different age groups. This study suggests that future chronic disease education in China need to be more focused on areas with high density of internal migrants and younger internal migrants with low level of education and income. Attention should be paid to use tailored education methods to different populations.

Abstract

End-of-life care in the intensive care unit is fraught with complicated psychological responses by patients, families, and staff. Empathic and mindful communication, inclusion of all integral staff in decision-making meetings, and multidimensional support of patients and families can ease the transition away from aggressive life-prolonging to comfort-oriented end of life care. Primary palliative care communication strategies can help clarify goals of care and facilitate transitions. Early integration of specialist palliative care is recommended.

Abstract

OBJECTIVE: The purpose of this study was to evaluate the psychometric properties of the 22-item Barriers to Healthy Eating (BHE) scale in four independent weight loss studies conducted over 13 years.METHODS: Principal axis factoring with promax rotation was performed to reveal the underlying factor structure. Internal consistency was assessed using Cronbach α, and convergent validity was assessed by correlating the baseline BHE with the Weight Efficacy Lifestyle questionnaire total and subscale scores. Predictive validity was examined by the association of BHE change with weight loss over 6 months.RESULTS: The four studies had similar gender (82.9%-89.9% female) and race (70.5%-81.4% white) distributions. Factor analyses suggested removal of two items and a three-factor structure: self-control and motivation (10 items), daily mechanics (7 items), and social support (3 items). The Cronbach α for the 20-item BHE ranged from 0.849 to 0.881 across the four studies. The BHE and Weight Efficacy Lifestyle questionnaire total and subscale scores were all negatively correlated with each other, showing good convergent validity (r = 0.120-0.544, P < 0.05). BHE change was associated with weight loss from 0 to 6 months (r = 0.282-0.450, P < 0.05).CONCLUSIONS: The BHE scale showed very good psychometric properties over time, supporting its use in measuring barriers to one's ability to adopt or maintain a healthy eating plan.

Abstract

Purpose of Review: This review discusses recent evidence on the association of dietary carbohydrates (quantity, quality, and timing of intake) with hypertension (HTN) risk and out-of-clinic blood pressure (BP) measures. Recent Findings: Studies on carbohydrate quantity are inconclusive, but low carbohydrate diets may be associated with lower BP. Plant-based carbohydrate-containing foods such as fruits, vegetables, and whole grains may lower HTN risk and 24-h BP. Excessive sugar intakes from sugar-sweetened beverages are associated with higher BP levels and HTN risk, with evidence of a dose-response relationship. Preliminary data suggest that timing of carbohydrate intake may influence HTN risk and 24-h BP. Summary: The role of carbohydrate nutrition in HTN’s etiology warrants further investigation. Additional studies are needed to investigate the influence of dietary carbohydrates on HTN risk and the circadian pattern of BP, evaluate potential sex and racial/ethnic differences in these associations, and elucidate underlying mechanisms.

Abstract

Information regarding nutritional risk among users of American adult day health centers (ADHCs), 60% of whom are racial minorities, is scant. This study examined nutritional risk and associated factors in a diverse sample ADHC users aged 50+ using secondary cross-sectional analysis of data collected between 2013 and 2017. Risk was assessed using the DETERMINE checklist, and results were stratified by race. The majority of the sample (N = 188) was at moderate (45.2%) or high (38.5%) nutritional risk, with statistically significant racial differences. Blacks were at greater risk than any other group: 65% had high nutritional risk; 76.5% ate <5 servings of fruits, vegetables, or milk daily; 21% ate <2 meals daily, 48.5% reported involuntary weight loss/gain, and 41.2% had tooth loss/mouth pain. Older adults in ADHCs are at elevated risk of malnutrition, disproportionately so amongst blacks. Both routine nutrition screening and population-specific approaches are needed to attenuate risk.

Abstract

This study examines racial/ethnic disparities of dental service utilization for foreign-born and U.S.-born dentate residents aged 50 years and older. Generalized linear mixed-effects models (GLMM) were used to perform longitudinal analyses of five-wave data of dental service utilization from the Health and Retirement Study (HRS). We used stratified analyses for the foreign-born and U.S.-born and assessed the nonlinear trend in rates of dental service utilization for different racial/ethnic groups. Findings indicate that Whites had higher rates of service utilization than Blacks and Hispanics regardless of birthplace. For all groups, the rates of service utilization decreased around age 80, and the rates of decline for Whites were slower than others. The U.S.-born showed the trend of higher rates of service utilization than the foreign-born for all racial/ethnic groups. These findings suggest the importance of developing culturally competent programs to meet the dental needs of the increasingly diverse populations in the United States.

Abstract

Background: Much of the discourse surrounding children's advocacy in the United States relies on a rights-based approach. We argue that this approach has limitations that impede progress in advancing children's well-being. Purpose: The purpose of this article is to explain alternatives to a rights-based approach in advocating for children, such as developmental, economic, capabilities, and mutualism frameworks. Methods: Our analysis is based on the independent work of two separate university-based groups studying children's rights; the authors were each members of one of the groups and subsequently integrated their findings for this article. Discussion: US policies for children, especially in the domains of health and education, depict an unevenness that results in many children failing to receive certain critical services and benefits. Relying on a rights-based approach to correct these disparities and inequities is contentious and has yet to sufficiently change state and federal policies or improve children's health outcomes. Other approaches are needed to advance children's well-being. Conclusion: Nurses individually and collectively need to be mindful of the pitfalls of a rights-based approach and use other frameworks in advocating for children and youth.

Abstract

Many older adults transfer from the hospital to a post-acute care (PAC) facility and back to the hospital in the final phase of life. This phenomenon, which we have dubbed “Rehabbing to death,” is emblematic of how our healthcare system does not meet the needs of older adults and their families. Policy has driven practice in this area including seemingly benign habits such as calling PAC facilities “rehab.” We advocate for practice changes: (1) calling PAC “after-hospital transitional care,” rather than “rehab”; (2) adopting a serious illness communication model when discussing new care needs at the end of a hospitalization; and (3) policies that incentivize comprehensive care planning for older adults across all settings and provide broad support and training for caregivers. In realigning health and social policies to meet the needs of older adults and their caregivers, fewer patients will be rehabbed to death, and more will receive care consistent with their preferences and priorities. J Am Geriatr Soc 67:2398–2401, 2019.

Abstract

Objectives: To assess the association between rural and urban residential mobility and cognitive function among middle-aged and older adults in China. Method: We used data from the World Health Organization Study on global AGEing and adult health that included adults age 50+ from China (N = 12,410). We used multivariate linear regressions to examine how residential mobility and age at migration were associated with cognitive function. Results: Urban and urban-to-urban residents had the highest level of cognitive function, whereas rural and rural-to-rural residents had the poorest cognitive function. Persons who migrated to/within rural areas before age 20 had poorer cognitive function than those who migrated during later adulthood. Socioeconomic factors played a major role in accounting for the disparities in cognition; however, the association remained significant after inclusion of all covariates. Discussion: Residential mobility and age at migration have significant implications for cognitive function among middle-aged and older adults in China.