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Allison P Pack,1 Mary Clare Masters,2 Rachel O’Conor,1 Kenya Alcantara,1 Sophia Svoboda,1 Reneaki Smith,1 Fangyu Yeh,1 Guisselle Wismer,1 Amisha Wallia,2,3 Stacy C Bailey1 1Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; 2Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; 3Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USACorrespondence: Allison P Pack, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA, Email allison.pack@northwestern.eduBackground: People living with HIV (PLWH) are at higher risk of developing type 2 diabetes (T2DM). Both chronic conditions require individuals to adhere to medication regimens, yet few studies have sought to explore medication-taking behaviors among individuals with comorbid HIV and T2DM (HIV+T2DM).Objective: This qualitative study sought to: 1) identify and compare perceived determinants of medication adherence for HIV and, separately, for T2DM, and 2) explore how participants prioritize conditions.Methods: Between October 2022 and January 2023, we conducted in-depth interviews with individuals aged 50 or older, living with comorbid HIV+T2DM. Participants were prescribed oral medications to treat their conditions and had recent clinical measures indicating probable challenges with medication adherence. Interviews with consented participants from a large academic health center in the Midwest were conducted remotely. Questions largely drew from the Theoretical Domains Framework (TDF), a widely used implementation science framework. Additional questions explored the prioritization of conditions. Analysis employed the Framework Method and a side-by-side comparison of key determinants of medication adherence by condition.Results: A total of 19 interviews were audio recorded, transcribed, and analyzed. Participants were an average age of 61, mostly male (89.5%), and Non-Hispanic White (47.4%). Although results revealed many commonalities between perceived determinants of medication adherence for HIV and for T2DM, differences relating to two TDF domains were noted: nature of the behavior (taking medications as prescribed), and motivations and goals. Many participants viewed their conditions as equally important, though they suggested T2DM was more difficult to manage, largely due to lifestyle modifications.Conclusion: As individuals with HIV develop chronic conditions, such as T2DM, they may require additional medication adherence support. Attention should be paid to offering support early. Disease perceptions may differ by condition, and as such, one’s motivations to take medication as prescribed may also differ by condition.Keywords: qualitative, HIV, type 2 diabetes, medication adherence

Sophia W Light,1 Allison Pack,1 Alyssa Vela,2 Stacy C Bailey,1 Andrea Zuleta,1 Rachel O’Conor,1 Michael S Wolf1 1Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; 2Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USACorrespondence: Sophia W Light, Center for Applied Health Research on Aging (CAHRA), Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USA, Tel +1(312)503-5015, Email sophia.wl@northwestern.eduPurpose: Historically marginalized communities disproportionately impacted by the pandemic are demonstrating lower uptake of COVID-19 vaccines. To facilitate the development of culturally tailored, language concordant educational materials promoting COVID-19 vaccination, we first explored older Latinx adults’ awareness, attitudes, and beliefs about COVID-19 vaccines and factors involved in vaccination decisions within their communities.Patients and Methods: Individual, semi-structured interviews were conducted with 15 participants who self-identified as Latinx/Hispanic, aged 50 and older, and living in Chicago. Eight interviews were conducted in English and seven in Spanish. Thematic analysis was used to analyze participants’ responses.Results: Participants revealed four key factors influencing vaccination decisions: 1. protecting oneself and loved ones (against COVID-19 (n=14), or from perceived dangers of the vaccine (n=9)); 2. trust in authorities (trusting information (n=9), or worrying the vaccine is being manipulated (n=5)); 3. access and availability (gratitude to live in a country where vaccines are available (n=5), or fear of going to vaccination sites due to immigration and insurance status (n=4)); and 4. Employment and semblance of normalcy (vaccination to create opportunities (n=6), or concern about missing out due to side effects (n=9)).Conclusion: Our findings illuminate key factors influencing decisions for COVID-19 vaccination among Latinx older adults in Chicago. Vaccination information aiming to increase vaccination rates among this important population may benefit from leveraging collective pronouns and spirituality, language concordance, low-tech options, building trust, and addressing insurance and immigration doubts. Next steps include developing educational materials based on these themes, followed by dissemination and evaluation. Lessons learned may be of interest to public health experts responding to the ongoing pandemic and other public health crises experienced by historically marginalized communities.Keywords: qualitative, COVID-19 vaccines, COVID-19, Latinx, older adult

Caroline Zhao, Stephanie Batio, Rebecca Lovett, Allison P Pack, Michael S Wolf, Stacy C Bailey Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine at Northwestern University, Chicago, IL, USACorrespondence: Stacy C BaileyDivision of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL, 60611, USATel +1 312-503-5595Fax +1 312-503-2777Email stacy-bailey@northwestern.eduPurpose: To assess the relationship between stress regarding COVID-19 and medication adherence.Patients and Methods: Older adults with ≥ 1 chronic condition(s) were recruited from 4 active, federally funded studies in Chicago to participate in a longitudinal telephone survey. Participants self-reported stress regarding COVID-19 in the last week. Adherence was measured via the ASK-12 survey.Results: Most participants reported feeling stressed “some of the time” (54.0%), while 18.2% felt stressed “most” or “all of the time” and 27.8% “never” felt stressed. In bivariate analyses, participants who reported being stressed “most” or “all of the time” had worse medication adherence than participants who reported being stressed “some of the time” or “never” (p < 0.001). In multivariable analyses, participants who reported feeling stressed “most” or “all of the time” had worse adherence than those who “never” felt stressed (Adjusted Least Square Mean (Standard Error): 21.3 (0.6) vs 19.7 (0.6), p=0.01).Conclusion: Stress due to COVID-19 has significantly impacted medication adherence, which has negative implications for the course of both COVID-19 and comorbid conditions. Healthcare providers should be aware of the potential impact of COVID-19 on patients’ mental and physical well-being and consider ways to routinely assess patient experiences.Keywords: COVID-19, stress, medication adherence, comorbidity

Gang Fang,1 Stacy Cooper Bailey,2 Izabela E Annis,1 Michael K Paasche-Orlow,3 Michael S Wolf,2 Laurie T Martin,4 Michael Emch,5 M Alan Brookhart,6 Karen B Farris7 1Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; 2Division of General Internal Medicine & Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; 3Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; 4RAND Corporation, Arlington, VA, USA; 5Department of Geography and Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA; 6Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA; 7College of Pharmacy, The University of Michigan, Ann Arbor, MI, USACorrespondence: Gang FangDivision of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 2202, Kerr Hall, Chapel Hill, NC 27599-7573, USATel +1 919-966-7517Fax +1 919-966-8486Email gang_fang@unc.eduPurpose: Individual measures of health literacy are not feasible for administration on a large scale, yet estimates of community-level health literacy in the US recently became available. We sought to investigate whether community-level health literacy estimates are associated with the initiation of oral antihyperglycemic agents (OHA) and the use of standard preventive care services among older adults with newly diagnosed diabetes.Patients and methods: We conducted a retrospective cohort study of 169,758 patients, ≥65 years old with hypertension and newly diagnosed type 2 diabetes using 2007–2011 data from the Center for Medicare and Medicaid Services Chronic Conditions Warehouse. We examined the relationship between community-level health literacy estimates and initiation of OHA, receipt of flu shots, eye exams, Hemoglobin A1c tests, and lipid tests within 12 months post diabetes diagnosis.Results: Patients living in communities with above basic health literacy (vs. basic/below basic) were 15% more likely to initiate OHA (Hazard Ratio=1.15; 95% CI 1.12 to 1.18). After classifying the health literacy distribution as quintiles, the analysis revealed a dose–response relationship with OHA initiation that plateaued at the third and fourth quintiles and declined at the fifth quintile. Individuals residing in communities with higher health literacy were more likely to participate in preventive care services (relative risk ranged from 1.09 for lipid test [95% CI 1.07–1.11] to 1.43 for flu shot [95% CI 1.41–1.46]).Conclusion: Community-level health literacy estimates were associated with the initiation of OHA and uptake of standard preventive care services in older adults. Community-level health literacy may help to inform targeted diabetes education and support efforts.Keywords: health literacy, diabetes mellitus, adherence, preventive care

Stacy Cooper Bailey,1 Izabela E Annis,1 Daniel S Reuland,2 Autumn D Locklear,1 Betsy L Sleath,1 Michael S Wolf3 1Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, 2Department of Medicine, Division of General Internal Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, 3Health Literacy and Learning Program, Division of General Internal Medicine, Feinberg School of Medicine at Northwestern University, Chicago, IL, USA Background: Current adherence scales often fail to assess the full spectrum of behaviors associated with safe and appropriate drug use and may be unsuitable for patients with limited health literacy. We sought to develop and evaluate a comprehensive yet brief Measure of Drug Self-Management (MeDS) for use in research and clinical settings among diverse patient groups.Methods: Expert opinion, literature reviews, and interviews with patients and providers were utilized to create and revise potential items. Item performance testing was then conducted among 193 adult English-speaking patients with hypertension and diabetes. Factor analysis was used to inform item selection. Reliability was assessed via calculations of internal consistency. To assess construct and predictive validity, MeDS scores were compared with scores from the 8-item Morisky Medication Adherence Scale and relevant clinical measures (HbA1c, blood pressure, and low-density lipoprotein cholesterol).Results: The MeDS demonstrated adequate internal consistency with a Cronbach’s α of 0.72. The MeDS was significantly correlated with the Morisky Medication Adherence Scale (r= -0.62; P

Objective: Improved drug labelling for chronic pillform medications has been shown to promote patient comprehension, adherence and safety. We extended health literacy principles and included patients' perspectives to improve instructions for: (1) non-pill

Abstract Background Escherichia coli is the most common cause of human bloodstream infections and bacterial sepsis/septic shock. However, translation of preclinical septic shock resuscitative therapies remains limited mainly due to low-fidelity of available models in mimicking clinical illness. To overcome the translational barrier, we sought to replicate sepsis complexity by creating an acutely critically-ill preclinical bacterial septic shock model undergoing active 48-h intensive care management. Aim To develop a clinically relevant large-animal (ovine) live-bacterial infusion model for septic shock. Methods Septic shock was induced by intravenous infusion of the live antibiotic resistant extra-intestinal pathogenic E. coli sequence type 131 strain EC958 in eight anesthetised and mechanically ventilated sheep. A bacterial dose range of 2 × 105–2 × 109 cfu/mL was used for the dose optimisation phase (n = 4) and upon dose confirmation the model was developed (n = 5). Post-shock the animals underwent an early-vasopressor and volume-restriction resuscitation strategy with active haemodynamic management and monitoring over 48 h. Serial blood samples were collected for testing of pro-inflammatory (IL-6, IL-8, VEGFA) and anti-inflammatory (IL-10) cytokines and hyaluronan assay to assess endothelial integrity. Tissue samples were collected for histopathology and transmission electron microscopy. Results The 2 × 107 cfu/mL bacterial dose led to a reproducible distributive shock within a pre-determined 12-h period. Five sheep were used to demonstrate consistency of the model. Bacterial infusion led to development of septic shock in all animals. The baseline mean arterial blood pressure reduced from a median of 91 mmHg (71, 102) to 50 mmHg (48, 57) (p = 0.004) and lactate levels increased from a median of 0.5 mM (0.3, 0.8) to 2.1 mM (2.0, 2.3) (p = 0.02) post-shock. The baseline median hyaluronan levels increased significantly from 25 ng/mL (18, 86) to 168 ng/mL (86, 569), p = 0.05 but not the median vasopressor dependency index which increased within 1 h of resuscitation from zero to 0.39 mmHg−1 (0.06, 5.13), p = 0.065, and. Over the 48 h, there was a significant decrease in the systemic vascular resistance index (F = 7.46, p = 0.01) and increase in the pro-inflammatory cytokines [IL-6 (F = 8.90, p = 0.02), IL-8 (F = 5.28, p = 0.03), and VEGFA (F = 6.47, p = 0.02)]. Conclusions This critically ill large-animal model was consistent in reproducing septic shock and will be applied in investigating advanced resuscitation and therapeutic interventions.

Abstract Introduction In December 2019, the COVID-19 pandemic highlighted the urgent need for rapid collaboration, research, and interventions. International research collaborations foster more significant responses to rapid global changes by enabling international, multicentre research, decreasing biases, and increasing study validity while reducing overall research time and costs. However, there has been low uptake of collaborative research by African institutions and individuals. Aim To systematically review facilitating factors and challenges to collaborative surgical research studies conducted in Africa. Methodology A meta-research review using PubMed®/MEDLINE and Embase on surgical collaboration in Africa from 1st of January 2011 to 31st of September 2021 in accordance to PRISMA guidelines. Surgical studies by collaborative groups involving African authors and sites were included (55 papers). Data on the study period, geographical regions, and research scope, facilitating factors, and challenges were extracted from the studies retrieved from the search. Results Most of the collaborations in Africa occurred with European institutions (76%). Of the 54 African countries, 63% (34/54) participated in surgical collaborations. The highest collaboration frequency occurred in South Africa (11%) and Nigeria (8%). However, most publications originated from Eastern Africa (43%). Leveraging synergies between high- and low- to middle-income countries (LMICs), well-defined structures, and secure data platforms facilitated collaboration. However, the underrepresentation of collaborators from LMICs was a significant challenge. Conclusion Available literature provides critical insights into the facilitating factors and challenges of research collaboration with Africa. However, there is a need for a detailed prospective study to explore the themes highlighted further. Systematic review registration PROSPERO 2022 CRD42022352115 .

Abstract Introduction Shock-induced endotheliopathy (SHINE), defined as a profound sympathoadrenal hyperactivation in shock states leading to endothelial activation, glycocalyx damage, and eventual compromise of end-organ perfusion, was first described in 2017. The aggressive resuscitation therapies utilised in treating shock states could potentially lead to further worsening endothelial activation and end-organ dysfunction. Objective This study aimed to systematically review the literature on resuscitation-associated and resuscitation-induced endotheliopathy. Methods A predetermined structured search of literature published over an 11-year and 6-month period (1 January 2011 to 31 July 2023) was performed in two indexed databases (PubMed/MEDLINE and Embase) per PRISMA guidelines. Inclusion was restricted to original studies published in English (or with English translation) reporting on endothelial dysfunction in critically ill human subjects undergoing resuscitation interventions. Reviews or studies conducted in animals were excluded. Qualitative synthesis of studies meeting the inclusion criteria was performed. Studies reporting comparable biomarkers of endothelial dysfunction post-resuscitation were included in the quantitative meta-analysis. Results Thirty-two studies met the inclusion criteria and were included in the final qualitative synthesis. Most of these studies (47%) reported on a combination of mediators released from endothelial cells and biomarkers of glycocalyx breakdown, while only 22% reported on microvascular flow changes. Only ten individual studies were included in the quantitative meta-analysis based on the comparability of the parameters assessed. Eight studies measured syndecan-1, with a heterogeneity index, I 2 = 75.85% (pooled effect size, mean = 0.27; 95% CI − 0.07 to 0.60; p = 0.12). Thrombomodulin was measured in four comparable studies (I 2 = 78.93%; mean = 0.41; 95% CI − 0.10 to 0.92; p = 0.12). Three studies measured E-selectin (I 2 = 50.29%; mean = − 0.15; 95% CI − 0.64 to 0.33; p = 0.53), and only two were comparable for the microvascular flow index, MFI (I 2 = 0%; mean = − 0.80; 95% CI − 1.35 to − 0.26; p

Beef flavor has been identified as a driver of consumer acceptability; however, little is known about variability of flavor in major United States retail beef cuts. Four beef cuts (chuck roast; top sirloin steaks; top loin steaks; and 80/20 ground beef) were obtained from retail stores (n=30 per cut per city) in Miami, Los Angeles, Portland, New York, and Denver during a 2-mo period in 2018. Production systems or package claims were documented. An expert trained flavor and texture descriptive attribute sensory panel evaluated beef flavors, aromas, and textures (n=10 cuts per city or 50 cuts evaluated). Consumer sensory panels in Fort Collins, CO (n=10 per cut/city), and Lubbock, TX (n=10 per cut/city), evaluated beef for overall liking, overall flavor, beef flavor, grilled flavor, juiciness, and texture liking. Ground beef patties (GB) were more intense (P

Blood lactate and blood pressure measurements are important predictors of life-threatening complications after infant open-heart surgeries requiring cardiopulmonary bypass (CPB). We have developed an intravascular nitric oxide (NO)-releasing 5-Fr catheter that contains a lactate sensor for continuous in-blood lactate monitoring and a dedicated lumen for third-party pressure sensor attachment. This device has antimicrobial and antithrombotic properties and can be implanted intravascularly. The importance of this design is its ability to inhibit thrombosis, due to the slow release of NO through the surface of the catheter and around the electrochemical lactate sensors, to allow continuous data acquisition for more than 48 h. An in vivo study was performed using six piglets undergoing open-heart surgery with CPB and cardioplegic arrest, in order to mimic intra-operative conditions for infants undergoing cardiac surgery with CPB. In each study of 3 h, two 5-Fr NO-releasing lactate and blood-pressure monitoring catheters were implanted in the femoral vessels (arteries and veins) and the CPB circuitry to monitor changing lactate levels and blood pressures during and immediately after aortic cross-clamp removal and separation from CBP. Electrical signals continuously acquired through the sensors were processed and displayed on the device’s display and via Bluetooth to a computer in real-time with the use of a two-point in vivo calibration against blood gas results. The study results show that lactate levels measured from those sensors implanted in the CPB circuit during CPB were comparable to those acquired by arterial blood gas measurements, whereas lactate levels measured from sensors implanted in the femoral artery were closely correlated with those acquired intermittently by blood gas prior to CPB initiation, but not during CPB. Blood pressure sensors attached to one lumen of the device displayed accurate blood pressure readings compared to those measured using an FDA approved pressure sensor already on the market. We recommend that the sensor be implanted in the CPB’s circuit to continuously monitor lactate during CPB, and implanted in the femoral arteries or jugular veins to monitor lactate before and after CPB. Blood pressures dramatically drop during CPB due to lower blood flow into the lower body, and we suspect that the femoral arteries are likely collapsing or constricting on the implanted catheter and disrupting the sensor-to-blood contact. This study shows that the device is able to accurately and continuously monitor lactate levels during CPB and potentially prevent post-surgery complications in infants.

OBJECTIVE: We developed a standardized educational tool to inform women about preeclampsia. The objective of this study was to assess whether exposure to this tool led to superior understanding of the syndrome. STUDY DESIGN: This was a randomized controlled trial in which 120 women were assigned to (1) a newly developed preeclampsia educational tool, (2) a standard pamphlet addressing preeclampsia that had been created by the American College of Obstetricians and Gynecologists, or (3) no additional information. Preeclampsia knowledge was assessed with the use of a previously validated questionnaire. RESULTS: There were no demographic differences among the groups. Patients who received the tool scored significantly better on the preeclampsia questionnaire than those who received the American College of Obstetricians and Gynecologists pamphlet or no additional information (71%, 63%, 49%, respectively; P < .05). This improved understanding was evident equally among women with and without adequate health literacy (interaction: P > .05). CONCLUSION: Patients who were exposed to a graphics-based educational tool demonstrated superior preeclampsia-related knowledge, compared with those patients who were exposed to standard materials or no education. [ABSTRACT FROM AUTHOR]

Background: In the U.S., acetaminophen overdose has surpassed viral hepatitis as the leading cause of acute liver failure, and misuse contributes to more than 30,000 hospitalizations annually. Half to two thirds of acetaminophen overdoses are unintentional, suggesting the root cause is likely poor understanding of medication labeling or failure to recognize the consequences of exceeding the recommended maximum daily dosage. Purpose: Elicit subject feedback about active ingredient and dosing information on over-the-counter (OTC) acetaminophen and elicit feedback on proposed plain-language text and icons. Methods: Six focus groups, preceded by individual interviews, were conducted in April 2010 among 45 adults in two cities from two clinics and an adult basic education center. The individual interviews evaluated knowledge of OTC pain relievers, attention to product label information and literacy level while the group discussion elicited preference for label messages and icons. Analyses were conducted from April to June 2010. Results: Forty-four percent read at or below the 6th-grade level. Individual interviews revealed that <50% of participants routinely examine product label information. Only 31% know acetaminophen is in Tylenol®. The groups achieved consensus on a preferred icon for acetaminophen, desired explicit statement of potential liver damage in the warning against simultaneous use of acetaminophen products, and indicated preference for an icon and wording for maximum dose. Conclusions: With the high prevalence of OTC use, a consumer-centered approach to developing icons and messages to promote awareness and safe use of acetaminophen could benefit consumers. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether literacy mediates the association between education, hypertension knowledge and control. METHODS: In-person interviews with a literacy assessment and chart review were conducted with 330 hypertensive patients from six primary care safety net clinics. Mediational analysis was used to test the role of literacy skills in explaining the relationship between education and hypertension knowledge and control. RESULTS: In multivariate analyses that did not make an adjustment for the other variable, both lower educational attainment and more limited literacy were found to be significant independent predictors of poorer hypertension knowledge and control. When literacy was entered into models that included education only, the association between education and knowledge was fully attenuated and no longer significant (Grades 1-8: beta=-0.30, 95% CI=-1.44-0.83), while the relationship between education and blood pressure control was only minimally reduced (AOR 2.46, 95% CI 2.10-2.88). More limited literacy skills also was associated with hypertension control in the final model (AOR 2.68, 95% CI 1.54-4.70). CONCLUSION: Patient literacy mediated the relationship between education and hypertension knowledge. Literacy was a significant independent predictor of blood pressure control, but only minimally explained the relationship between education and blood pressure. PRACTICE IMPLICATIONS: Health literacy is critical to the design of educational tools to improve knowledge acquisition. However, in order to impact health outcome, future health literacy studies should also address other psychosocial factors that impact motivation and capability to manage disease. [ABSTRACT FROM AUTHOR]

Objective: To create a brief assessment tool, the Medication Understanding and Use Self-Efficacy Scale (MUSE).Methods: An existing scale (Communication and Attitudinal Self-Efficacy Scale) was modified, augmented, and piloted among 267 primary care patients in Chicago, New York City, and Shreveport, LA. Participant sociodemographics, literacy, current medication use, understanding medication instructions, and medication self-efficacy were measured.Results: Using principal components analysis, two scales emerged: taking medication and learning about medication; these two factors accounted for 55% of the total variance of understanding medication instructions. Performance on the MUSE differed by literacy level; multivariate analysis detected no interaction between literacy level and MUSE score. Regression analysis, adjusted for age, education, literacy level and number of current prescription medications indicated that participants' MUSE scores predicted patient understanding of common medication instructions (beta=0.07, 95% CI 0.001-0.14, p=0.04).Conclusion: The MUSE is a valid and reliable tool measuring self-efficacy of understanding and using prescription medication. This scale differs from existing medication-specific self-efficacy scales as it addresses both learning about one's medications and adherence to the prescribed regimen.Practice Implications: The MUSE is an effective and brief research tool that can be utilized among participants with varying literacy levels. [ABSTRACT FROM AUTHOR]

Importance: While continuous glucose monitoring (CGM) has been found to improve diabetes care processes and outcomes, adoption remains low., Objective: To examine the association between CGM prescriptions and individual characteristics among patients with type 1 or 2 diabetes (T1D and T2D, respectively)., Design, Setting, and Participants: Retrospective cross-sectional study using electronic health record data for patients with T1D or T1D from 275 clinic sites nationwide between January 2014 and February 2021. All participating clinics were federally qualified health centers (FQHCs), the largest US system of primary care for vulnerable populations. Data were analyzed from September 2022 to August 2024., Main Outcomes and Measures: Sociodemographic factors, clinical characteristics, and CGM prescription orders., Results: A total of 1168 patients with T1D (mean [SD] age, 41.8 [16.0] years; 600 [51.4%] male; 372 [31.9%] Black; 262 [22.4%] Hispanic, and 750 [64.2%] White patients) and 35 216 patients with T2D (mean [SD] age, 58.4 [13.1] years; 19 772 [56.1%] female; 12 030 [34.2%] Black; 12 979 [36.9%] Hispanic, and 20 413 [58.0] White patients) were included. Overall, CGM prescriptions were infrequent (129 [11.0%] for patients with T1D and 362 [1.0%] for those with T2D) but increased throughout the study period. Among patients with T1D, those who reported Hispanic ethnicity (odds ratio [OR], 0.30; 95% CI, 0.16-0.57), Black race (OR, 0.61; 95% CI, 0.38-0.99), or were uninsured (OR, 0.42; 95% CI, 0.23-0.74) had lower multivariable odds of receiving a CGM prescription than White or insured adults, respectively. Similar findings were observed among patients with T2D reporting Hispanic ethnicity (OR, 0.43; 95% CI, 0.32-0.57), Black race (OR, 0.76; 95% CI, 0.59-0.98), or being uninsured (OR, 0.42; 95% CI, 0.31-0.58), relative to their counterparts. Among patients with T2D, hemoglobin A1c values higher than 9.0% (OR, 3.17; 95% CI, 2.37-4.21) and a greater burden of diabetes complications were associated with higher odds of CGM prescription., Conclusions and Relevance: In this cross-sectional study of electronic health record data, rates of CGM prescription orders were low among FQHC patients with T1D and T2D. Disparities in CGM orders were observed among patients reporting Hispanic ethnicity, Black race, and those who lacked health insurance. Future research is needed to understand the causes of infrequent CGM orders in FQHCs and drivers of observed disparities in this vulnerable patient population.

Background: Older adults with multiple chronic conditions (MCC) and polypharmacy often face challenges with medication adherence. Nonadherence can lead to suboptimal treatment outcomes, adverse drug events, and poor quality of life., Objective: To facilitate medication adherence among older adults with MCC and polypharmacy in primary care, we are adapting a technology-enabled intervention previously implemented in a specialty clinic. The objective of this study was to obtain multilevel feedback to inform the adaptation of the proposed intervention (Phenotyping Adherence Through Technology-Enabled Reports and Navigation [PATTERN])., Methods: We conducted a formative qualitative study among patients, clinicians, and clinic administrators affiliated with a large academic health center in Chicago, Illinois. Patient eligibility included being aged 65 years or older, living with MCC, and contending with polypharmacy. Eligibility criteria for clinicians and administrators included being employed by any primary care clinic affiliated with the participating health center. Individual semistructured interviews were conducted remotely by a trained member of the study team using interview guides informed by the Exploration, Preparation, Implementation, and Sustainment Framework. Thematic analysis of interview audio recordings drew from the Rapid Identification of Themes from Audio Recordings procedures., Results: In total, we conducted 25 interviews, including 12 with clinicians and administrators, and 13 with patients. Thematic analysis revealed participants largely found the idea of technology-based medication adherence monitoring to be acceptable and appropriate for the target population in primary care, although several concerns were raised; we discuss these in detail., Conclusions: Our medication adherence monitoring intervention, adapted from specialty care, will be implemented in primary care. Formative interviews, informed by the Exploration, Preparation, Implementation, and Sustainment Framework and conducted among patients, clinicians, and administrators, have identified intervention adaptation needs. Results from this study could inform other interventions using the patient portal with older adults., (©Allison P Pack, Stacy C Bailey, Rachel O'Conor, Evelyn Velazquez, Guisselle Wismer, Fangyu Yeh, Laura M Curtis, Kenya Alcantara, Michael S Wolf. Originally published in JMIR Formative Research (https://formative.jmir.org), 17.10.2024.)

Frequent use of pain relief medications among patients with migraine can result in disease worsening and medication-overuse headache (MOH), a painful and debilitating condition. We sought to conduct a cross-sectional survey among adult patients diagnosed with migraine to determine: 1) their awareness of MOH, and 2) their knowledge of the condition and its prevention, and 3) the association of these factors with actual use of pain relief medications. We recruited and interviewed 200 English-speaking adults with migraine who had a clinic visit with a neurologist or primary care provider within the past month. Patients were identified via an electronic health record query. Almost 40% of participants had never heard of the term 'medication-overuse headache.' In bivariate analyses, participants who were Black or Hispanic and those with limited health literacy were less likely to have heard of MOH. Participants scored an average of 2.1 (range: 0-3) on a MOH knowledge measure; older participants, those with limited health literacy, lower education, and little or no migraine-related disability demonstrated less knowledge. Almost a third (31.5%) of patients reported overusing pain relief medication and were at risk for MOH. Overuse was not significantly associated with MOH awareness, knowledge, or sociodemographic factors, but was related to greater migraine-related disability. Our findings suggest that patient awareness and knowledge of MOH is suboptimal, particularly among older adults, racial and ethnic minority groups, and those with limited health literacy. Interventions are needed to prevent MOH and better inform patients about risks associated with frequent use of pain relief medications., Competing Interests: SCB reports grants from Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, Gilead and Eli Lilly through her institution; and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto outside the submitted work. APP reports grants from Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, Gilead, and Eli Lilly through her institution; and personal fees from Gilead. MPH and DF are employees of H. Lundbeck A/S and Lundbeck LLC, respectively. SMK was an employee of Lundbeck LLC at the time when this manuscript was written. All other study authors have no conflicts of interest to report., (Copyright: © 2024 Bailey et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Older adults with HIV are at increased risk of developing certain chronic health conditions including type 2 diabetes mellitus (T2DM). As the number and complexity of conditions increases, so do treatment and health care needs. We explored patient and clinician preferences for HIV+T2DM care and perceived solutions to improving care., Methods: We conducted an exploratory qualitative study comprised of individual in-depth interviews. Participants included English-speaking patients aged 50 and older living with HIV and T2DM and infectious disease (ID) and primary care (PC) clinicians from a large academic health center in Chicago. Thematic analysis drew from the Framework Method., Results: A total of 19 patient and 10 clinician participants were interviewed. Many patients reported seeking HIV and T2DM care from the same clinician; they valued rapport and a 'one-stop-shop'. Others reported having separate clinicians; they valued perceived expertise and specialty care. Nearly all clinicians reported comfort screening for T2DM and initiating first line oral therapy; ID clinicians reported placing referrals for newer, complex therapies. Patients would like educational support for T2DM management; clinicians would like to learn more about newer therapies and easier referral processes., Conclusions: Patient-centered care includes managing T2DM from a variety of clinical settings for individuals with HIV, yet strategies are needed to better support clinicians. Future research should examine how best to implement these strategies., Competing Interests: APP reports grants from RRF Foundation for Aging and commercial funders Merck, Pfizer, Gordon and Betty Moore Foundation, Lundbeck, Gilead, and Eli Lilly through her institution; and personal fees from commercial funder Gilead. SCB reports grants from the NIH and RRF Foundation for Aging, and commercial funders Merck, Pfizer, Gordon and Betty Moore Foundation, Lundbeck, Gilead and Eli Lilly through her institution; and personal fees from commerical funders Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto outside the submitted work. MCM reports grants from the NIH and commerical funder Merck through her institution. AW reports grants from commerical funder NovoNordisk through her institution, and research salary support from UnitedHealth Group. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Pack et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Medication overuse headache (MOH) is a common, debilitating condition occurring when migraine patients overuse pain relief medications. We conducted a convergent mixed methods study examining patient-provider communication on MOH., Methods: Migraine patients were identified from one academic health center via electronic health records. Research staff recruited patients and administered a remote survey on MOH awareness, knowledge, and communication; descriptive and bivariate analyses were conducted. Neurologists from the same health center were invited to participate in qualitative interviews; analysis drew from the Rapid Identification of Themes from Audio Recordings procedures. A side-by-side comparison of results followed., Results: Participants included 200 patients and 13 neurologists. More than one third of patients (39.5 %) had never heard of 'medication overuse headache.' Among those who had, 38.4 % learned about MOH ≥ 5 years after their migraine diagnosis. Neurologists similarly reported limited patient awareness of MOH and suggested communication was provider-initiated, reactive to patient-reported symptoms and behaviors. Participants agreed MOH was described as a 'consequence' of frequent medication taking, though specific terminology varied with neurologists suggesting they choose terms they perceive to be easier to understand and less stigmatizing to patients. Neurologists felt they lacked effective patient education resources., Conclusions: Findings reveal delayed opportunities to inform patients about MOH. Standardized education supporting early preventive communication is needed, perhaps in primary care where many patients seek initial care for migraine symptoms., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Pack reports grants from Merck, Pfizer, Gilead, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly through her institution, and personal fees from Gilead. Dr. Bailey reports grants from the NIH, Gilead, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly via her institution and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto UK outside the submitted work. Ms. Herman is employed full time by Lundbeck and Dr. Kymes was employed full time by Lundbeck at the time of the research., (© 2024 The Author(s).)

Background: The COVID-19 pandemic increased telehealth services in federally funded community health centers (CHCs). Yet little is known about common determinants of use among CHC patients., Objective: We examined the use of telehealth among patient participants at 1 large CHC network providing care to underserved populations at urban and suburban sites in the Midwest., Methods: We conducted a mixed-methods study utilizing a sequential explanatory design. Participants were English and/or Spanish-speaking adults who attended ≥1 visits for themselves or their child over a 12-month period at any practice location. Research staff conducted a structured phone survey of eligible adults. The results subsequently facilitated purposive sampling of telehealth "users" and "nonusers" for qualitative phone interviews., Results: The survey participants included 500 adults. Most had access to the resources needed to utilize telehealth, including a smartphone (90.4%) and home internet (83.0%). About half (50.8%) "rarely or never" had problems with internet speed, reliability, or quality. Most (81.1%) were aware of the patient portal and 59.8% had utilized video visits. Participants who were Spanish-speaking and with limited English proficiency faced some of the greatest barriers. Qualitative interview participants included 12 users and 12 nonusers of telehealth. Users found telehealth convenient and efficient, while nonusers lacked awareness about how telehealth services could be beneficial or needed assistance to sign up, join, or use telehealth., Conclusions: Most participants had the resources and awareness necessary to use telehealth services. Those who use them appreciate the convenience and efficiency. Nevertheless, additional support may be needed to prevent telehealth from exacerbating health inequities., Competing Interests: S.C.B. reports grants from the NIH, Gilead, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly via her institution and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto UK outside the submitted work. A.P.P reports grants from Eli Lilly, Merck, Pfizer, Gordon and Betty More Foundation, RRF Foundation for Aging, Lundbeck, and Gilead, and through her institution, and personal fees from Gilead. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Missed visits have been estimated to cost the U.S. healthcare system $50 billion annually and have been linked to healthcare inefficiency, higher rates of emergency department visits, and worse outcomes. COVID-19 disrupted existing outpatient healthcare utilization patterns. In our study, we sought to examine the frequency of missed outpatient visits over the course of the COVID-19 pandemic and to examine patient-level characteristics associated with non-attendance., Methods: This study utilized data from a longitudinal cohort study (the Chicago COVID-19 Comorbidities (C3) study). C3 participants were enrollees in 1 of 4 active, "parent" studies; they were rapidly enrolled in C3 at the onset of the pandemic. Multiple waves of telephone-based interviews were conducted to collect experiences with the pandemic, as well as socio-demographic and health characteristics, health literacy, patient activation, and depressive and anxiety symptoms. For the current analysis, data from waves 3 to 8 (05/01/20-05/19/22) were analyzed. Participants included 845 English or Spanish-speaking adults with 1 or more chronic conditions., Results: The percentage of participants reporting missed visits due to COVID-19 across study waves ranged from 3.1 to 22.4%. Overall, there was a decline in missed visits over time. No participant sociodemographic or health characteristic was consistently associated with missed visits across the study waves. In bivariate and multivariate analysis, only patient-reported anxiety was significantly associated with missed visits across all study waves., Conclusion: Findings reveal that anxiety was consistently associated with missed visits during the COVID-19 pandemic, but not sociodemographic or health characteristics. Results can inform future public health initiatives to reduce absenteeism by considering patients' emotional state during times of uncertainty., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SCB reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, Gilead, and Eli Lilly through her institution; and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto outside the submitted work. APP reports grants from Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, Gilead, and Eli Lilly through her institution; and personal fees from Gilead. MSW reports grants from the NIH, Gordon and Betty Moore Foundation, and Eli Lilly, and personal fees from Pfizer, Sanofi, Luto UK, University of Westminster, and Lundbeck outside the submitted work. All other study authors have no conflicts of interest to report.

Background: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended screening for prediabetes and diabetes among adults aged 35-70 years with overweight or obesity. Studying dysglycemia screening in federally qualified health centers (FQHCs) that serve vulnerable patient populations is needed to understand health equity implications of this recommendation., Objective: To investigate screening practices among FQHC patients who would be eligible according to the 2021 USPSTF recommendation., Design: Retrospective cohort study analyzing electronic health records from a national network of 282 FQHC sites., Participants: We included 183,329 patients without prior evidence of prediabetes or diabetes, who had ≥ 1 office visit from 2018-2020., Main Measures: Screening eligibility was based on age and measured body mass index (BMI). The primary outcome, screening completion, was ascertained using hemoglobin A1c or fasting plasma glucose results from 2018-2020., Key Results: Among 89,543 patients who would be eligible according to the 2021 USPSTF recommendation, 53,263 (59.5%) were screened. Those who completed screening had higher BMI values than patients who did not (33.0 ± 6.7 kg/m 2 vs. 31.9 ± 6.2 kg/m 2 , p < 0.001). Adults aged 50-64 years had greater odds of screening completion relative to younger patients (OR 1.13, 95% CI: 1.10-1.17). Patients from racial and ethnic minority groups, as well as those without health insurance, were more likely to complete screening than White patients and insured patients, respectively. Clinical risk factors for diabetes were also associated with dysglycemia screening. Among patients who completed screening, 23,588 (44.3%) had values consistent with prediabetes or diabetes., Conclusions: Over half of FQHC patients who would be eligible according to the 2021 USPSTF recommendation were screened. Screening completion was higher among middle-aged patients, those with greater BMI values, as well as vulnerable groups with a high risk of developing diabetes. Future research should examine adoption of the 2021 USPSTF screening recommendation and its impact on health equity., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Introduction: Women with type 2 diabetes (T2DM) are more likely to experience adverse reproductive outcomes, yet preconception care can significantly reduce these risks. For women with T2DM, preconception care includes reproductive planning and patient education on: (1) the importance of achieving glycaemic control before pregnancy, (2) using effective contraception until pregnancy is desired, (3) discontinuing teratogenic medications if pregnancy could occur, (4) taking folic acid, and (5) managing cardiovascular and other risks. Despite its importance, few women with T2DM receive recommended preconception care., Methods and Analysis: We are conducting a two-arm, clinic-randomised trial at 51 primary care practices in Chicago, Illinois to evaluate a technology-based strategy to 'hardwire' preconception care for women of reproductive age with T2DM (the PREPARED (Promoting REproductive Planning And REadiness in Diabetes) strategy) versus usual care. PREPARED leverages electronic health record (EHR) technology before and during primary care visits to: (1) promote medication safety, (2) prompt preconception counselling and reproductive planning, and (3) deliver patient-friendly educational tools to reinforce counselling. Post-visit, text messaging is used to: (4) encourage healthy lifestyle behaviours. English and Spanish-speaking women, aged 18-44 years, with T2DM will be enrolled (N=840; n=420 per arm) and will receive either PREPARED or usual care based on their clinic's assignment. Data will be collected from patient interviews and the EHR. Outcomes include haemoglobin A1c (primary), reproductive knowledge and self-management behaviours. We will use generalised linear mixed-effects models (GLMMs) to evaluate the impact of PREPARED on these outcomes. GLMMs will include a fixed effect for treatment assignment (PREPARED vs usual care) and random clinic effects., Ethics and Dissemination: This study was approved by the Northwestern University Institutional Review Board (STU00214604). Study results will be published in journals with summaries shared online and with participants upon request., Trial Registration Number: ClinicalTrials.gov Registry (NCT04976881)., Competing Interests: Competing interests: SCB reports grants from the NIH, Gilead, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck and Eli Lilly via her institution; and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck and Luto UK outside the submitted work. AP reports grants from Merck, Pfizer, Lundbeck, Eli Lilly, Gordon and Betty Moore Foundation, RRF Foundation for Aging and Gilead and through her institution, and personal fees from Gilead. MW reports grants from the NIH, Gordon and Betty Moore Foundation and Eli Lilly; and personal fees from Pfizer, Sanofi, Luto UK, University of Westminster and Lundbeck outside the submitted work., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: COVID-19 is an unprecedented public health threat in modern times, especially for older adults or those with chronic illness. Beyond the threat of infection, the pandemic may also have longer-term impacts on mental and physical health. The COVID-19 & Chronic Conditions ('C3') study offers a unique opportunity to assess psychosocial and health/healthcare trajectories over 5 years among a diverse cohort of adults with comorbidities well-characterised from before the pandemic, at its onset, through multiple surges, vaccine rollouts and through the gradual easing of restrictions as society slowly returns to 'normal'., Methods and Analysis: The C3 study is an extension of an ongoing longitudinal cohort study of 'high-risk' adults (aged 23-88 at baseline) with one or more chronic medical conditions during the COVID-19 pandemic. Five active studies with uniform data collection prior to COVID-19 were leveraged to establish the C3 cohort; 673 adults in Chicago were interviewed during the first week of the outbreak. The C3 cohort has since expanded to include 1044 participants across eight survey waves (T 1 -T 8 ). Four additional survey waves (T 9 -T 12 ) will be conducted via telephone interviews spaced 1 year apart and supplemented by electronic health record and pharmacy fill data, for a total of 5 years of data post pandemic onset. Measurement will include COVID-19-related attitudes/behaviours, mental health, social behaviour, lifestyle/health behaviours, healthcare use, chronic disease self-management and health outcomes. Mental health trajectories and associations with health behaviours/outcomes will be examined in a series of latent group and mixed effects modelling, while also examining mediating and moderating factors., Ethics and Dissemination: This study was approved by Northwestern University's Feinberg School of Medicine Institutional Review Board (STU00215360). Results will be published in international peer-reviewed journals and summaries will be provided to the funders of the study., Competing Interests: Competing interests: SCB reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, Retirement Research Foundation for Aging, Lundbeck, Gilead and Eli Lilly via her institution and personal fees from Sanofi, Pfizer, University of Westminster, Lundbeck, Gilead and Luto UK outside the submitted work. MW reports grants from the NIH, Gordon and Betty Moore Foundation, and Eli Lilly, and personal fees from Pfizer, Sanofi, Luto UK, University of Westminster and Lundbeck outside the submitted work. All other authors have no conflicts of interest to disclose., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The American Diabetes Association (ADA) recommends screening for prediabetes and diabetes (dysglycemia) starting at age 35, or younger than 35 years among adults with overweight or obesity and other risk factors. Diabetes risk differs by sex, race, and ethnicity, but performance of the recommendation in these sociodemographic subgroups is unknown., Methods: Nationally representative data from the National Health and Nutrition Examination Surveys (2015-March 2020) were analyzed from 5,287 nonpregnant US adults without diagnosed diabetes. Screening eligibility was based on age, measured body mass index, and the presence of diabetes risk factors. Dysglycemia was defined by fasting plasma glucose ≥100mg/dL (≥5.6 mmol/L) or haemoglobin A1c ≥5.7% (≥39mmol/mol). The sensitivity, specificity, and predictive values of the ADA screening criteria were examined by sex, race, and ethnicity., Results: An estimated 83.1% (95% CI=81.2-84.7) of US adults were eligible for screening according to the 2023 ADA recommendation. Overall, ADA's screening criteria exhibited high sensitivity [95.0% (95% CI=92.7-96.6)] and low specificity [27.1% (95% CI=24.5-29.9)], which did not differ by race or ethnicity. Sensitivity was higher among women [97.8% (95% CI=96.6-98.6)] than men [92.4% (95% CI=88.3-95.1)]. Racial and ethnic differences in sensitivity and specificity among men were statistically significant ( P =0.04 and P =0.02, respectively). Among women, guideline performance did not differ by race and ethnicity., Discussion: The ADA screening criteria exhibited high sensitivity for all groups and was marginally higher in women than men. Racial and ethnic differences in guideline performance among men were small and unlikely to have a significant impact on health equity. Future research could examine adoption of this recommendation in practice and examine its effects on treatment and clinical outcomes by sex, race, and ethnicity., Competing Interests: SB has received consultant fees from Lundbeck, Luto, Pfizer, and Sanofi. SB has received research support from Eli Lilly, Gordon and Betty Moore Foundation, Lundbeck, Merk, Pfizer, and Retirement Research Foundation for Aging. RA has received consultant fees from UnitedHealth Group. MA has received advisory panel support from Bayer AG and research support from Merk. All potential financial dualities of interest reported here were unrelated to the current study. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 O’Brien, Zhang, Bailey, Khan, Ackermann, Ali, Bowen, Benoit, Imperatore, Holliday and McKeever Bullard.)

Objective: Advancements in diagnostics and treatment options for cardiac amyloidosis have improved patient outcomes, yet few patient education materials exist to help patients understand the disease and diagnosis process. We sought to develop and evaluate a set of plain language, patient-centered infographics describing the condition and common diagnostic tests., Methods: Using health literacy best practices, we developed 7 infographics which were further revised based on multilevel stakeholder feedback. To evaluate the materials, we recruited 100 patients from healthcare settings in Chicago, IL; participants completed a web-assisted interview during which they were randomized 1:1 to first view either our infographics or a standard material. Participants completed a knowledge assessment on their assigned material and subsequently reported impressions of both materials., Results: No differences were found between study arms in knowledge. The infographics took significantly less time to read and were more highly rated by participants in terms of appearance and understandability. Over two-thirds of participants preferred the infographics to the standard., Conclusions: The infographics created may improve the learning process about a complex condition and diagnosis process unknown to most adults., Innovation: These infographics are the first of their kind for cardiac amyloidosis and were created using health literacy best practices., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Allison Pack reports financial support was provided by Pfizer Inc. and the National Institutes of Health's National Institute on Aging, Grant Number P30AG059988. Andrea Zuleta, Eleanor Daugrdas, Wei Huang, Stephanie Batio, Sophia Svoboda, Emily P. Zeitler, Stacy Cooper Bailey reports financial support was provided by Pfizer Inc. Nisith Kumar, Stephen Watt, Mehnaz Bader, Annlouise R. Assaf, Maria Isabel Fernandez-Arias reports a relationship with Pfizer that includes: employment. Conflicts of interest. APP reports grants from Merck, Pfizer, Gilead, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly; and personal fees from Gilead. SCB reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly through her institution; and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto outside the submitted work. EPZ reports consulting for Medtronic Inc., Biosense Webster, Sanofi, Pfizer, and Boston Scientific; research support from Boston Scientific, Sanofi, and Biosense Webster. All Pfizer authors are employees and stockholders of Pfizer, Inc., (© 2023 Published by Elsevier B.V.)

Objectives: Health-related chatbots have demonstrated early promise for improving self-management behaviors but have seldomly been utilized for hypertension. This research focused on the design, development, and usability evaluation of a chatbot for hypertension self-management, called "Medicagent.", Materials and Methods: A user-centered design process was used to iteratively design and develop a text-based chatbot using Google Cloud's Dialogflow natural language understanding platform. Then, usability testing sessions were conducted among patients with hypertension. Each session was comprised of: (1) background questionnaires, (2) 10 representative tasks within Medicagent, (3) System Usability Scale (SUS) questionnaire, and (4) a brief semi-structured interview. Sessions were video and audio recorded using Zoom. Qualitative and quantitative analyses were used to assess effectiveness, efficiency, and satisfaction of the chatbot., Results: Participants ( n  = 10) completed nearly all tasks (98%, 98/100) and spent an average of 18 min (SD = 10 min) interacting with Medicagent. Only 11 (8.6%) utterances were not successfully mapped to an intent. Medicagent achieved a mean SUS score of 78.8/100, which demonstrated acceptable usability. Several participants had difficulties navigating the conversational interface without menu and back buttons, felt additional information would be useful for redirection when utterances were not recognized, and desired a health professional persona within the chatbot., Discussion: The text-based chatbot was viewed favorably for assisting with blood pressure and medication-related tasks and had good usability., Conclusion: Flexibility of interaction styles, handling unrecognized utterances gracefully, and having a credible persona were highlighted as design components that may further enrich the user experience of chatbots for hypertension self-management., Competing Interests: A.E.C. is now employed by Google, LLC and has equity in the company. However, this work was completed prior to employment at Google when A.E.C. was at the University of North Carolina at Chapel Hill School of Medicine. No resources or funding were provided by Google for this research. S.C.B. reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, Retirement Research Foundation for Aging, Lundbeck, and Eli Lilly via her institution and personal fees from Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto outside the submitted work., (Published by Oxford University Press on behalf of the American Medical Informatics Association 2023.)

Objectives: We qualitatively explored patient and clinician experiences with biomarker testing in one academic health system to identify current communication practices and unmet testing information needs., Methods: We conducted 1:1 in-depth interviews with 15 clinicians (i.e., nurses, oncologists, pathologists) and 12 patients diagnosed with non-small cell lung cancer between January and May 2022. Participants described experiences with biomarker testing as well as associated communication practices and needs. Interviews were audio-recorded and transcribed. Analysis was informed by the Framework Method., Results: Patients described challenges retaining information early in their patient journey. While patients were generally aware of biomarkers and their effect on treatment options, they expressed limited knowledge of expected time delays between testing and receiving results. Additionally, many did not know their testing results. Clinicians and patients both noted no standard education material on biomarker testing is currently available. They suggested such materials could support patient knowledge and decision-making., Conclusions: Communication between patients and clinicians about biomarker testing is largely delivered through verbal counseling at a time when patients may be cognitively compromised. All participants supported the idea of delivering standard, tangible education materials on biomarker testing to patients., Practice Implications: Education materials may enhance counseling efforts and patient knowledge., Competing Interests: Declaration of Competing Interest Dr. Pack reports grants from RRF Foundation for Aging, Gordon and Betty Moore Foundation, Merck, Pfizer, Eli Lilly, and Gilead through her institution, and personal fees from Gilead. Dr. Bailey reports grants from the NIH, Gilead, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly via her institution and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto UK outside the submitted work. Ms. Weldon is an employee of Executive Frameworks, Ltd who receives consulting fees from Genentech, Roche, and LUNGevity; and reports grants from Pfizer Foundation, Eli Lilly, Lung Cancer Research Foundation, and Association of Community Cancer Centers; and is a sub-awardee under UCSF’s NHGRI R01HG011792. Dr. Wolf reports grants from the NIH (NIA, NIDDK, NINR, NHLBI, NINDS), Gordon and Betty Moore Foundation, RRF Foundation for Aging and Eli Lilly, Glaxo Smith Klein, and personal fees from Pfizer, Sanofi, Luto UK, University of Westminster, and Lundbeck., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: At the onset of the pandemic, there was poor public awareness and inaction in response to COVID-19; it is less known whether this translated to subsequent infections., Objectives: To explore whether adults who perceived COVID-19 as less of a threat and who were not taking early actions were more likely to become infected over the following year., Research Design: Survey data from the ongoing (COVID-19 & Chronic Conditions (C3) anonymized for review) cohort study., Participants: Six hundred forty-two adults with a mean age of 63 and ≥1 chronic condition., Measures: Self-reported attitudes and behaviors regarding COVID-19 were assessed from March 13 to April 3, 2020, and COVID-19 infection status was captured between May 2020 and January 2021. Bivariate and multivariable analyses examined associations between early perceptions and behaviors with later infection., Results: Approximately 7% reported infection with COVID-19 (N = 46). Adults who perceived the threat of COVID-19 less seriously at the initial outbreak were more likely to test positive over the following year [odds ratio (OR): 0.81, CI: 0.70-0.94; P = 0.006]. Those who were less likely to believe their actions would affect whether they would become infected were more likely to test positive (OR: 0.87, CI: 0.77-0.99; P = 0.03), as were adults who reported not changing their routines (OR: 0.45; CI: 0.24-0.85; P = 0.01)., Conclusions: Adults with delayed responses in acknowledging the threat of COVID-19 and in changing behaviors were more likely to contract the virus. This investigation provides insight into the consequences of inadequate public understanding and response to COVID-19, and it highlights the importance of promoting early awareness among high-risk groups during public health crises., Competing Interests: M.S.W. reports grants from the NIH during the conduct of the study; grants from Merck, the Gordon and Betty Moore Foundation, the NIH, and Eli Lilly outside the submitted work; and personal fees from Sanofi, Pfizer, GlaxoSmithKline, Lundbeck, Bristol Myers Squibb, and Luto outside the submitted work. S.C.B reports grants from the NIH during the conduct of the study; grants from Merck, Lundbeck, Pfizer, NIH, and Eli Lilly outside the submitted work; grants and personal fees from Pfizer, Sanofi, Lundbeck, the Gordon and Betty Moore Foundation outside the submitted work; and personal fees from Sanofi, Pfizer, and Luto outside the submitted work. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: In 2021, the U.S. Preventive Services Task Force (USPSTF) recommended prediabetes and diabetes screening for asymptomatic adults aged 35-70 years with overweight/obesity, lowering the age from 40 years in its 2015 recommendation. The USPSTF suggested considering earlier screening in racial and ethnic groups with high diabetes risk at younger ages or lower BMI. This study examined the clinical performance of these USPSTF screening recommendations as well as alternative age and BMI cutoffs in the U.S. adult population overall, and separately by race and ethnicity., Methods: Nationally representative data were collected from 3,243 nonpregnant adults without diagnosed diabetes in January 2017-March 2020 and analyzed from 2021 to 2022. Screening eligibility was based on age and measured BMI. Collectively, prediabetes and undiagnosed diabetes were defined by fasting plasma glucose ≥100 mg/dL or hemoglobin A 1c ≥5.7%. The sensitivity, specificity, and predictive values of alternate screening criteria were examined overall, and by race and ethnicity., Results: The 2021 criteria exhibited marginally higher sensitivity (58.6%, 95% CI=55.5, 61.6 vs 52.9%, 95% CI=49.7, 56.0) and lower specificity (69.3%, 95% CI=65.7, 72.2 vs 76.4%, 95% CI=73.3, 79.2) than the 2015 criteria overall, and within each racial and ethnic group. Screening at lower age and BMI thresholds resulted in even greater sensitivity and lower specificity, especially among Hispanic, non-Hispanic Black, and Asian adults. Screening all adults aged 35-70 years regardless of BMI yielded the most equitable performance across all racial and ethnic groups., Conclusions: The 2021 USPSTF screening criteria will identify more adults with prediabetes and diabetes in all racial and ethnic groups than the 2015 criteria. Screening all adults aged 35-70 years exhibited even higher sensitivity and performed most similarly by race and ethnicity, which may further improve early detection of prediabetes and diabetes in diverse populations., (Copyright © 2023 American Journal of Preventive Medicine. All rights reserved.)

Objective: To investigate well-being, lifestyle behaviors, self-management capacity and healthcare utilization among adults with chronic conditions at the outbreak of the COVID-19 pandemic., Methods: Data was collected from two interviewer-administered telephone surveys conducted between March 27 - May 22, 2020. Participants were patients at Chicago-area clinics. Self-report and validated measures were used for study-related outcomes., Results: A total of 553 participants (age range 23-88) completed data collection at both timepoints. One in five (20.7%) participants experienced stress due to the coronavirus most or all the time and rates of negative well-being were high (WHO-5 Index mean = 58.7%). Almost a quarter (22.3%) engaged in hazardous drinking and 79.7% reported insufficient physical activity. Nearly one in four participants (23.7%) avoided seeking medical care due to worry about COVID-19. In multivariable analyses, greater COVID-19 related stress was associated with less physical activity, lower self-efficacy, greater difficulty managing health and medications, and delays in seeking medical care due to the coronavirus., Conclusions: Mental well-being, lifestyle behaviors, self-management capacity, and healthcare utilization were impacted in the months following the COVID outbreak., Innovation: These findings suggest health systems should implement proactive measures for detecting and treating emotional and behavioral COVID-related concerns., Competing Interests: Study authors AR, MS, SF, LO, SB, RO, LC, MK, JYB, GW, ME, PZ, RL, MA, KM, and JL have no conflicts to disclose. SCB reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, Lundbeck, RRF for Aging and Eli Lilly and personal fees from Sanofi, Pfizer, University of Westminster, Lundbeck and Luto. MSW reports grants from the NIH, Amgen, Lundbeck, Merck, Pfizer, Gordon and Betty Moore Foundation, and Eli Lilly during the conduct of the study and personal fees from Sanofi, Pfizer, University of Westminster and Luto outside the submitted work., (© 2023 The Authors.)

Introduction: Type 2 diabetes mellitus (T2DM) and comorbid conditions require patients to take complex medication regimens. Greater regimen complexity has been associated with poorer T2DM management; however, the relationship between overall regimen complexity and glycemic control is unclear., Objectives: Our objectives were: (1) to examine associations between regimen complexity (with the Medication Regimen Complexity Index [MRCI]) and glycemic control (A1C), and (2) to compare overall MRCI with other measures of regimen complexity (overall and diabetes-specific medication count) and diabetes-specific MRCI., Methods: This was a secondary data analysis of cross-sectional data from a parent trial. Participants were patients with T2DM taking at least 3 chronic medications followed in safety net clinics in the Chicago area. The MRCI measures complexity based on dosing frequency, route of administration, and special instructions for prescribed medications. MRCI scores were created for overall regimens and diabetes-specific medications. Sociodemographics and outpatient visit utilization were included in models as covariates. Linear regression was used to examine the associations between variables of interest and hemoglobin A1C., Results: Participants (N = 432) had a mean age of 56.9 years, most were female (66.0%), and Hispanic or Latino (73.3%). Regimen complexity was high based on overall medications (mean = 6.6 medications, SD: 3.09) and MRCI (mean = 21.4, SD: 11.3). Higher diabetes-specific MRCI was associated with higher A1C in bivariate and multivariable models. In multivariable models, overall MRCI greater than 14, fewer outpatient health care visits, male gender, and absence of health insurance were independently associated with higher A1C. The variance in A1C explained by MRCI was higher compared to medication count for overall and diabetes-specific regimen complexity., Conclusions: More complex regimens are associated with worse A1C and measuring complexity with MRCI may have advantages. Deprescribing, increasing insurance coverage, and promoting engagement in health care may improve A1C among underserved populations with complex regimens., (Copyright © 2023 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

With pervasive health misinformation and mistrust, many of those at greatest risk from COVID-19 have demonstrated lower vaccine acceptance. In Chicago, IL, surveillance data has revealed lower rates of vaccine uptake among Black and Latinx individuals compared with others. We partnered with two local federally qualified health centers (FQHCs) to develop and implement language-concordant, low literacy patient education materials to promote COVID-19 vaccine knowledge, acceptance, and uptake. Our multi-phase study included: 1) iterative content generation and refinement by health literacy experts, health center providers and staff, and community-dwelling adults; and 2) materials testing via a two-arm randomized experiment among adults from Latinx communities in the Chicagoland area. Results indicate that our English and Spanish-language COVID-19 Fact Sheets increase knowledge about COVID-19 vaccination. These materials are publicly available and can be used by health centers or community organizations to promote COVID-19 vaccination among diverse populations.

Introduction: The lack of definitive means to prevent or treat cognitive impairment or dementia is driving intense efforts to identify causal mechanisms. Recent evidence suggests clinically meaningful declines in cognition might present as early as middle age. Studying cognitive changes in middle adulthood could elucidate modifiable factors affecting later cognitive and health outcomes, yet few cognitive ageing studies include this age group. The purpose of the MidCog study is to begin investigations of less-studied and potentially modifiable midlife determinants of later life cognitive outcomes., Methods and Analysis: MidCog is a prospective cohort study of adults ages 35-64, with two in-person interviews 2.5 years apart. Data will be collected from interviews, electronic health records and pharmacy fill data. Measurements will include health literacy, self-management skills, cognitive function, lifestyle and health behaviours, healthcare use, health status and chronic disease outcomes. Associations of health literacy and self-management skills with health behaviours and cognitive/health outcomes will be examined in a series of regression models, and moderating effects of modifiable psychosocial factors.Finally, MidCog data will be linked to an ongoing, parallel cohort study of older adults recruited at ages 55-74 in 2008 ('LitCog'; ages 70-90 in 2023), to explore associations between age, health literacy, self-management skills, chronic diseases, health status and cognitive function among adults ages 35-90., Ethics and Dissemination: The Institutional Review Board at Northwestern University has approved the MidCog study protocol (STU00214736). Results will be published in peer-reviewed journals and summaries will be provided to the funders of the study as well as patients., Competing Interests: Competing interests: SCB reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, Retirement Research Foundation for Aging, Lundbeck, Gilead, and Eli Lilly via her institution and personal fees from Sanofi, Pfizer, University of Westminster, Lundbeck, Gilead, and Luto UK outside the submitted work. PCZ reports grants from the NIH and Vanda via her institution and personal consulting fees from Jazz, Eisai, Harmony and Sleep Number that are outside the submitted work. MW reports grants from the NIH, Gordon and Betty Moore Foundation, and Eli Lilly, and personal fees from Pfizer, Sanofi, Luto UK, University of Westminster, and Lundbeck outside the submitted work. RO’C is supported by a training grant from the National Institute on Aging (K01AG070107). All the other authors report no conflict of interest., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Most health literacy measures require in-person administration or rely upon self-report., Objective: We sought to develop and test the feasibility of a brief, objective health literacy measure that could be deployed via text messaging or online survey., Design: Participants were recruited from ongoing NIH studies to complete a phone interview and online survey to test candidate items. Psychometric analyses included parallel analysis for dimensionality and item response theory. After 9 months, participants were randomized to receive the final instrument via text messaging or online survey., Participants: Three hundred six English and Spanish-speaking adults with ≥ 1 chronic condition MAIN MEASURES: Thirty-three candidate items for the new measure and patient-reported physical function, anxiety, depression, and medication adherence. All participants previously completed the Newest Vital Sign (NVS) in parent NIH studies., Key Results: Participants were older (average 67 years), 69.6% were female, 44.3% were low income, and 22.0% had a high school level of education or less. Candidate items loaded onto a single factor (RMSEA: 0.04, CFI: 0.99, TLI: 0.98, all loadings >.59). Six items were chosen for the final measure, named the HL6. Items demonstrated acceptable internal consistency (α=0.73) and did not display differential item functioning by language. Higher HL6 scores were significantly associated with greater educational attainment (r=0.41), higher NVS scores (r=0.55), greater physical functioning (r=0.26), fewer depressive symptoms (r=-0.20), fewer anxiety symptoms (r=-0.15), and fewer barriers to medication adherence (r=-0.30; all p<.01). In feasibility testing, 75.2% of participants in the text messaging arm completed the HL6 versus 66.2% in the online survey arm (p=0.09). Socioeconomic disparities in completion were more common in the online survey arm., Conclusions: The HL6 demonstrates adequate reliability and validity in both English and Spanish. This performance-based assessment can be administered remotely using commonly available technologies with fewer logistical challenges than assessments requiring in-person administration., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

This study examined how patients take complex medication regimens at home. Participants were primary care patients, 21 years or older, and prescribed three or more medications. Interviews assessed medication dosing schedules, medication knowledge, and dosing errors. Participants (N=441) were middle aged (mean 56.9); the majority were Hispanic/Latino (73.4%), had limited English proficiency (59.0%), and had limited health literacy (89.0%). One in five participants dosed medication five or more times per day, although no participants in the sample had a label instructing them to take medication more than times times daily. On average, participants correctly identified the purpose of 65% of their medications. Half of participants made one or more dosing errors. Less than high school education and a regimen size of six or more medications were independently associated with less medication knowledge, whereas language discordant label instructions were associated with dosing errors. Screening for regimen dosing complication and interventions to simplify dosing schedules are needed.

Objective: While health podcasts can be effective in reducing stigma and increasing knowledge, we know little about their mechanisms of action. This qualitative study explored the mechanisms of how women connected with the podcast 'menopause: unmuted', which presented menopause information in a storytelling format., Methods: A diverse sample of 30 women aged 40-60 years were interviewed after listening to the podcast. Interviews covered participant's views and perceptions of the stories presented. Transcripts were analyzed thematically., Findings: Two overarching themes were identified. 'Openness and authenticity' describes the value of personal stories told in an authentic way by real experts-by-experience. 'Relatability and representation' explores participants' emotional reaction to the podcast, influenced by the extent to which they identified with the stories and storytellers on the podcast., Conclusions: Authenticity and relatability were identified as key mechanisms through which participants connected with audio stories, consistent with Fisher's narrative theory. These findings have important implications for the application of storytelling in podcasts designed to influence health behaviors., Practice Implications: Diverse stories representing a range of demographic characteristics and experiences are needed when creating podcasts about health information to increase listener's relatability and connection., Competing Interests: Competing interest statement Philippa Shaw was remunerated for the current project through funding provided by Pfizer to the University of Westminster. Philippa is also a freelance researcher at Studio Health, which has received consultancy fees from Pfizer, Roche, Takeda, MSD, and AstraZeneca. Amy Sumner was remunerated for the current project through funding provided by Pfizer to the University of Westminster. Amy is also a freelance researcher at Studio Health, which has received consultancy fees from Pfizer, Roche, Takeda, MSD, and AstraZeneca. Candida Halton is a director at Studio Health which has received consultancy fees from Pfizer, Roche, Takeda, MSD, and AstraZeneca. Stacy Bailey reports that she has received personal fees from the University of Westminster related to the conduct of this study. She also receives grants (via her institution) from Merck, Gordon and Betty Moore Foundation, National Institutes of Health, Eli Lilly, Pfizer, and Lundbeck. She has received personal fees from Sanofi, Pfizer, and Luto outside the submitted work. Michael Wolf reports that he has received personal fees from the University of Westminster related to the conduct of this study. He also receives grants (via his institution) from Merck, Gordon and Betty Moore Foundation, National Institutes of Health, Eli Lilly, Pfizer, and Lundbeck. Michael has received personal fees from Sanofi, Pfizer, and Luto outside the submitted work. Emma Andrews receives salary and stock from Pfizer Inc., where she is an employee. Tina Cartwright reports that she has received research funding (via her institution) from Pfizer for this study. She has previously received research funding from Takeda., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Mixed methods are valuable in understanding multifaceted health behaviors like medication adherence. Kidney transplant recipients (KTRs) have complex medication regimens and are more vulnerable to nonadherence relative to other transplant recipients. Yet mixed methods have not been widely applied to examine adherence among KTRs, especially in relation to prescribed medications beyond immunosuppressants., Objectives: As part of a sequential approach, we used in-depth interviews to better understand findings from a previous quantitative study and to describe additional factors that influence prescription medication-taking among adult KTRs., Methods: Semi-structured interviews were conducted with a purposive sample of 14 adult KTRs recruited from a transplant center in Chicago, IL. Deductive and inductive content analysis was used to code transcripts and identify key themes., Results: Across the sample, we identified insurance challenges, disruptions in routine, and poor mental well-being as barriers to adherence at the patient level. For Black and Hispanic KTRs, poor communication between providers and disjointed care transitions posed additional barriers at the health system level. Compared with White KTRs, Black and Hispanic KTRs experienced greater medication burden due to comorbidities, while medication and digital literacy challenges were unique to Hispanic KTRs., Conclusion: KTRs are often motivated to take medications as prescribed, but sometimes lack the capacity or support to do so. Eliciting KTR perspectives is necessary in addressing knowledge and resource gaps at the patient and health system levels to improve adherence. In addition, recognizing the relative burden of taking comorbidity medications compared with immunosuppressants may important, particularly for Black and Hispanic KTRs., (Copyright © 2022 Elsevier Inc. All rights reserved.)

To determine the prevalence of sleep disturbance during the coronavirus disease 2019 (COVID-19) pandemic among US adults who are more vulnerable to complications because of age and co-morbid conditions, and to identify associated sociodemographic and psychosocial factors. Cross-sectional survey linked to 3 active clinical trials and 2 cohort studies, conducted between 11/30/2020 and 3/3/2021. Five academic internal medicine practices and 2 federally qualified health centers. A total of 715 adults ages 23 to 91 years living with one or more chronic conditions. A fifth (20%) of participants reported poor sleep. Black adults were twice as likely to report poor sleep compared to Whites. Self-reported poor physical function (51%), stress (42%), depression (28%), and anxiety (36%) were also common and all significantly associated with poor sleep. Age ≥70 years and having been vaccinated for COVID-19 were protective against poor sleep. Sex, education, income, alcohol use, and employment status were not significantly associated with sleep quality. In this diverse sample of adults with chronic conditions, by race, ethnicity, and socioeconomic status, disparities in sleep health amid the ongoing pandemic were apparent. Worse physical function and mental health were associated with poor sleep and should be considered targets for health system interventions to prevent the many subsequent consequences of disturbed sleep on health outcomes. Measurements: self-reported sleep quality, physical function, stress, depression, and anxiety., Competing Interests: SCB reports grants from the NIH, Merck, Pfizer, Gordon and Betty Moore Foundation, RRF Foundation for Aging, Lundbeck, and Eli Lilly through her institution; and personal fees from Gilead, Sanofi, Pfizer, University of Westminster, Lundbeck, and Luto outside the submitted work. All other authors report no conflict of interest., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: The U.S. public health response to coronavirus disease 2019 (COVID-19) has been widely criticized as having downplayed the potential implications COVID-19 could have on one's personal health. Despite the unprecedented threat of COVID-19, many individuals still believed that it was not at all likely that they would become infected. We sought to investigate trends in adults' perceived susceptibility to COVID-19 over the first year of the pandemic, whether distinct trajectories emerged, and if these trajectories differed by participant socio-demographic characteristics.This was a longitudinal cohort study with 5 time points of data collection (March 13, 2020-March 3, 2021). Subjects included 627 adults living with ≥1 chronic conditions, who completed a baseline interview and at least one follow-up interview. In addition to collecting relevant socio-demographic characteristics, participants' perceived susceptibility to COVID-19 across time was assessed and classified into distinct trajectories.Nearly two-thirds (62.2%) of participants perceived themselves to be highly susceptible to COVID-19 from the onset of the pandemic ("early responders") and sustained this over a year, a third (29.0%) eventually perceived themselves to be highly susceptible ("late responders"), and 8.8% maintained a low likelihood of susceptibility throughout the pandemic ("non-responders"). In multivariable analyses, compared to White participants, Latinx participants were significantly more likely to be non-responders and report low likelihood of perceived susceptibility (Risk Ratio [RR]: 3.46; 95% confidence interval: 1.19, 10.1), as were Black participants (RR: 5.49; 95% confidence interval: 2.19, 13.8).A year into the COVID-19 pandemic, 1 out of 11 participants persistently did not think they might be susceptible and potentially infected. Future studies are needed to understand reasons why certain individuals, particularly those of racial/ethnic minorities, did not perceive themselves at risk for infection., Competing Interests: MSW reports grants from the NIH during the conduct of the study; grants from Merck, the Gordon and Betty Moore Foundation, the NIH, and Eli Lilly outside the submitted work; and personal fees from Sanofi, Pfizer, and Luto outside the submitted work. SCB reports grants from the NIH during the conduct of the study; grants from Merck, the NIH, and Eli Lilly outside the submitted work; grants and personal fees from the Gordon and Betty Moore Foundation outside the submitted work; and personal fees from Sanofi, Pfizer, and Luto outside the submitted work. LAO, LMC, MJK, RO, GAW, JYB, RML, MRE, and AMZ have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Limited health literacy and numeracy are associated with worse patient-reported outcomes and higher disease activity in systemic lupus erythematosus (SLE), but which factors may mediate this association is unknown. We sought to determine the association of health literacy and numeracy with SLE knowledge., Methods: Patients with SLE were recruited from an academic center clinic. Participants completed validated assessments of health literacy (Newest Vital Sign [NVS]; n = 96) and numeracy (Numeracy Understanding in Medicine Instrument, Short Version [S-NUMI]; n = 85). They also completed the Lupus Knowledge Assessment Test (LKAT), which consists of 4 questions assessing SLE knowledge that were determined through consensus expert opinion for their wide applicability and importance related to self-management of the disease. Descriptive statistics and multivariable logistic regression modeling were used to analyze the results., Results: In our SLE cohort (n = 125), 33% (32/96) had limited health literacy and 76% (65/85) had limited numeracy. The majority correctly identified that hydroxychloroquine prevented SLE flares (91%); however, only 23% of participants correctly answered a numeracy question assessing which urine protein to creatinine (UPC) ratio was > 1000 mg/g. The mean LKAT score was 2.7 out of 4.0. Limited health literacy, but not numeracy, was associated with lower knowledge about SLE as measured by the LKAT, even after adjusting for education., Conclusion: Patients with SLE with limited health literacy had lower knowledge about SLE. The LKAT could be further refined and/or used as a screening tool to identify patients with knowledge gaps. Further work is needed to improve patients' understanding of proteinuria and investigate whether literacy-sensitive education can improve care., (Copyright © 2022 by the Journal of Rheumatology.)

Background: Inadequate adherence to prescribed immunosuppressive medication regimens among kidney transplant recipients is common, yet interventions are needed to support patients in sustaining adequate adherence to prescribed regimens and achieving optimal transplant outcomes., Objective: We examined the preliminary fidelity of a transplant center-based, multifaceted adherence monitoring strategy known as TAKE IT., Methods: The TAKE IT strategy includes: (1) routine, online, monthly patient self-report adherence assessments; (2) care alerts directed to nurses; (3) quarterly reports monitoring tacrolimus values and adherence trends; (4) support tools tailored to specific adherence concerns. A 2-arm, patient-randomized trial is underway at two large transplant centers (N=449). To evaluate the initial fidelity of TAKE IT, we investigated patient uptake of monthly adherence assessments during the course of a 3-month period, whether any disparities emerged, and the nature of any reported adherence concerns., Results: Among 202 patients randomized and exposed to TAKE IT for 3-months or more, 81% (164/202) completed an adherence assessment, 73% (148/202) completed at least two, and 57% (116/202) completed all monthly assessments. Overall, 50% (82/164) of kidney transplant recipients reported at least one adherence concern over the 3-month assessment period. The most common barriers were classified as regimen-related (eg, regimen complexity), cognitive (eg, forgetfulness), and medical (eg, side effects). Higher-income participants were more likely to complete all surveys compared to lower-income participants (P=.01)., Conclusions: TAKE IT demonstrated 81% (164/202) completion of an adherence assessment, 73% (148/202) completion of at least two, and 57% (116/202) completion of all monthly assessments during this brief, initial observation period. Among those that did respond to the online assessments, the majority demonstrated sustained engagement. Additional monitoring modalities could also be offered to meet patient preferences to ensure all patients' medication use can be properly monitored., Trial Registration: ClinicalTrials.gov NCT03104868; https://clinicaltrials.gov/ct2/show/NCT03104868., (©Esther S Yoon, Scott Hur, Laura M Curtis, Aiden H Wynia, Pauline Zheng, Sumi S Nair, Stacy C Bailey, Marina Serper, Peter P Reese, Daniela P Ladner, Michael S Wolf. Originally published in JMIR Formative Research (https://formative.jmir.org), 05.05.2022.)