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Publications

2021

Zhang J, Shang T, Ahn D, et al. How to Best Protect People With Diabetes From the Impact of SARS-CoV-2: Report of the International COVID-19 and Diabetes Summit. J Diabetes Sci Technol. Published online 2021.
Publisher's Version
The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has rapidly involved the entire world and exposed the pressing need for collaboration between public health and other stakeholders from the clinical, scientific, regulatory, pharmaceutical, and medical device and technology communities. To discuss how to best protect people with diabetes from serious outcomes from COVID-19, Diabetes Technology Society, in collaboration with Sansum Diabetes Research Institute, hosted the "International COVID-19 and Diabetes Virtual Summit" on August 26-27, 2020. This unique, unprecedented real-time conference brought together physicians, scientists, government officials, regulatory experts, industry representatives, and people with diabetes from six continents to review and analyze relationships between COVID-19 and diabetes. Over 800 attendees logged in. The summit consisted of five sessions: (I) Keynotes, (II) Preparedness, (III) Response, (IV) Recovery, and (V) Surveillance; eight parts: (A) Background, (B) Resilience, (C) Outpatient Care, (D) Inpatient Care, (E) Resources, (F) High-Risk Groups, (G) Regulation, and (H) The Future; and 24 sections: (1) Historic Pandemics and Impact on Society, (2) Pathophysiology/Risk Factors for COVID-19, (3) Social Determinants of COVID-19, (4) Preparing for the Future, (5) Medications and Vaccines, (6) Psychology of Patients and Caregivers, (7) Outpatient Treatment of Diabetes Mellitus and Non-Pharmacologic Intervention, (8) Technology and Telehealth for Diabetes Outpatients, (9) Technology for Inpatients, (10) Management of Diabetes Inpatients with COVID-19, (11) Ethics, (12) Accuracy of Diagnostic Tests, (13) Children, (14) Pregnancy, (15) Economics of Care for COVID-19, (16) Role of Industry, (17) Protection of Healthcare Workers, (18) People with Diabetes, (19) International Responses to COVID-19, (20) Government Policy, (21) Regulation of Tests and Treatments, (22) Digital Health Technology, (23) Big Data Statistics, and 24) Patient Surveillance and Privacy. The two keynote speeches were entitled (1) COVID-19 and Diabetes-Meeting the Challenge and (2) Knowledge Gaps and Research Opportunities for Diabetes and COVID-19. While there was an emphasis on diabetes and its interactions with COVID-19, the panelists also discussed the COVID-19 pandemic in general. The meeting generated many novel ideas for collaboration between experts in medicine, science, government, and industry to develop new technologies and disease treatment paradigms to fight this global pandemic.

2020

Chen K, Wisk L, Nuckols T, Elmore J, Steers N, Zimmerman F. Unmet Medical Needs Among Adults Who Move due to Unaffordable Housing: California Health Interview Survey, 2011-2017. J Gen Intern Med. Published online 2020.
Publisher's Version

Background: Stable, affordable housing is an established determinant of health. As affordable housing shortages across the USA threaten to displace people from their homes, it is important to understand the implications of cost-related residential moves for healthcare access.

Objective: To examine the relationship between cost-related moves and unmet medical needs.

Design: We performed a cross-sectional analysis of 7 waves (2011-2017) of the California Health Interview Survey.

Participants: We included all respondents ages 18 and older.

Main measures: The primary predictor variable was residential move history in the past 5 years (cost-related move, non-cost-related move, or no move). The primary outcome was unmet medical needs in the past year (necessary medications and/or medical care that were delayed or not received).

Key results: Our sample included 146,417 adults (42-47% response rate), representing a weighted population of 28,518,590. Overall, 20.3% of the sample reported unmet medical needs in the past year, and 4.9% reported a cost-related move in the past 5 years. In multivariable logistic regression models, adjusted risk of unmet medical needs increased for adults with both cost-related moves (aOR 1.38; 95% CI 1.19-1.59) and non-cost-related moves (aOR 1.17; 95% CI 1.09-1.26) compared to those with no moves. Among people who had moved, those with cost-related moves were more likely to report unmet medical needs compared to people with non-cost-related moves (p = 0.03).

Conclusions: People who have moved due to unaffordable housing represent a population at increased risk for unmet medical needs. Policy makers seeking to improve population health should consider strategies to limit cost-related moves and to mitigate their adverse effects on healthcare access.

Levy S, Weitzman E, Marin A, Magane K, Wisk L, Shrier L. Sensitivity and specificity of S2BI for identifying alcohol and cannabis use disorders among adolescents presenting for primary care. Subst Abus. Published online 2020:1-8. doi:10.1080/08897077.2020.1803180
BACKGROUND: The Screening to Brief Intervention (S2BI) tool was designed to identify substance use disorders in adolescents. We report the S2BI's sensitivity and specificity for identifying alcohol and cannabis use disorders (AUD and CUD) in adolescents presenting for primary care. Participants aged 14-18 ( = 517) completed an electronic survey, consisting of the S2BI, the Composite International Diagnostic Interview (CIDI), and anxiety and depression screens. We calculated sensitivity, specificity, and positive and negative predictive value (PPV, NPV) of the S2BI compared to the CIDI criterion standard, using past year "monthly" and "weekly or more" consumption of alcohol or marijuana as a threshold for AUD or CUD. Current AUD and CUD were present in 2.9% and 8.3% of the sample, respectively and severe AUD and CUD were present in 0.8% and 3.9%. The S2BI had 53.3% sensitivity and 94.2% specificity for identifying any AUD (PPV = 21.6%; NPV = 98.5%), and 81.4% sensitivity and 92.0% specificity for identifying any CUD (PPV = 47.9%; NPV = 98.2%). The same threshold had 100% sensitivity and 93.6% specificity for identifying moderate/severe AUD, and 90.0% sensitivity and 89.0% specificity for identifying moderate/severe CUD. S2BI had excellent sensitivity and specificity for identifying moderate and severe AUD and CUD. Sensitivity decreased when mild AUD and CUD were included.
Wisk L, Peltz A, Galbraith AA. Changes in Health Care-Related Financial Burden for US Families With Children Associated With the Affordable Care Act. JAMA Pediatr. 2020;174(11):1-9. doi:10.1001/jamapediatrics.2020.3973
Publisher's Version
Importance: The Affordable Care Act (ACA) sought to improve access and affordability of health insurance. Although most ACA policies targeted childless adults, the extent to which these policies also impacted families with children remains unclear. Objective: To examine changes in health care-related financial burden for US families with children before and after the ACA was implemented based on income eligibility for ACA policies. Design, Setting, and Participants: Data used for this cohort study were obtained from the 2000-2017 Medical Expenditure Panel Survey, a nationally representative, population-based survey. Multivariable regression with a difference-in-differences estimator was used to examine changes in family financial burden before and after ACA implementation according to income-based ACA eligibility groups (≤138% [lowest-income], 139%-250% [low-income], 251%-400% [middle-income], and >400% [high-income] federal poverty level). The cohort included 92 165 families with 1 or more children (age ≤18 years) and 1 or more adult parents/guardians. Exposures: Income-based eligibility groups during post-ACA years (calendar years 2014-2017) vs pre-ACA years (calendar years 2000-2013). Main Outcomes and Measures: Family annual out-of-pocket (OOP) health care and premium cost burden relative to income. High OOP burden was determined based on a previously validated algorithm with relative cost thresholds that vary across incomes, and extreme OOP burden was defined as costs exceeding 10% of income. Premiums exceeding 9.5% of income were classified as burdensome and premiums relative to median household income defined an unaffordability index. Results: Compared with high-income families who experienced a lesser change post-ACA implementation (high OOP burden, 1.1% pre-ACA vs 0.9% post-ACA), the lowest-income families saw the greatest reduction in high OOP burden (35.6% pre-ACA vs 23.7% post-ACA; difference-in-differences: -11.4%; 95% CI, -13.2% to -9.5%) followed by low-income families (24.6% pre-ACA vs 17.3% post-ACA, difference-in-differences: -6.8%; 95% CI, -8.7% to -4.9%) and middle-income families (6.1% pre-ACA vs 4.6% post-ACA, difference-in-differences: -1.2%; 95% CI, -2.3% to -0.01%). Although premiums rose for all groups, premium unaffordability was the least exacerbated for the lowest-, low-, and middle-income families compared with higher-income families. Conclusions and Relevance: The findings of this study suggest that low- and middle-income families with children who were eligible for ACA Medicaid expansions and Marketplace subsidies experienced greater reductions in health care-related financial burden after the ACA was implemented compared with families with higher incomes. However, despite ACA policies, many low- and middle-income families with children appear to continue to face considerable financial burden from premiums and OOP costs.
Harstad E, Sideridis G, Kaye D, Wisk L, Weitzman E, Levy S. Parental Perceptions About Alcohol Use for Their Adolescent with Attention-Deficit/Hyperactivity Disorder. J Dev Behav Pediatr. 2020;41(5):366-372. doi:10.1097/DBP.0000000000000794
Publisher's Version
OBJECTIVE: Alcohol use can worsen attention-deficit/hyperactivity disorder (ADHD) symptoms, interfere with treatment, and worsen outcomes. Our objective was to describe parental perceptions of alcohol use for their adolescents with ADHD. METHODS: Parents of adolescents with ADHD completed an online survey about perceptions of adolescent alcohol use for adolescents with ADHD. We described the level of parental concern about the impacts of alcohol use on their adolescent's functioning. We assessed whether specific covariates were associated with the level of parental concern. RESULTS: Of 290 parents who completed the survey, 96.5% were women, and 66.1% had an educational attainment of college degree or higher. Most adolescents (75.4%) took ADHD medication, and 59.9% had comorbid anxiety or depression. Almost one-third (30.3%) of parents perceived that their adolescent was more likely to use alcohol because of ADHD, whereas 34.8% of parents disagreed with this and 34.8% of parents were neutral. Parents who suspected their adolescent regularly used alcohol were less likely to report concern about the impact of alcohol on their adolescent's school performance or ADHD medication effectiveness compared with parents who did not suspect regular adolescent alcohol use. Almost half of the parents (48.5%) did not report discussing the impact of alcohol use on ADHD with their adolescent. CONCLUSION: Many parents of adolescents with ADHD do not understand the unique risks of alcohol use for their adolescents. In addition, if alcohol use harm is not obvious, parents may not perceive there to be concerns about alcohol use on functioning. Parental education about alcohol use and ADHD is needed.
Wisk L, Magane K, Levy S, Weitzman E. Alcohol Use Behaviors and Reasons to Abstain from or Limit Drinking among Medically Vulnerable Youth. Journal of Addiction Medicine. 2020;14(4):311-318.
Publisher's Version

Background: Youth with chronic medical conditions (YCMC) use alcohol at levels similar to their healthy peers but face elevated risk for adverse health consequences. As salient reasons to abstain from or limit drinking (RALD) among YCMC are unknown, we sought to identify clusters of RALD and test associations with use behaviors.

Methods: Eligible YCMC (ages 9-18) recruited from outpatient clinics reported their use behaviors and importance of potential RALD. Cluster analysis was used to discern RALD patterns, which were examined as predictors of alcohol use using multivariate regression.

Results: Among 398 participants, 30.9% reported past year alcohol use. Concerns about impacts on medications, school, and disease status were the most frequently endorsed RALD; prior negative experiences with alcohol and family history were the least frequently endorsed. Five RALD clusters were identified for all YCMC and 2 for recent drinkers. Compared to the cluster with high endorsement of multiple general and health-related RALD, those predominantly citing concerns about addiction and those not strongly endorsing any RALD consistently reported greater alcohol use. Among recent drinkers, the cluster characterized by low concern across multiple RALD also consistently reported greater alcohol use compared to their counterparts expressing moderate concern.

Conclusions: For YCMC, RALD are complex but endorsement of multiple general and health-related RALD is associated with less use, and health concerns are especially prevalent. More research is needed to understand how salient RALD can inform tailored interventions that aim to delay and reduce substance use and improve health outcomes for YCMC.

Weitzman E, Magane K, Chen PH, Amiri H, Naimi T, Wisk L. Online Searching and Social Media to Detect Alcohol Use Risk at Population Scale. American Journal of Preventive Medicine. 2020;58(1):79-88.
Publisher's Version

Introduction: Harnessing engagement in online searching and social media may provide complementary information for monitoring alcohol use, informing prevention and policy evaluation, and extending knowledge available from national surveys.

Methods: Relative search volumes for 7 alcohol-related keywords were estimated from Google Trends (data, 2014-2017), and the proportion of alcohol use-related Twitter posts (data, 2014-2015) was estimated using natural language processing. Searching/posting measures were created for all 50 U.S. states plus Washington, D.C. Survey reports of alcohol use and summaries of state alcohol policies were obtained from the Behavioral Risk Factor Surveillance System (data, 2014-2016) and the Alcohol Policy Scale. In 2018-2019, associations among searching/posting measures and same state/year Behavioral Risk Factor Surveillance System reports of recent (past-30-day) alcohol use and maximum number of drinks consumed on an occasion were estimated using logistic and linear regression, adjusting for sociodemographics and Internet use, with moderation tested in regressions that included interactions of select searching/posting measures and the Alcohol Policy Scale.

Results: Recent alcohol use was reported by 52.93% of 1,297,168 Behavioral Risk Factor Surveillance System respondents, which was associated with all state-level searching/posting measures in unadjusted and adjusted models (p<0.0001). Among drinkers, most searching/posting measures were associated with maximum number of drinks consumed (p<0.0001). Associations varied with exposure to high versus low levels of state policy controls on alcohol.

Conclusions: Strong associations were found among individual alcohol use and state-level alcohol-related searching/posting measures, which were moderated by the strength of state alcohol policies. Findings support using novel personally generated data to monitor alcohol use and possibly evaluate effects of alcohol control policies.

Chadi, Levy S, Wisk L, Weitzman E. Student Experience of School Screening, Brief Intervention and Referral to Treatment. Journal of School Health. 2020;90(6):431-438.
Publisher's Version

Background: Screening, Brief Intervention and Referral to Treatment (SBIRT) is a clinical guideline that can help delay, prevent or reduce substance use behaviors in youth. We aimed to describe the experiences of middle and high school (MS and HS) students attending a school with an SBIRT program.

Methods: This was a survey study conducted in 2 school districts that implemented SBIRT programs prior to statewide roll-out of mandatory school SBIRT in Massachusetts, in which students were asked about past-year substance use and then received brief counseling by a school professional. Students in grades that received SBIRT were subsequently invited to complete an electronic questionnaire about their SBIRT experience.

Results: A total of 890 students were included in the study (63.7% MS, 36.3% HS). Experiences of school SBIRT were predominantly positive: 74.0% of participants reported that the information received was useful. Students who reported having used substances were less likely to agree that "schools should screen for substance use" than students who did not report substance use (AOR: 0.39, 95%CI: 0.29-0.53).

Conclusions: Most respondents found SBIRT of value, though students with past-year substance use were less positive about the experience. More research is needed to optimize SBIRT delivery in schools.

2019

Adams J, Chien AT, Wisk L. Mental Illness Among Youth With Chronic Physical Conditions. Pediatrics. Published online 2019. doi:10.1542/peds.2018-1819
Publisher's Version
BACKGROUND AND OBJECTIVES: Youth with chronic physical conditions (CPCs) may be at greater risk for developing chronic mental health conditions (MHCs), and limitations in the ability to engage in developmentally appropriate activities may contribute to the risk of MHCs among youth with CPCs. We compared the risk of incident MHCs in youth with and without CPCs and explored whether activity limitations contribute to any such association. METHODS: The 2003-2014 Medical Expenditure Panel Survey provided a nationally representative cohort of 48 572 US youth aged 6 to 25 years. We calculated the 2-year cumulative incidence of MHCs overall and by baseline CPC status. Cox proportional hazard models were used to estimate the association between CPCs and incident MHCs, adjusting for sociodemographic characteristics. Stepwise models and the Sobel test evaluated activity limitations as a mediator of this relationship. RESULTS: The 2-year cumulative incidence of MHCs was 7.8% overall, 11.5% in youth with CPCs (14.7% of sample), and 7.1% in those without. The adjusted risk of incident MHCs was 51% greater (adjusted hazard ratio 1.51; 95% confidence interval 1.30-1.74) in youth with CPCs compared with those without. Activity limitations mediated 13.5% of this relationship ( < .001). CONCLUSIONS: This nationally representative cohort study supports the hypotheses that youth with CPCs have increased risk for MHCs and that activity limitations may play a role in MHC development. Youth with CPCs may benefit from services to bolster their ability to participate in developmentally important activities and to detect and treat new onset MHCs.