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All Publications

  • Analysis of unused prescription opioids and benzodiazepines remaining after death among Medicare decedents. Drug and alcohol dependence Baum, L. V., Bruzelius, E., Kiang, M. V., Humphreys, K., Basu, S., Baum, A. 2021; 219: 108502


    BACKGROUND: Millions of opioid and benzodiazepine prescriptions are dispensed near end-of-life. After death, patients' unused prescription pills belong to family members, who often save rather than dispose of them. We sought to quantify this exposure in Medicare beneficiaries.METHODS: We estimated the share of decedent Medicare beneficiaries who potentially left behind opioid or benzodiazepine pills at the time of death using Part D claims of a 20 % national sample of Medicare beneficiaries between 2006-2015 linked to the National Death Index.RESULTS: We estimated that 1 in 6 Medicare beneficiaries who died between 2006-2015 potentially left behind opioid pills, and 1 in 10 who died between 2013-2015 potentially left benzodiazepines as well. Leftover pills were more common among younger, dually enrolled, and lower-income beneficiaries, as well as beneficiaries living in non-urban areas and those with a history of mental illness, drug use disorders, and chronic pain. North American Natives and Non-Hispanic Whites had higher proportions than Black, Hispanic, and Asian decedents.CONCLUSIONS: Opioids and benzodiazepines are commonly left behind at death. Policies and interventions that encourage comprehensive and safe medication disposal after death may reduce risk for intra-household diversion and misuse of prescription opioids and benzodiazepines.

    View details for DOI 10.1016/j.drugalcdep.2020.108502

    View details for PubMedID 33421803

  • Power Outages and Community Health: a Narrative Review. Current environmental health reports Casey, J. A., Fukurai, M., Hernandez, D., Balsari, S., Kiang, M. V. 2020


    PURPOSE OF REVIEW: Power outages, a common and underappreciated consequence of natural disasters, are increasing in number and severity due to climate change and aging electricity grids. This narrative review synthesizes the literature on power outages and health in communities.RECENT FINDINGS: We searched Google Scholar and PubMed for English language studies with titles or abstracts containing "power outage" or "blackout." We limited papers to those that explicitly mentioned power outages or blackouts as the exposure of interest for health outcomes among individuals living in the community. We also used the reference list of these studies to identify additional studies. The final sample included 50 articles published between 2004 and 2020, with 17 (34%) appearing between 2016 and 2020. Exposure assessment remains basic and inconsistent, with 43 (86%) of studies evaluating single, large-scale power outages. Few studies used spatial and temporal control groups to assess changes in health outcomes attributable to power outages. Recent research linked data from electricity providers on power outages in space and time and included factors such as number of customers affected and duration to estimate exposure. The existing literature suggests that power outages have important health consequences ranging from carbon monoxide poisoning, temperature-related illness, gastrointestinal illness, and mortality to all-cause, cardiovascular, respiratory, and renal disease hospitalizations, especially for individuals relying on electricity-dependent medical equipment. Nonetheless the studies are limited, and more work is needed to better define and capture the relevant exposures and outcomes. Studies should consider modifying factors such as socioeconomic and other vulnerabilities as well as how community resiliency can minimize the adverse impacts of widespread major power outages.

    View details for DOI 10.1007/s40572-020-00295-0

    View details for PubMedID 33179170

  • Measuring mobility to monitor travel and physical distancing interventions: a common framework for mobile phone data analysis LANCET DIGITAL HEALTH Kishore, N., Kiang, M., Engo-Monsen, K., Vembar, N., Schroeder, A., Balsari, S., Buckee, C. O. 2020; 2 (11): E622–E628
  • US-county level variation in intersecting individual, household and community characteristics relevant to COVID-19 and planning an equitable response: a cross-sectional analysis. BMJ open Chin, T., Kahn, R., Li, R., Chen, J. T., Krieger, N., Buckee, C. O., Balsari, S., Kiang, M. V. 2020; 10 (9): e039886


    OBJECTIVES: To illustrate the intersections of, and intercounty variation in, individual, household and community factors that influence the impact of COVID-19 on US counties and their ability to respond.DESIGN: We identified key individual, household and community characteristics influencing COVID-19 risks of infection and survival, guided by international experiences and consideration of epidemiological parameters of importance. Using publicly available data, we developed an open-access online tool that allows county-specific querying and mapping of risk factors. As an illustrative example, we assess the pairwise intersections of age (individual level), poverty (household level) and prevalence of group homes (community-level) in US counties. We also examine how these factors intersect with the proportion of the population that is people of colour (ie, not non-Hispanic white), a metric that reflects histories of US race relations. We defined 'high' risk counties as those above the 75th percentile. This threshold can be changed using the online tool.SETTING: US counties.PARTICIPANTS: Analyses are based on publicly available county-level data from the Area Health Resources Files, American Community Survey, Centers for Disease Control and Prevention Atlas file, National Center for Health Statistic and RWJF Community Health Rankings.RESULTS: Our findings demonstrate significant intercounty variation in the distribution of individual, household and community characteristics that affect risks of infection, severe disease or mortality from COVID-19. About 9% of counties, affecting 10million residents, are in higher risk categories for both age and group quarters. About 14% of counties, affecting 31million residents, have both high levels of poverty and a high proportion of people of colour.CONCLUSION: Federal and state governments will benefit from recognising high intrastate, intercounty variation in population risks and response capacity. Equitable responses to the pandemic require strategies to protect those in counties at highest risk of adverse COVID-19 outcomes and their social and economic impacts.

    View details for DOI 10.1136/bmjopen-2020-039886

    View details for PubMedID 32873684

  • Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study. BMJ (Clinical research ed.) Kiang, M. V., Humphreys, K., Cullen, M. R., Basu, S. 2020; 368: l6968


    OBJECTIVE: To examine the distribution and patterns of opioid prescribing in the United States.DESIGN: Retrospective, observational study.SETTING: National private insurer covering all 50 US states and Washington DC.PARTICIPANTS: An annual average of 669495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.MAIN OUTCOME MEASURES: Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.RESULTS: In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.CONCLUSIONS: Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

    View details for DOI 10.1136/bmj.l6968

    View details for PubMedID 31996352

  • Every Body Counts: Measuring Mortality From the COVID-19 Pandemic. Annals of internal medicine Kiang, M. V., Irizarry, R. A., Buckee, C. O., Balsari, S. 2020


    As of mid-August 2020, more than 170 000 U.S. residents have died of coronavirus disease 2019 (COVID-19); however, the true number of deaths resulting from COVID-19, both directly and indirectly, is likely to be much higher. The proper attribution of deaths to this pandemic has a range of societal, legal, mortuary, and public health consequences. This article discusses the current difficulties of disaster death attribution and describes the strengths and limitations of relying on death counts from death certificates, estimations of indirect deaths, and estimations of excess mortality. Improving the tabulation of direct and indirect deaths on death certificates will require concerted efforts and consensus across medical institutions and public health agencies. In addition, actionable estimates of excess mortality will require timely access to standardized and structured vital registry data, which should be shared directly at the state level to ensure rapid response for local governments. Correct attribution of direct and indirect deaths and estimation of excess mortality are complementary goals that are critical to our understanding of the pandemic and its effect on human life.

    View details for DOI 10.7326/M20-3100

    View details for PubMedID 32915654

  • Measuring mobility to monitor travel and physical distancing interventions: a common framework for mobile phone data analysis. The Lancet. Digital health Kishore, N., Kiang, M. V., Engø-Monsen, K., Vembar, N., Schroeder, A., Balsari, S., Buckee, C. O. 2020


    A surge of interest has been noted in the use of mobility data from mobile phones to monitor physical distancing and model the spread of severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19. Despite several years of research in this area, standard frameworks for aggregating and making use of different data streams from mobile phones are scarce and difficult to generalise across data providers. Here, we examine aggregation principles and procedures for different mobile phone data streams and describe a common syntax for how aggregated data are used in research and policy. We argue that the principles of privacy and data protection are vital in assessing more technical aspects of aggregation and should be an important central feature to guide partnerships with governments who make use of research products.

    View details for DOI 10.1016/S2589-7500(20)30193-X

    View details for PubMedID 32905027

    View details for PubMedCentralID PMC7462565

  • Decomposition of the US black/white inequality in premature mortality, 2010-2015: an observational study. BMJ open Kiang, M. V., Krieger, N., Buckee, C. O., Onnela, J. P., Chen, J. T. 2019; 9 (11): e029373


    OBJECTIVE: Decompose the US black/white inequality in premature mortality into shared and group-specific risks to better inform health policy.SETTING: All 50 US states and the District of Columbia, 2010 to 2015.PARTICIPANTS: A total of 2.85million non-Hispanic white and 762639 non-Hispanic black US-resident decedents.PRIMARY AND SECONDARY OUTCOME MEASURES: The race-specific county-level relative risks for US blacks and whites, separately, and the risk ratio between groups.RESULTS: There is substantial geographic variation in premature mortality for both groups and the risk ratio between groups. After adjusting for median household income, county-level relative risks ranged from 0.46 to 2.04 (median: 1.03) for whites and from 0.31 to 3.28 (median: 1.15) for blacks. County-level risk ratios (black/white) ranged from 0.33 to 4.56 (median: 1.09). Half of the geographic variation in white premature mortality was shared with blacks, while only 15% of the geographic variation in black premature mortality was shared with whites. Non-Hispanic blacks experience substantial geographic variation in premature mortality that is not shared with whites. Moreover, black-specific geographic variation was not accounted for by median household income.CONCLUSION: Understanding geographic variation in mortality is crucial to informing health policy; however, estimating mortality is difficult at small spatial scales or for small subpopulations. Bayesian joint spatial models ameliorate many of these issues and can provide a nuanced decomposition of risk. Using premature mortality as an example application, we show that Bayesian joint spatial models are a powerful tool as researchers grapple with disentangling neighbourhood contextual effects and sociodemographic compositional effects of an area when evaluating health outcomes. Further research is necessary in fully understanding when and how these models can be applied in an epidemiological setting.

    View details for DOI 10.1136/bmjopen-2019-029373

    View details for PubMedID 31748287

  • Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS medicine Tsai, A. C., Kiang, M. V., Barnett, M. L., Beletsky, L., Keyes, K. M., McGinty, E. E., Smith, L. R., Strathdee, S. A., Wakeman, S. E., Venkataramani, A. S. 2019; 16 (11): e1002969


    Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.

    View details for DOI 10.1371/journal.pmed.1002969

    View details for PubMedID 31770387

  • Performance of Matching Methods as Compared With Unmatched Ordinary Least Squares Regression Under Constant Effects AMERICAN JOURNAL OF EPIDEMIOLOGY Vable, A. M., Kiang, M. V., Glymour, M., Rigdon, J., Drabo, E. F., Basu, S. 2019; 188 (7): 1345–54

    View details for DOI 10.1093/aje/kwz093

    View details for Web of Science ID 000492995600024

  • Performance of Matching Methods to Unmatched Ordinary Least Squares Regression Under Constant Effects. American journal of epidemiology Vable, A. M., Kiang, M. V., Glymour, M. M., Rigdon, J., Drabo, E. F., Basu, S. 2019


    Matching methods are assumed to reduce the likelihood of a biased inference compared to ordinary least squares regression. Using simulations, we compare inferences from propensity score matching, coarsened exact matching, and un-matched covariate-adjusted ordinary least squares regression (OLS) to identify which methods, in which scenarios, produced unbiased inferences at the expected type I error rate of 5%. We simulated multiple datasets and systematically varied common support, discontinuities in the exposure and / or outcome, exposure prevalence, and analytic model misspecification. Matching inferences were often biased compared to OLS, particularly when common support was poor; when analysis models were correctly specified and common support was poor, the type I error rate was 1.6% for propensity score matching (statistically inefficient), 18.2% for coarsened exact matching (high), and 4.8% for OLS (expected). Our results suggest when estimates from matching and OLS are similar (i.e. confidence intervals overlap), OLS inferences are unbiased more often than matching inferences, however, when estimates from matching and OLS are dissimilar (i.e. confidence intervals do not overlap), matching inferences are unbiased more often than OLS inferences. This empirical 'rule of thumb' may help applied researchers identify situations when OLS inferences may be unbiased compared to matching inferences.

    View details for PubMedID 30995301

  • Assessment of Changes in the Geographical Distribution of Opioid-Related Mortality Across the United States by Opioid Type, 1999-2016. JAMA network open Kiang, M. V., Basu, S., Chen, J., Alexander, M. J. 2019; 2 (2): e190040


    Importance: As the opioid epidemic evolves, it is vital to identify changes in the geographical distribution of opioid-related deaths, and the specific opioids to which those deaths are attributed, to ensure that federal and state public health interventions remain appropriately targeted.Objective: To identify changes in the geographical distribution of opioid-related mortality across the United States by opioid type.Design, Setting, and Participants: Cross-sectional study using joinpoint modeling and life table analysis of individual-level data from the National Center for Health Statistics on 351 630 US residents who died from opioid-related causes from January 1, 1999, to December 31, 2016, for all of the United States and the District of Columbia. The analysis was conducted from September 6 to November 23, 2018.Exposures: Deaths involving any opioid, heroin, synthetic opioids, and natural and semisynthetic opioids.Main Outcomes and Measures: Opioid-related mortality rate, annual percent change in the opioid-related mortality rate, and life expectancy lost at age 15 years by state and opioid type.Results: From 1999 to 2016, a total of 231 264 men and 120 366 women died from opioid-related causes across the whole United States. Sixty-six observations were removed owing to missing data on age; therefore, 351 564 US residents were included in this study. The mean (SD) age at death was 39.8 (12.5) years for men and was 43.5 (12.9) years from women. Opioid-related mortality rates, especially from synthetic opioids, rapidly increased in all of the eastern United States. In most states, mortality associated with natural and semisynthetic opioids (ie, prescription painkillers) remained stable. In contrast, 28 states had mortality rates from synthetic opioids that more than doubled every 2 years (ie, annual percent change, ≥41%), including 12 with high mortality rates from synthetic opioids (>10 per 100 000 people). Among these 28 states, the mortality rate from natural and semisynthetic opioids ranged from 2.0 to 18.7 per 100 000 people (with a mean mortality rate of 6.0 per 100 000 people). The District of Columbia had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013 (annual percent change, 228.3%; 95% CI, 169.7%-299.6%; P<.001), and a high mortality rate from synthetic opioids in 2016 (18.8 per 100 000 people); the mortality rate from natural and semisynthetic opioids was 6.9 per 100 000 people. Nationally, overall opioid-related mortality resulted in 0.36 years of life expectancy lost in 2016, which was 14% higher than deaths due to firearms and 18% higher than deaths due to motor vehicle crashes; 0.17 years of the life expectancy lost was due specifically to synthetic opioids. In 2016, New Hampshire and West Virginia lost more than 1 year of life expectancy due to opioid-related mortality.Conclusions and Relevance: Opioid-related mortality, particularly mortality associated with synthetic opioids, has increased in the eastern United States. These findings indicate that policies focused on reducing opioid-related deaths may need to prioritize synthetic opioids and rapidly expanding epidemics in northeastern states and consider the potential for synthetic opioid epidemics outside of the heroin supply.

    View details for PubMedID 30794299

  • Assessment of Changes in the Geographical Distribution of Opioid-Related Mortality Across the United States by Opioid Type, 1999-2016 JAMA NETWORK OPEN Kiang, M. V., Basu, S., Chen, J., Alexander, M. J. 2019; 2 (2)
  • Trends in pregnancy-associated mortality involving opioids in the United States, 2007-2016. American journal of obstetrics and gynecology Gemmill, A., Kiang, M. V., Alexander, M. J. 2018

    View details for PubMedID 30273587

  • Trends in Black and White Opioid Mortality in the United States, 1979-2015 EPIDEMIOLOGY Alexander, M. J., Kiang, M. V., Barbieri, M. 2018; 29 (5): 707–15


    Recent research on the US opioid epidemic has focused on the white or total population and has largely been limited to data after 1999. However, understanding racial differences in long-term trends by opioid type may contribute to improving interventions.Using multiple cause of death data, we calculated age-standardized opioid mortality rates, by race and opioid type, for the US resident population from 1979 to 2015. We analyzed trends in mortality rates using joinpoint regression.From 1979 to 2015, the long-term trends in opioid-related mortality for Earlier data did not include ethnicity so this is incorrect. It is all black and all white residents in the US. blacks and whites went through three successive waves. In the first wave, from 1979 to the mid-1990s, the epidemic affected both populations and was driven by heroin. In the second wave, from the mid-1990s to 2010, the increase in opioid mortality was driven by natural/semi-synthetic opioids (e.g., codeine, morphine, hydrocodone, or oxycodone) among whites, while there was no increase in mortality for blacks. In the current wave, increases in opioid mortality for both populations have been driven by heroin and synthetic opioids (e.g., fentanyl and its analogues). Heroin rates are currently increasing at 31% (95% confidence interval [CI] = 27, 35) per year for whites and 34% (95% CI = 30, 40) for blacks. Concurrently, respective synthetic opioids are increasing at 79% (95% CI = 50, 112) and 107% (95% CI = -15, 404) annually.Since 1979, the nature of the opioid epidemic has shifted from heroin to prescription opioids for the white population to increasing of heroin/synthetic deaths for both black and white populations. See video abstract at,

    View details for PubMedID 29847496

    View details for PubMedCentralID PMC6072374

  • Mortality in Puerto Rico after Hurricane Maria NEW ENGLAND JOURNAL OF MEDICINE Kishore, N., Marques, D., Mahmud, A., Kiang, M. V., Rodriguez, I., Fuller, A., Ebner, P., Sorensen, C., Racy, F., Lemery, J., Maas, L., Leaning, J., Irizarry, R. A., Balsari, S., Buckee, C. O. 2018; 379 (2): 162–70


    Quantifying the effect of natural disasters on society is critical for recovery of public health services and infrastructure. The death toll can be difficult to assess in the aftermath of a major disaster. In September 2017, Hurricane Maria caused massive infrastructural damage to Puerto Rico, but its effect on mortality remains contentious. The official death count is 64.Using a representative, stratified sample, we surveyed 3299 randomly chosen households across Puerto Rico to produce an independent estimate of all-cause mortality after the hurricane. Respondents were asked about displacement, infrastructure loss, and causes of death. We calculated excess deaths by comparing our estimated post-hurricane mortality rate with official rates for the same period in 2016.From the survey data, we estimated a mortality rate of 14.3 deaths (95% confidence interval [CI], 9.8 to 18.9) per 1000 persons from September 20 through December 31, 2017. This rate yielded a total of 4645 excess deaths during this period (95% CI, 793 to 8498), equivalent to a 62% increase in the mortality rate as compared with the same period in 2016. However, this number is likely to be an underestimate because of survivor bias. The mortality rate remained high through the end of December 2017, and one third of the deaths were attributed to delayed or interrupted health care. Hurricane-related migration was substantial.This household-based survey suggests that the number of excess deaths related to Hurricane Maria in Puerto Rico is more than 70 times the official estimate. (Funded by the Harvard T.H. Chan School of Public Health and others.).

    View details for PubMedID 29809109

  • Military Service, Childhood Socio-Economic Status, and Late-Life Lung Function: Korean War Era Military Service Associated with Smaller Disparities. Military medicine Vable, A. M., Kiang, M. V., Basu, S., Rudolph, K. E., Kawachi, I., Subramanian, S. V., Glymour, M. M. 2018


    Background: Military service is associated with smoking initiation, but U.S. veterans are also eligible for special social, financial, and healthcare benefits, which are associated with smoking cessation. A key public health question is how these offsetting pathways affect health disparities; we assessed the net effects of military service on later life pulmonary function among Korean War era veterans by childhood socio-economic status (cSES).Methods: Data came from U.S.-born male Korean War era veteran (service: 1950-1954) and non-veteran participants in the observational U.S. Health and Retirement Study who were alive in 2010 (average age = 78). Veterans (N = 203) and non-veterans (N = 195) were exactly matched using coarsened exact matching on birth year, race, coarsened height, birthplace, childhood health, and parental and childhood smoking. Results were evaluated by cSES (defined as maternal education <8 yr/unknown or ≥8 yr), in predicting lung function, as assessed by peak expiratory flow (PEF), measured in 2008 or 2010.Findings: While there was little overall association between veterans and PEF [beta = 12.8 L/min; 95% confidence interval (CI): (-12.1, 37.7); p = 0.314; average non-veteran PEF = 379 L/min], low-cSES veterans had higher PEF than similar non-veterans [beta = 81.9 L/min; 95% CI: (25.2, 138.5); p = 0.005], resulting in smaller socio-economic disparities among veterans compared to non-veterans [difference in disparities: beta = -85.0 L/min; 95% CI: (-147.9, -22.2); p = 0.008].Discussion: Korean War era military service appears to disproportionately benefit low-cSES veteran lung functioning, resulting in smaller socio-economic disparities among veterans compared with non-veterans.

    View details for PubMedID 29509934

  • Reproductive justice & preventable deaths: state funding, family planning, abortion, and infant mortality, US 1980-2010. SSM - population health Krieger, N., Gruskin, S., Singh, N., Kiang, M. V., Chen, J. T., Waterman, P. D., Beckfield, J., Coull, B. A. 2016; 2: 277–93


    INTRODUCTION: Little current research examines associations between infant mortality and US states' funding for family planning services and for abortion, despite growing efforts to restrict reproductive rights and services and documented associations between unintended pregnancy and infant mortality.MATERIAL AND METHODS: We obtained publicly available data on state-only public funding for family planning and abortion services (years available: 1980, 1987, 1994, 2001, 2006, and 2010) and corresponding annual data on US county infant death rates. We modeled the funding as both fraction of state expenditures and per capita spending (per woman, age 15-44). State-level covariates comprised: Title X and Medicaid per capita funding, fertility rate, and percent of counties with no abortion services; county-level covariates were: median family income, and percent: black infants, adults without a high school education, urban, and female labor force participation. We used Possion log-linear models for: (1) repeat cross-sectional analyses, with random state and county effects; and (2) panel analysis, with fixed state effects.RESULTS: Four findings were robust to analytic approach. First, since 2000, the rate ratio for infant death comparing states in the top funding quartile vs. no funding for abortion services ranged (in models including all covariates) between 0.94 to 0.98 (95% confidence intervals excluding 1, except for the 2001 cross-sectional analysis, whose upper bound equaled 1), yielding an average 15% reduction in risk (range: 8 to 22%). Second, a similar risk reduction for state per capita funding for family planning services occurred in 1994. Third, the excess risk associated with lower county income increased over time, and fourth, remained persistently high for counties with a high percent of black infants.CONCLUSIONS: Insofar as reducing infant mortality is a government priority, our data underscore the need, despite heightened contention, for adequate public funding for abortion services and for redressing health inequities.

    View details for PubMedID 27453928

  • Implementation of the Surgical Safety Checklist in South Carolina Hospitals Is Associated with Improvement in Perceived Perioperative Safety JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Molina, G., Jiang, W., Edmondson, L., Gibbons, L., Huang, L. C., Kiang, M. V., Haynes, A. B., Gawande, A. A., Berry, W. R., Singer, S. J. 2016; 222 (5): 725-+


    Previous research suggests that surgical safety checklists (SSCs) are associated with reductions in postoperative morbidity and mortality as well as improvement in teamwork and communication. These findings stem from evaluations of individual or small groups of hospitals. Studies with more hospitals have assessed the relationship of checklists with teamwork at a single point in time. The objective of this study was to evaluate the impact of a large-scale implementation of SSCs on staff perceptions of perioperative safety in the operating room.As part of the Safe Surgery 2015 initiative to implement SSCs in South Carolina hospitals, we administered a validated survey designed to measure perception of multiple dimensions of perioperative safety among clinical operating room personnel before and after implementation of an SSC.Thirteen hospitals administered baseline and follow-up surveys, separated by 1 to 2 years. Response rates were 48.4% at baseline (929 of 1,921) and 42.7% (815 of 1,909) at follow-up. Results suggest improvement in all of the 5 dimensions of teamwork (relative percent improvement ranged from +2.9% for coordination to +11.9% for communication). These were significant after adjusting for respondent characteristics, hospital fixed-effects, multiple comparisons, and clustering robust standard errors by hospital (all p < 0.05). More than half of respondents (54.1%) said their surgical teams always used checklists effectively; 73.6% said checklists had averted problems or complications.A large-scale initiative to implement SSCs is associated with improved staff perceptions of mutual respect, clinical leadership, assertiveness on behalf of safety, team coordination and communication, safe practice, and perceived checklist outcomes.

    View details for PubMedID 27049781

  • New Tools for New Research in Psychiatry: A Scalable and Customizable Platform to Empower Data Driven Smartphone Research JMIR MENTAL HEALTH Torous, J., Kiang, M. V., Lorme, J., Onnela, J. 2016; 3 (2): e16


    A longstanding barrier to progress in psychiatry, both in clinical settings and research trials, has been the persistent difficulty of accurately and reliably quantifying disease phenotypes. Mobile phone technology combined with data science has the potential to offer medicine a wealth of additional information on disease phenotypes, but the large majority of existing smartphone apps are not intended for use as biomedical research platforms and, as such, do not generate research-quality data.Our aim is not the creation of yet another app per se but rather the establishment of a platform to collect research-quality smartphone raw sensor and usage pattern data. Our ultimate goal is to develop statistical, mathematical, and computational methodology to enable us and others to extract biomedical and clinical insights from smartphone data.We report on the development and early testing of Beiwe, a research platform featuring a study portal, smartphone app, database, and data modeling and analysis tools designed and developed specifically for transparent, customizable, and reproducible biomedical research use, in particular for the study of psychiatric and neurological disorders. We also outline a proposed study using the platform for patients with schizophrenia.We demonstrate the passive data capabilities of the Beiwe platform and early results of its analytical capabilities.Smartphone sensors and phone usage patterns, when coupled with appropriate statistical learning tools, are able to capture various social and behavioral manifestations of illnesses, in naturalistic settings, as lived and experienced by patients. The ubiquity of smartphones makes this type of moment-by-moment quantification of disease phenotypes highly scalable and, when integrated within a transparent research platform, presents tremendous opportunities for research, discovery, and patient health.

    View details for PubMedID 27150677

  • Police Killings and Police Deaths Are Public Health Data and Can Be Counted PLOS MEDICINE Krieger, N., Chen, J. T., Waterman, P. D., Kiang, M. V., Feldman, J. 2015; 12 (12): e1001915


    Nancy Krieger and colleagues argue that law-enforcement-related deaths in the United States should be treated as notifiable conditions, which would allow public health departments to report these data in real-time.

    View details for PubMedID 26645383

  • Making time for learning-oriented leadership in multidisciplinary hospital management groups HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Hayes, J. E., Gray, G. C., Kiang, M. V. 2015; 40 (4): 300–312


    Although the clinical requirements of health care delivery imply the need for interdisciplinary management teams to work together to promote frontline learning, such interdisciplinary, learning-oriented leadership is atypical.We designed this study to identify behaviors enabling groups of diverse managers to perform as learning-oriented leadership teams on behalf of quality and safety.We randomly selected 12 of 24 intact groups of hospital managers from one hospital to participate in a Safety Leadership Team Training program. We collected primary data from March 2008 to February 2010 including pre- and post-staff surveys, multiple interviews, observations, and archival data from management groups. We examined the level and trend in frontline perceptions of managers' learning-oriented leadership following the intervention and ability of management groups to achieve objectives on targeted improvement projects. Among the 12 intervention groups, we identified higher- and lower-performing intervention groups and behaviors that enabled higher performers to work together more successfully.Management groups that achieved more of their performance goals and whose staff perceived more and greater improvement in their learning-oriented leadership after participation in Safety Leadership Team Training invested in structures that created learning capacity and conscientiously practiced prescribed learning-oriented management and problem-solving behaviors. They made the time to do these things because they envisioned the benefits of learning, valued the opportunity to learn, and maintained an environment of mutual respect and psychological safety within their group.Learning in management groups requires vision of what learning can accomplish; will to explore, practice, and build learning capacity; and mutual respect that sustains a learning environment.

    View details for PubMedID 25029508

  • Why history matters for quantitative target setting: Long-term trends in socioeconomic and racial/ethnic inequities in US infant death rates (1960-2010) JOURNAL OF PUBLIC HEALTH POLICY Krieger, N., Singh, N., Chen, J. T., Coull, B. A., Beckfield, J., Kiang, M. V., Waterman, P. D., Gruskin, S. 2015; 36 (3): 287–303


    Policy-oriented population health targets, such as the Millennium Development Goals and national targets to address health inequities, are typically based on trends of a decade or less. To test whether expanded timeframes might be more apt, we analyzed 50-year trends in US infant death rates (1960-2010) jointly by income and race/ethnicity. The largest annual per cent changes in the infant death rate (between -4 and -10 per cent), for all racial/ethnic groups, in the lowest income quintile occurred between the mid-1960s and early 1980s, and in the second lowest income quintile between the mid-1960s and 1973. Since the 1990s, these numbers have hovered, in all groups, between -1 and -3 per cent. Hence, to look back only 15 years (in 2014, to 1999) would ignore gains achieved prior to the onset of neoliberal policies after 1980. Target setting should be informed by a deeper and longer-term appraisal of what is possible to achieve.

    View details for PubMedID 25971237

    View details for PubMedCentralID PMC4711344

  • Surgical Team Member Assessment of the Safety of Surgery Practice in 38 South Carolina Hospitals MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Jiang, W., Huang, L. C., Gibbons, L., Kiang, M. V., Edmondson, L., Gawande, A. A., Berry, W. R. 2015; 72 (3): 298-323


    We assessed surgical team member perceptions of multiple dimensions of safe surgical practice in 38 South Carolina hospitals participating in a statewide initiative to implement surgical safety checklists. Primary data were collected using a novel 35-item survey. We calculated the percentage of 1,852 respondents with strongly positive, positive, and neutral/negative responses about the safety of surgical practice, compared results by hospital and professional discipline, and examined how readiness, teamwork, and adherence related to staff perception of care quality. Overall, 78% of responses were positive about surgical safety at respondent's hospitals, but in each survey dimension, from 16% to 40% of responses were neutral/negative, suggesting significant opportunity to improve surgical safety. Respondents not reporting they would feel safe being treated in their operating rooms varied from 0% to 57% among hospitals. Surgeons responded more positively than nonsurgeons. Readiness, teamwork, and practice adherence related directly to staff perceptions of patient safety (p < .001).

    View details for DOI 10.1177/1077558715577479

    View details for Web of Science ID 000354117900004

    View details for PubMedID 25828528

  • Reproductive Justice and the Pace of Change: Socioeconomic Trends in US Infant Death Rates by Legal Status of Abortion, 1960-1980 AMERICAN JOURNAL OF PUBLIC HEALTH Krieger, N., Gruskin, S., Singh, N., Kiang, M. V., Chen, J. T., Waterman, P. D., Gottlieb, J., Beckfield, J., Coull, B. A. 2015; 105 (4): 680–82


    US infant death rates for 1960 to 1980 declined most quickly in (1) 1970 to 1973 in states that legalized abortion in 1970, especially for infants in the lowest 3 income quintiles (annual percentage change = -11.6; 95% confidence interval = -18.7, -3.8), and (2) the mid-to-late 1960s, also in low-income quintiles, for both Black and White infants, albeit unrelated to abortion laws. These results imply that research is warranted on whether currently rising restrictions on abortions may be affecting infant mortality.

    View details for PubMedID 25713932

    View details for PubMedCentralID PMC4358198

  • Age at Menarche: 50-Year Socioeconomic Trends Among US-Born Black and White Women AMERICAN JOURNAL OF PUBLIC HEALTH Krieger, N., Kiang, M. V., Kosheleva, A., Waterman, P. D., Chen, J. T., Beckfield, J. 2015; 105 (2): 388–97


    We investigated 50-year US trends in age at menarche by socioeconomic position (SEP) and race/ethnicity because data are scant and contradictory.We analyzed data by income and education for US-born non-Hispanic Black and White women aged 25 to 74 years in the National Health Examination Survey (NHES) I (1959-1962), National Health Examination and Nutrition Surveys (NHANES) I-III (1971-1994), and NHANES 1999-2008.In NHES I, average age at menarche among White women in the 20th (lowest) versus 80th (highest) income percentiles was 0.26 years higher (95% confidence interval [CI] = -0.09, 0.61), but by NHANES 2005-2008 it had reversed and was -0.33 years lower (95% CI = -0.54, -0.11); no socioeconomic gradients occurred among Black women. The proportion with onset at younger than 11 years increased only among women with low SEP, among Blacks and Whites (P for trend < .05), and high rates of change occurred solely among Black women (all SEP strata) and low-income White women who underwent menarche before 1960.Trends in US age at menarche vary by SEP and race/ethnicity in ways that pose challenges to several leading clinical, public health, and social explanations for early age at menarche and that underscore why analyses must jointly include data on race/ethnicity and socioeconomic position. Future research is needed to explain these trends.

    View details for PubMedID 25033121

    View details for PubMedCentralID PMC4318288

  • 50-year trends in US socioeconomic inequalities in health: US-born Black and White Americans, 1959-2008 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Krieger, N., Kosheleva, A., Waterman, P. D., Chen, J. T., Beckfield, J., Kiang, M. V. 2014; 43 (4): 1294–1313


    Debates exist over whether health inequities are bound to rise as population health improves, due to health improving more quickly among the better off, with most analyses focused on mortality data.We analysed 50 years of socioeconomic inequities in measured health status among US-born Black and White Americans, using data from the National Health Examination Surveys (NHES) I-III (1959-70), National Health and Nutrition Examination Surveys (NHANES) I-III (1971-94) and NHANES 1999-2008.Absolute US socioeconomic health inequities for income percentile and education variously decreased (serum cholesterol; childhood height), stagnated [systolic blood pressure (SBP)], widened [body mass index (BMI), waist circumference (WC)] and in some cases reversed (age at menarche), even as on-average values rose (BMI, WC), idled (childhood height) and fell (SBP, serum cholesterol, age at menarche), with patterns often varying by race/ethnicity and socioeconomic measure; similar results occurred for relative inequities. For example, for WC, the adverse 20th (low) vs 80th (high) income percentile gap increased only among Whites (NHES I: 0.71 cm [95% confidence interval (CI) -0.74, 2.16); NHANES 2005-08: 2.10 (95% CI 0.96, 3.62)]. By contrast, age at menarche for girls in the 20th vs 80th income percentile among Black girls remained consistently lower, by 0.34 years (95% CI 0.12, 0.55) whereas among White girls the initial null difference became inverse [NHANES 2005-08: -0.49 years (95% CI -0.86, -0.12; overall P = 0.0015)]. Adjusting for socioeconomic position only modestly altered Black/White health inequities.Health inequities need not rise as population health improves.

    View details for PubMedID 24639440

    View details for PubMedCentralID PMC4121555

  • Jim Crow and Premature Mortality Among the US Black and White Population, 1960-2009 An Age-Period-Cohort Analysis EPIDEMIOLOGY Krieger, N., Chen, J. T., Coull, B. A., Beckfield, J., Kiang, M. V., Waterman, P. D. 2014; 25 (4): 494–504


    Scant research has analyzed the health impact of abolition of Jim Crow (ie, legal racial discrimination overturned by the US 1964 Civil Rights Act).We used hierarchical age-period-cohort models to analyze US national black and white premature mortality rates (death before 65 years of age) in 1960-2009.Within a context of declining US black and white premature mortality rates and a persistent 2-fold excess black risk of premature mortality in both the Jim Crow and non-Jim Crow states, analyses including random period, cohort, state, and county effects and fixed county income effects found that, within the black population, the largest Jim Crow-by-period interaction occurred in 1960-1964 (mortality rate ratio [MRR] = 1.15 [95% confidence interval = 1.09-1.22), yielding the largest overall period-specific Jim Crow effect MRR of 1.27, with no such interactions subsequently observed. Furthermore, the most elevated Jim Crow-by-cohort effects occurred for birth cohorts from 1901 through 1945 (MRR range = 1.05-1.11), translating to the largest overall cohort-specific Jim Crow effect MRRs for the 1921-1945 birth cohorts (MRR ~ 1.2), with no such interactions subsequently observed. No such interactions between Jim Crow and either period or cohort occurred among the white population.Together, the study results offer compelling evidence of the enduring impact of both Jim Crow and its abolition on premature mortality among the US black population, although insufficient to eliminate the persistent 2-fold black excess risk evident in both the Jim Crow and non-Jim Crow states from 1960 to 2009.

    View details for PubMedID 24825344

    View details for PubMedCentralID PMC4710482

  • Religiosity and Exposure to Users in Explaining Illicit Drug Use among Emerging Adults JOURNAL OF RELIGION & HEALTH Palamar, J. J., Kiang, M. V., Halkitis, P. N. 2014; 53 (3): 658–74


    Religiosity is a protective factor against illicit drug use, but further investigation is needed to delineate which components of religiosity are protective against use. A racially diverse sample (N = 962) was surveyed about religiosity, exposure to users, and recent use of marijuana, powder cocaine, ecstasy, and nonmedical use of opioids and amphetamine. Results suggest that identifying as Agnostic increased odds of use for each of the five drugs; however, this effect disappeared when controlling for religious importance and attendance. High levels of religious attendance were protective against recent use of marijuana and cocaine, but protective effects diminished when controlling for exposure to users, which was a robust predictor of use of every drug. Religion is a protective mechanism against drug use, but this effect may diminish in light of exposure to users. Alternative preventative methods need to be directed toward individuals who are not religious or are highly exposed to users.

    View details for PubMedID 23114835

  • A qualitative descriptive study of perceived sexual effects of club drug use in gay and bisexual men PSYCHOLOGY & SEXUALITY Palamar, J. J., Kiang, M. V., Storholm, E. D., Halkitis, P. N. 2014; 5 (2): 143–60


    Club drug use is often associated with unsafe sexual practices and use remains prevalent among gay and bisexual men. Although epidemiological studies commonly report the risk of engaging in unsafe sex due to the effects of particular club drugs, there remain gaps in the literature regarding the specific sexual effects of such substances and the context for their use in this population. We examined secondary data derived from interviews with 198 club drug using gay and bisexual males in New York City and qualitatively describe subjective sexual effects of five drugs: ecstasy, GHB, ketamine, powder cocaine and methamphetamine. Differences and commonalities across the five drugs were examined. Results suggest that each drug tends to provide: 1) unique sexual effects, 2) its own form of disinhibition, and 3) atypical sexual choices, often described as "lower sexual standards." Differences across drugs emerged with regard to social, sensual and sexual enhancement, sexual interest, and impotence. Although some common perceived sexual effects exist across drugs, the wide variation in these effects suggests different levels of risk and may further suggest varying motivations for using each substance. This study seeks to educate public health officials regarding the sexual effects of club drug use in this population.

    View details for PubMedID 24883174

    View details for PubMedCentralID PMC4036458

  • Development and Preliminary Validation of the Patient Perceptions of Integrated Care Survey MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Friedberg, M. W., Kiang, M. V., Dunn, T., Kuhn, D. M. 2013; 70 (2): 143–64


    Valid measures of the integration of patient care could provide rapid and accurate feedback on the successfulness of current efforts to improve health care delivery systems. This article describes the development and pilot testing of a new survey, based on a novel conceptual model, which measures the integration of patient care as experienced by patients. We administered the survey to 1,289 patients with multiple chronic conditions from one health system and received responses from 527 patients (43%). Psychometric analysis of responses supported a six-dimension model of integration with satisfactory internal consistency, discriminant validity, and goodness of fit. The Patient Perceptions of Integrated Care survey can be used to measure the integration of care received by chronically ill patients for two main purposes: as a research tool to compare interventions intended to improve the integration of care and as a quality improvement tool intended to guide the refinement of delivery system innovations.

    View details for PubMedID 23161612

  • Perceived public stigma and stigmatization in explaining lifetime illicit drug use among emerging adults ADDICTION RESEARCH & THEORY Palamar, J. J., Halkitis, P. N., Kiang, M. V. 2013; 21 (6): 516–25
  • Predictors of Stigmatization Towards Use of Various Illicit Drugs Among Emerging Adults JOURNAL OF PSYCHOACTIVE DRUGS Palamar, J. J., Kiang, M. V., Halkitis, P. N. 2012; 44 (3): 243–51


    The stigma associated with illegal drug use is nearly universal, but each drug is associated with its own specific level of stigma. This study examined level of stigmatization towards users of various illegal drugs and determined what variables explain such attitudes. A sample of emerging adults (age 18 to 25) was surveyed throughout New York City (N = 1021) and lifetime use, level of exposure to users, and level of stigmatization was assessed regarding use of marijuana, powder cocaine, Ecstasy, and nonmedical use of opioids and amphetamine. Bivariate and multivariate analyses were conducted to examine predictors of stigmatization towards each drug. Results suggest that non-illegal drug users reported high levels of stigmatization towards users of all drugs, but lifetime marijuana users reported significantly lower levels of stigmatization towards users of all harder drugs. This may suggest that once an individual enters the realm of illegal drug use, stigmatization towards use of harder drugs decreases, potentially leaving individuals at risk for use of more dangerous substances. Since stigma and social disapproval may be protective factors against illegal drug use, policy experts need to consider the potential flaws associated with classifying marijuana with harder, more dangerous drugs.

    View details for PubMedID 23061324

  • Sex Parties among Young Gay, Bisexual, and Other Men Who Have Sex with Men in New York City: Attendance and Behavior JOURNAL OF URBAN HEALTH-BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Solomon, T. M., Halkitis, P. N., Moeller, R. M., Siconolfi, D. E., Kiang, M. V., Barton, S. C. 2011; 88 (6): 1063–75


    Very little information exists with regard to sex party behaviors in young men who have sex with men (YMSM), often defined as men ranging in age from 13 to 29 years. The current analysis examines sex party attendance and behavior in a sample of 540 emergent adult gay, bisexual, and other YMSM in New York City, ages 18-29 years. Findings indicate that 8.7% (n = 47) of the sample had attended a sex party 3 months prior to assessment. Sex party attendees reported that parties included both HIV-positive and HIV-negative men; attendees also reported unprotected sex and limited access to condoms and lubricant. As compared with those who did not attend sex parties, those who did indicated significantly more lifetime and recent (last 3 months) casual sex partners, drug use (both number of different drugs used and total lifetime use), psychosocial burden (history of partner violence and number of arrests), and total syndemic burden (a composite of unprotected anal sex, drug use and psychosocial burden). These results indicate that while only a small percentage of the overall sample attended sex parties, the intersection of both individual risk factors coupled with risk factors engendered within the sex party environment itself has the potential to be a catalyst in the proliferation of the HIV/AIDS epidemic in urban settings. Lastly, given that sex parties are different than other sex environments, commercial and public, with regard to how they are accessed, public health strategies may need to become more tailored in order to reach this potentially highly risky group.

    View details for PubMedID 21698548

  • A case for safety leadership team training of hospital managers HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Hayes, J., Cooper, J. B., Vogt, J. W., Sales, M., Aristidou, A., Gray, G. C., Kiang, M. V., Meyer, G. S. 2011; 36 (2): 188–200


    Delivering safe patient care remains an elusive goal. Resolving problems in complex organizations like hospitals requires managers to work together. Safety leadership training that encourages managers to exercise learning-oriented, team-based leadership behaviors could promote systemic problem solving and enhance patient safety. Despite the need for such training, few programs teach multidisciplinary groups of managers about specific behaviors that can enhance their role as leadership teams in the realm of patient safety.The aims of this study were to describe a learning-oriented, team-based, safety leadership training program composed of reinforcing exercises and to provide evidence confirming the need for such training and demonstrating behavior change among management groups after training.Twelve groups of managers from an academic medical center based in the Northeast United States were randomly selected to participate in the program and exposed to its customized, experience-based, integrated, multimodal curriculum. We extracted data from transcripts of four training sessions over 15 months with groups of managers about the need for the training in these groups and change in participants' awareness, professional behaviors, and group activity.Training transcripts confirmed the need for safety leadership team training and provided evidence of the potential for training to increase targeted behaviors. The training increased awareness and use of leadership behaviors among many managers and led to new routines and coordinated effort among most management groups. Enhanced learning-oriented leadership often helped promote a learning orientation in managers' work areas.Team-based training that promotes specific learning-oriented leader behaviors can promote behavioral change among multidisciplinary groups of hospital managers.

    View details for PubMedID 21317660

  • Development and Psychometric Evaluation of Scales that Assess Stigma Associated With Illicit Drug Users SUBSTANCE USE & MISUSE Palamar, J. J., Kiang, M. V., Halkitis, P. N. 2011; 46 (12): 1457–67


    This study established validity evidence for scales that assess perceived public stigma and stigmatization of illicit drug use. These concepts were measured with respect to five commonly used drugs: marijuana, powder cocaine, ecstasy, and nonmedical use of opioids and amphetamine. Data were collected from a diverse sample of 1,048 emerging adults in New York City in 2009. Exploratory and confirmatory factor analyses suggested two distinct factors, which were inversely related to exposure to users and recent use of each drug. These measures demonstrated good criterion, construct, and incremental validity and effectiveness in analyzing predictors of use. Study limitations were discussed.

    View details for PubMedID 21767076

  • Personality traits and mental health states of methamphetamine-dependent and methamphetamine non-using MSM ADDICTIVE BEHAVIORS Solomon, T. M., Kiang, M. V., Halkitis, P. N., Moeller, R. W., Pappas, M. K. 2010; 35 (2): 161–63


    This analysis considers the relation between personality traits, mental health states and methamphetamine (MA) use in 60 men who have sex with men (MSM). Thirty MA-dependent and 30 MA non-using MSM were assessed on the Neo Five Factor Inventory, the Brief Symptom Inventory, the Perceived Stress Scale, and the Posttraumatic Stress Disorder Checklist-Civilian Version tests. Our results indicate differences between groups on a variety of measures of personality traits and mental states. Specifically, MA-dependent participants were found to be more Neurotic, less Open, less Agreeable, and less Conscientious. Further, MA-dependent participants were found to have higher levels of Paranoid Ideation and higher levels of Interpersonal Sensitivity. Given the high prevalence of MA use in the MSM community and the association between MA use and sexual risk taking, our findings provided a clearer understanding of how individual personality traits may be a factor in the continued use of this drug among MSM. Further research should seek to incorporate individual personality traits into the development of efficacious MA-specific treatment interventions.

    View details for PubMedID 19786324

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