Dementia is a stigmatizing condition requiring enhanced awareness and understanding. Churches are a trusted source of support for African Americans, a demographic disproportionately affected by dementia. However, many African American churches are not equipped with the knowledge and means to provide safe environments, resources, and spiritual and social support for their parishioners living with dementia and their families. This protocol is written to detail the design and implementation of a nurse-led, dementia-friendly congregation program, Alter. The Alter program was developed to increase dementia awareness, develop a supportive, faith-based dementia-friendly infrastructure, and create a community supporting the well-being of African Americans living with dementia and their families. Engagement in this program aims to improve brain health status of older adults, improve physical and mental health outcomes, reduce dementia stigma, and enhance personal agency. Improved outcomes for persons living with dementia translate into lower use of acute and emergency services due to more stability in community care. It is expected that the churches participating in this program will be recognized by their community as a great resource for dementia information and support. The long-term goal of the Alter program is to be widely adapted in various health systems to reduce health disparities associated with dementia in the African American community.

Objective: To measure changes in micronutrient adequacy and diet quality in healthcare and university employees who underwent a 10-week teaching kitchen program. Methods: Thirty-eight healthcare and university employees participated in a 10-week teaching kitchen program. Twenty-seven completed self-administered, 24-hour dietary recalls to measure dietary intake at baseline and 3-months. Micronutrient adequacy and diet quality was assessed using Dietary Reference Intakes (DRIs) and the Healthy Eating Index (HEI). Results: Seventy percent of participants were classified as low or moderate micronutrient adequacy at baseline. The proportion of participants with high micronutrient adequacy increased from 30% to 48% at 3-month follow-up. Total HEI and most HEI components increased at follow-up; with a statistically significant increase in seafood/plant protein score (P =.007). Conclusions and Implications for Practice: Our results suggest an inadequacy in micronutrient intake in university and healthcare employees and that teaching kitchens may help improve micronutrient adequacy and diet quality.

Background: COVID-19 concerns remain among health care providers, as there are few outpatient treatment options. In the early days of the pandemic, treatment options for nonhospitalized patients were limited, and symptomatic treatment and home-grown guidelines that used recommendations from the Global Initiative for Asthma Management and Treatment were used. Objective: The possibility that inhaled corticosteroids (ICS) might reduce the risk of respiratory symptoms and promote recovery was the impetus for this review, as it has already been shown that in the nonhospitalized patient population, oral corticosteroids (OCS) in the acute phase could have an adverse effect on recovery. We investigated if (1) patients treated with ICS were less likely to require referral to a post-COVID-19 clinic or pulmonary specialist than patients without ICS treatment or with OCS therapy, and (2) if OCS use was associated with worse health outcomes. Methods: In a retrospective chart review, we identified all patients with acute illness due to COVID-19 that were followed and managed by a telemedicine clinic team between June and December 2020. The data were electronically pulled from electronic medical records through April 2021 and reviewed to determine which patients eventually required referral to a post-COVID-19 clinic or pulmonary specialist due to persistent respiratory symptoms of COVID-19. The data were then analyzed to compare outcomes between patients prescribed OCS and those prescribed ICS. We specifically looked at patients treated acutely with ICS or OCS that then required referral to a pulmonary specialist or post-COVID-19 clinic. We excluded any patients with a history of chronic OCS or ICS use for any reason. Results: Prescribing ICS during the acute phase did not reduce the possibility of developing persistent symptoms. There was no difference in the referral rate to a pulmonary specialist or post-COVID-19 clinic between patients treated with OCS versus ICS. However, our data may not be generalizable to other populations, as it represents a patient population enrolled in a telemedicine program at a single center. Conclusions: We found that ICS, as compared to OCS, did not reduce the risk of developing persistent respiratory symptoms. This finding adds to the body of knowledge that ICS and OCS medications remain potent treatments in patients with acute and postacute COVID-19 seen in an outpatient setting.

Background: Structural inequities have important implications for the health of marginalized groups. Neighborhood-level redlining and lending bias represent state-sponsored systems of segregation, potential drivers of adverse health outcomes. We sought to estimate the effect of redlining and lending bias on breast cancer mortality and explore differences by race. Methods: Using Georgia Cancer Registry data, we included 4,943 non-Hispanic White (NHW) and 3,580 non-Hispanic Black (NHB) women with a first primary invasive breast cancer diagnosis in metro-Atlanta (2010-2014). Redlining and lending bias were derived for census tracts using the Home Mortgage Disclosure Act database. We calculated hazard ratios and 95% confidence intervals (CI) for the associations of redlining, lending bias on breast cancer mortality and estimated race-stratified associations. Results: Overall, 20% of NHW and 80% of NHB women lived in redlined census tracts, and 60% of NHW and 26% of NHB women lived in census tracts with pronounced lending bias. Living in redlined census tracts was associated with a nearly 1.60-fold increase in breast cancer mortality (hazard ratio = 1.58; 95% CI, 1.37-1.82) while residing in areas with substantial lending bias reduced the hazard of breast cancer mortality (hazard ratio = 0.86; 95% CI, 0.75-0.99). Among NHB women living in redlined census tracts, we observed a slight increase in breast cancer mortality (hazard ratio = 1.13; 95% CI, 0.90-1.42); among NHW women the association was more pronounced (hazard ratio = 1.39; 95% CI, 1.09-1.78). Conclusions: These findings underscore the role of ecologic measures of structural racism on cancer outcomes. Impact: Place-based measures are important contributors to health outcomes, an important unexplored area that offers potential interventions to address disparities.

Objectives: The number of people living with dementia is growing and most patients go years without receiving a specific diagnosis or support services, leading to suboptimal care, negative impacts on the quality of life, and increased costs of care. To address these gaps, the State of Georgia Department of Human Services collaborated with academic and community partners to create the Georgia Memory Net (GMN). Design: GMN is a hub and spoke model partnered with Emory University's Cognitive Neurology Clinic and Emory Goizueta Alzheimer's Disease Research Center to provide training and support for best practices in diagnosis and management to Memory Assessment Clinics (MACs) throughout the state. Setting: Communities across the State of Georgia. Participants: GMN is a mix of academic and community providers, hospital systems, state and community agencies. Patients and families are evaluated at the MACs and connected to community services. Intervention: A dedicated clinic workflow: primary care providers (PCPs) identify a memory problem and refer to the MACs for diagnostic evaluation; meeting with a community services educator, and development of a care plan. The patient is reconnected with the PCP for continuity of care. Measurements: Initial metrics include numbers of unique patients, total patient visits, and referrals to state agency partners for community services. Results: GMN established five MACs across Georgia with annual state funding. Partners at Emory University provided initial training; refined patient workflows for best practices; and provide ongoing support, guidance, and continuing education for MAC teams. Local PCPs and community services partners demonstrated strong engagement with the new model. Conclusions: GMN is an innovative care model to improve access to accurate and timely diagnosis in patients with memory loss. GMN may help improve the quality of life for patients and families through preventive and early care.

Importance Clinician burnout is a major risk to the health of the US. Nurses make up most of the health care workforce, and estimating nursing burnout and associated factors is vital for addressing the causes of burnout. Objective To measure rates of nurse burnout and examine factors associated with leaving or considering leaving employment owing to burnout. Design, Setting, and Participants This secondary analysis used cross-sectional survey data collected from April 30 to October 12, 2018, in the National Sample Survey of Registered Nurses in the US. All nurses who responded were included (N = 3 957 661). Data were analyzed from June 5 to October 1, 2020. Exposures Age, sex, race and ethnicity categorized by self-reported survey question, household income, and geographic region. Data were stratified by workplace setting, hours worked, and dominant function (direct patient care, other function, no dominant function) at work. Main Outcomes and Measures The primary outcomes were the likelihood of leaving employment in the last year owing to burnout or considering leaving employment owing to burnout. Results The 3 957 661 responding nurses were predominantly female (90.4%) and White (80.7%); the mean (weighted SD) age was 48.7 (0.04) years. Among nurses who reported leaving their job in 2017 (n = 418 769), 31.5% reported burnout as a reason, with lower proportions of nurses reporting burnout in the West (16.6%) and higher proportions in the Southeast (30.0%). Compared with working less than 20 h/wk, nurses who worked more than 40 h/wk had a higher likelihood identifying burnout as a reason they left their job (odds ratio, 3.28; 95% CI, 1.61-6.67). Respondents who reported leaving or considering leaving their job owing to burnout reported a stressful work environment (68.6% and 59.5%, respectively) and inadequate staffing (63.0% and 60.9%, respectively). Conclusions and Relevance These findings suggest that burnout is a significant problem among US nurses who leave their job or consider leaving their job. Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.

BACKGROUND: Sacubitril/valsartan improves health outcomes for heart failure with reduced ejection fraction relative to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, but it carries higher out-of-pocket costs. Neither the impact of cost nor how to integrate cost into medical decisions is well studied. METHODS AND RESULTS: To evaluate the impact of out-of-pocket costs and a novel cost-priming intervention on willingness to take sacubitril/valsartan for heart failure with reduced ejection fraction, participants with self-reported heart disease were surveyed using the online Ipsos Knowledge Panel. Participants were presented with a modified decision aid for sacubitril/ valsartan and then, in a 3×2 factorial design, randomly assigned to 1 of 3 cost conditions ($10, $50, or $100/month) and to a control group or cost-priming intervention, defined by being asked questions about their financial situation before learning about the benefits of sacubitril/valsartan. Of the 1013 participants included in the analysis, 85% of respondents were willing to take sacubitril/valsartan at $10, 62% at $50, and 33% at $100 (P<0.0001). In a multivariable logistic regression model, participants were more likely to take sacubitril/valsartan at $10 versus $100 (odds ratio [OR], 14.3 [95% CI, 9.4–21.8]) and $50 compared with $100 (OR, 3.6 [95% CI, 2.5–5.1]). Overall, participants in the cost-primed group were more willing to take sacubitril/valsartan than those not primed to consider their financial situation (63% versus 56%, P=0.04). There was no statistically significant interaction between cost conditions and cost priming. Perceived benefit of sacubitril/valsartan over angiotensin-converting enzyme inhibitors or angiotensin receptor blockers decreased as cost increased but did not vary by cost priming. CONCLUSIONS: Commonly encountered out-of-pocket costs of sacubitril/valsartan may impact individuals’ willingness to take the medication even when recommended by their physicians. Priming individuals to consider personal finances before learning about the drug increased willingness to take sacubitril/valsartan.

While much attention has been paid to healthcare provider and trainee burnout, less is known about provider well-being (i.e., flourishing) or about the effects of well-being on immune function. This study examined the demographic and psycho-social correlates of well-being among healthcare trainees (resident physicians and physician assistant (PA) trainees) and evaluated the association of well-being with the “conserved transcriptional response to adversity” (CTRA) charac-terized by up-regulated expression of pro-inflammatory genes and down-regulated expression of innate antiviral genes. Participants (n = 58) completed self-reported assessments of sleep disturbance, loneliness, depressive symptoms, anxiety, stress, and well-being (flourishing). Blood sample RNA profiles were analyzed by RNA sequencing to assess the CTRA. Slightly over half (n = 32; 55.2%) of healthcare trainees were categorized as flourishing. Flourishing was less prevalent among primary caregivers, and more prevalent among trainees who exercised more frequently and those with fewest days sick. Loneliness (AOR = 0.75; 95% CI = 0.61, 0.91; p = 0.003) and stress (AOR = 0.65; 95% CI = 0.45, 0.94; p = 0.02) were associated with decreased odds of flourishing when controlling for other variables. Flourishing was associated with down-regulated CTRA gene expression, whereas loneliness was associated with up-regulated CTRA gene expression (both p < 0.05). Assessing these relationships in a larger, multi-site study is of critical importance to inform policy, curricula, and interventions to bolster sustainable trainee well-being.

The characteristics of patients with coronavirus disease 2019 (COVID-19) have primarily been described in hospitalized adults. Characterization of COVID-19 in ambulatory care is needed for a better understanding of its evolving epidemiology. Our aim is to provide a description of the demographics, comorbidities, clinical presentation, and social factors in confirmed SARS-CoV-2-positive non-hospitalized adults. We conducted a retrospective medical record review of 208 confirmed SARS-CoV-2-positive patients treated in a COVID-19 virtual outpatient management clinic established in an academic health system in Georgia. The mean age was 47.8 (range 21-88) and 69.2% were female. By race/ethnicity, 49.5% were non-Hispanic African American, 25.5% other/unknown, 22.6% non-Hispanic white, and 2.4% Hispanic. Nearly 70% had at least one preexisting medical condition. The most common presenting symptoms were cough (75.5%), loss of smell or taste (63%), headache (62%), and body aches (54.3%). Physician or advanced practice provider assessed symptom severity ranged from 51.9% mild, 30.3% moderate, and 1.4% severe. Only eight reported limitations to home care (3.8%), 55.3% had a caregiver available, and 93.3% reported initiating self-isolation. Care needs were met for 83.2%. Our results suggest the demographic and clinical characteristics of COVID-19 illness in non-hospitalized adults differ considerably from hospitalized patients and warrant greater awareness of risk among younger and healthier individuals and consideration of testing and recommending self-isolation for a wider spectrum of clinical symptoms by clinicians. Social factors may also influence the efficacy of preventive strategies and allocation of resources toward the SARS-CoV-2 pandemic.

Black churches have traditionally been a haven for Black American families; however, many churches do not currently have programs to support families living with dementia. Alter™ was established to assist faith communities in meeting the needs of these families and becoming a viable resource to promote their health and wellness. Alter™ achieves this aim through a three-pronged approach: (1) conducting educational sessions, (2) modifying Black churches to be dementia-inclusive spaces, and (3) providing ongoing support. The principal goal of Alter™ is to offer guidance to churches in adapting their community to reflect a supportive environment for families affected by dementia. Alter™ uses a partnership checklist to encourage activities that incorporate dementia education opportunities, environmental modifications, and dementia resources and support. This paper reports on a formative mixed-methods evaluation of church partners enrolled in Alter™. Church partner ambassadors within the faith communities participated in the evaluation survey (n = 8) and two focus groups (n = 11). Ambassadors are appointed by church leadership to lead the implementation of program activities. Data were collected concerning the levels of helpfulness, difficulty, usefulness, or utility of checklist activities and modifications and the ease of program implementation. The evaluation also assessed the COVID-19 pandemic’s impact on each church’s ability to implement activities and modifications. The survey results revealed that most required partnership activities and modifications were found to be at least moderately helpful. Some of the items (themes) that differed across church partners included barriers to implementing activities, the support provided and needed, and the use of program funding. This evaluation provides key insights to consider in developing and refining community-based, dementia-friendly communities (including faith communities). As implementation science expands and improves, the need to evaluate the implementation of programs continues to be highlighted. Our formative evaluation shed light on key areas in which modifications to our original programming would lead to program improvement and sustainability. Additionally, implementing the modifications identified in our evaluation will facilitate the achievement of the mission of Alter™ to improve the well-being of older adults affected by dementia and their families. Other programs would reap substantial benefits from engaging in similar formative evaluation efforts.