John S. Preisser’s research while affiliated with University of North Carolina at Chapel Hill and other places

Objective Psychosocial factors can affect health. Patterns of psychosocial stressors and resources among older adults were examined for oral health status. Methods The Health and Retirement Study (HRS) is a representative sample of US adults > 50 years. Participants completed the 2018 HRS CORE survey and the Psychosocial and Lifestyle Questionnaire–Panel A “Leave Behind” survey (HRS‐LB) ( N = 4703). All measures were self‐reported and stratified into outcome groups: (1) edentulous/dentate, (2) with/without a recent dental visit in the last 2 years. Psychosocial measures covered three domains: well‐being, beliefs, and lifestyle. Specifically, loneliness, life satisfaction, perceived age, social status, control, mastery, and chronic stressors were included in this analysis. Latent class analysis (LCA) identified profiles of adults based on the distribution of psychological and social stressors and resources. Associations between latent classes and being edentulous and a recent dental visit were examined in logistic regression models. Results About 30% reported no recent dental visit; 14% were edentulous. Three latent classes were identified; profiles had different distributions of psychosocial factors. About half (47%) were in Class A: “Satisfied/Connected” ( n = 2230), 28% in Class B: “Satisfied/Lonely” ( n = 1293), and 25% in Class C: “Unsatisfied/Lonely” ( n = 1180). “Satisfied/Connected” adults had the fewest psychosocial risk factors, most resources, were dentate, and had a recent dental visit. “Unsatisfied/Lonely” adults exhibited the most psychosocial risk factors and fewest resources and lacked a recent dental visit. “Satisfied/Lonely” adults exhibited characteristics between Classes A and C. In fully adjusted regression models, Class B adults had 1.29 (1.03–1.62) times greater odds than Class A to be edentulous and 1.26 (1.07–1.50) times greater odds to not have a recent dental visit. Class C adults had 1.22 (0.97–1.53) times greater odds than Class A to be edentulous and 1.31 (1.10–1.57) times greater odds to not have a recent dental visit. Conclusion Adverse psychosocial factors are associated with edentulism and lack of routine dental visits. Exposure to psychosocial risk and resource factors can affect oral health. Health providers should assess older adults for loneliness and other psychosocial risk factors, and policies and programmes that support older adults' psychosocial needs should be expanded.

Background The purpose of this study was two-fold: (1) describe the relationship between patient or caregiver reported preparedness for care transitions, and acute care use in 30 days after discharge from a skilled nursing facility (SNF); and (2) explore how this relationship is influenced by patient, Charlson index, race and social determinants. Method The design was a secondary analysis of data collected as part of a cluster randomized trial of the Connect-Home transitional care intervention. The setting was 6 skilled nursing facilities located in the US state of North Carolina. The sample was 249 patient and caregiver dyads with acute care use data (i.e., emergency department or hospital readmission) in 30 days after transfers from SNFs to home. Preparedness for care transitions was measured with the Care Transitions Measure-15 (CTM-15), a 15 item Likert scaled measure with scores potentially ranging from 0 to 100, with higher scores indicating better preparedness. The association of preparedness and acute care use, in the overall study sample and within subgroups defined by five selected dyad background characteristics, was quantified as an incident rate ratio corresponding to the multiplicative change in the mean number of acute care use days for a 10 unit increase in CTM-15 score, using marginalized zero-inflated negative binomial regression. Results Patients had a mean age of 76.4 years, 63.8% were female, and 73.6% were White. Caregivers were female (73.6%) and adult children (42.3%). The mean CTM-15 score was 72.9 and the mean days of acute care use in 30 days after SNF discharge was 0.62. For a 10 unit increase in preparedness score, among male patients the mean number of acute care use days decreased by 33% (IRR = 0.67; 95%CI: 0.44, 0.99); White patients had a 25% reduction (IRR = 0.75; 95%CI: 0.55, 1.02), patients with low area deprivation score (lower quartile, ADI = 54) had a 31% reduction in acute care use (IRR = 0.69; 95%CI: 0.47, 1.01), and patients with a high Charlson total score (upper quartile of 9) have a 22% reduction in acute care use (IRR = 0.78; 95%CI: 0.61, 1.02). Conclusion Preparedness of care transitions is an important outcome of high-quality SNF care and is associated with reduced use of further acute care. More research is necessary to evaluate the CTM-15 as an outcome measure among sociodemographic subgroups.

Purpose Persistent opioid use is one of the most common post-operative complications. Identification of at-risk patients pre-operatively is key to reducing post-operative opioid use. We sought to develop a predictive model for persistent post-operative opioid used and to determine if geographic factors from community databases improve model prediction based solely on electronic health records (EHRs) and claims data. Methods EHR and claims data for 4,116 opioid-naïve surgical patients older than 18 in North Carolina were linked with census tract-level unemployment data from the American Community Survey and Centers for Disease Control and Prevention data on opioid prescriptions and deaths attributed to drug poisoning. Primary outcome was new persistent opioid use and covariates included patient factors from EHR, claims data, and geographic factors. Multivariable logistic regression models of potential risk factors were evaluated. Results 6.0% of patients developed new persistent opioid use. Associated risk factors based on multivariable logistic regressions include age (adjusted odds ratio [AOR] 1.08; 95% confidence interval [CI] 1.00, 1.16), back and neck pain (1.82; 1.39, 2.39), joint disorders (1.58; 1.18, 2.11), mood disorders (1.71; 1.28, 2.28), opioid retail prescription (1.04; 1.00, 1.07) and drug poisoning rates (1.33; 1.09, 1.62). On Monte-Carlo cross-validation, the addition of geographic factors to EHRs and claims may modestly improve prediction performance (area under the curve, AUC) of logistic regression models compared to those based on EHRs and claims data (AUC 0.667 (95% CI 0.619, 0.717) vs AUC 0.653 (0.600, 0.706)). Conclusions Co-morbidities and area-based factors are predictive of new persistent post-operative opioid use. As the addition of geographic-based factors did not significantly improve performance of multivariable logistic regression, larger samples are needed to fully differentiate models.

Accreditation is a widely used health care review process to determine if an organization meets a defined standard of quality. The opportunity for accreditation recently moved into the field of assisted living (AL); today, seven states have statutes and regulations allowing third party accreditation to satisfy full or partial compliance with state licensure or certification. Data indicate that compliance with accreditation standards may result in improved care, but it has not been evaluated in AL. In 2021, the state of North Carolina funded an AL accreditation pilot program to evaluate whether accreditation improves or maintains quality. Communities were randomly allocated to a control or accreditation arm and are being followed for two years to evaluate care and outcomes in five areas (workforce, resident outcomes, care coordination and transitions, medication management, person-centered care). Of the 146 communities originally enrolled that provided data, most are for-profit (96%) and part of a chain (73%); 44% pf residents have dementia, 25% have mental illness, and 53% receive state financial assistance. Preliminary results in the first two quarters (Q) found an overall increase in advance care planning discussions (53% in Q1 and 63% in Q2), and a decrease in medication administrations with one or more errors (1.2% in Q1 and 0.6% in Q2). This session will present results comparing communities in the control arm, accreditation arm, and those that successfully achieved accreditation, with findings having wide-ranging implications for the future of AL accreditation and regulation in North Carolina, and implications across the country.

In 2021, the North Carolina Legislature approved and funded the Adult Care Home [Assisted Living] Accreditation Pilot Program. Across the state, the program’s goal is to evaluate the effectiveness of accreditation through quality outcome measures to determine whether accreditation achieves compliance with licensure requirements and improves or maintains quality of care compared to a control group. Assisted living communities were selected using stratified random sampling that accounted for geographic region and state-assigned quality rating. A total of 146 communities originally agreed to participate. Of the 73 communities randomly assigned to the accreditation arm, to date 39 (53%) either withdrew or chose to not go through the process of accreditation; 4 (5%) withdrew after beginning the accreditation process; 24 (33%) achieved accredited status; and 6 (8%) are delayed in completing the process or not likely to do so. The key reason for withdrawal from the accreditation process is the time and effort required in the context of staffing shortages, which has implications for long-range implementation even if accreditation is found to be beneficial. This session will present the aims and methods of the evaluation; the accreditation process itself (including benefits, potential administrative burden, and types of deficiencies found during surveys); the feasibility of becoming accredited for diverse participating communities; and potential strategies to bolster capacity for accreditation. (Additional contributors to this and the outcome presentation include Teresa Hoosier [ACHC], Jeff Horton [NCSLA], Frances Messer [NCALA], Barbara Sylvester [ACHC], and London Grantham, Aja Johnson, Danielle Owens, Toni Parker, and Katrice Perry [UNC].)

This chapter considers a two-period clinical trial in which patients are randomized to either a placebo (or control) arm or a test treatment arm. At the end of the first period of the trial, the patients are assessed for treatment failure via a dichotomous outcome, and all patients who are identified as having treatment failure receive test treatment for the second period. All patients are assessed for their dichotomous response at the end of the second period. While the risk difference in period 1 will appropriately estimate the treatment effect in period 1, the intention-to-treat (ITT) risk difference in period 2 will underestimate the treatment effect in period 2 for an effective treatment because it does not account for such treatment switching. Estimators for the treatment difference in period 2 are proposed, and they have similar structure to the ITT risk difference and account for treatment switching. Properties of the proposed estimators are evaluated under various simulation scenarios using means, standard errors, standardized effect sizes, powers, and confidence interval coverages, and the estimators are illustrated in a hypothetical data example and a real data example.

Early childhood caries (ECC) is the most common noncommunicable childhood disease—an important health problem with known environmental and social/behavioral influences lacking consensus genetic risk loci. To address this knowledge gap, we conducted a genome-wide association study of ECC in a multiancestry population of U.S. preschool-age children ( N = 6,103) ages 3 to 5 y participating in a community-based epidemiologic study of early childhood oral health. Calibrated examiners used International Caries Detection and Assessment System criteria to measure ECC; the primary trait was the number of primary tooth surfaces with caries experience (i.e., dmfs index). We estimated heritability and concordance rates and conducted genome-wide association analyses to estimate overall genetic effects as well as stratified by sex, household water fluoride, and dietary sugar and leveraged combined gene/gene-environment effects using 2-degree-of-freedom joint tests. Common genetic variants explained 24% of ECC phenotypic variance among unrelated individuals, while concordance rates were 0.64 (95% confidence interval [CI] = 0.42–0.79) among monozygotic twins and 0.44 (95% CI = 0.34–0.53) among first-degree relatives. Across all analyses, we identified 21 novel nonoverlapping genome-wide significant loci ( P < 5 × 10 ⁻⁸ ) and 1 genome-wide significant gene ( TAAR6) associated with ECC. The taste receptor activity gene set, with known roles in chemosensing, bacterial recognition, and innate immunity in the oral cavity, was strongly associated with ECC. While no locus remained significant after studywise multiple-testing correction, 3 loci were nominally significant ( P < 0.05) and directionally consistent in external cohorts of 285,248 adults (rs1442369, DLGAP1 and rs74606067, RP11-856F16.2) and 18,994 children (rs71327750, SLC41A3). Meanwhile, the strongest marker known to be associated with adult caries (rs1122171, tagging the long noncoding RNA PITX1-AS1) was nominally significant ( P = 0.01) and directionally consistent with ECC in our study. Taken together, the results of this study add to the genomics knowledge base for early childhood caries, offer several plausible candidates for future mechanistic studies, and underscore the importance of accounting for sex and pertinent environmental exposures in genetic investigations.

Poor oral health can impact overall health. This study assessed the association between dental factors (dentate status and dental utilization) and self-rated health (S-RH) among older adults in two cross-sectional datasets: (1) NIH “All of Us (AoU) Research Program” (May 2018—July 2022 release) and (2) U.S. nationally representative “Health and Retirement Study” (HRS) 2018 wave. Participants aged ≥ 51 years were included in these analyses if (1) from AoU, they had clinical dental and medical data from electronic health records (EHRs) and surveys (n = 5480), and (2) from HRS, they had dental and socio-demographic survey data (n = 14,358). S-RH was dichotomized (fair/poor vs. better) and analyzed with logistic regression. Sample survey weights for HRS and stratification and averaging AoU results used the weighted HRS race–ethnicity and age distribution standardized respective analyses to the U.S. population. Fair/poor S-RH was reported by 32.6% in AoU and 28.6% in HRS. Dentate status information was available from 7.7% of AoU EHRs. In population-standardized analyses, lack of dental service use increased odds of fair/poor S-RH in AoU, OR (95% CI) = 1.28 (1.11–1.48), and in HRS = 1.45 (1.09–1.94), as did having diabetes, less education, and ever being a smoker. Having no natural teeth was not statistically associated with fair/poor S-RH. Lack of dental service was positively associated with fair/poor S-RH in both datasets. More and better oral health information in AoU and HRS are needed.

Background Acute respiratory illness (ARI) is one of the most common reasons children receive antibiotic treatment. Measurement of C-reaction protein (CRP) has been shown to reduce unnecessary antibiotic use among children with ARI in a range of clinical settings. In many resource-constrained contexts, patients seek care outside the formal health sector, often from lay community health workers (CHW). This study’s objective was to determine the impact of CRP measurement on antibiotic use among children presenting with febrile ARI to CHW in Uganda. Methods and findings We conducted a cross-sectional, stepped wedge cluster randomized trial in 15 villages in Bugoye subcounty comparing a clinical algorithm that included CRP measurement by CHW to guide antibiotic treatment (STAR Sick Child Job Aid [SCJA]; intervention condition) with the Integrated Community Care Management (iCCM) SCJA currently in use by CHW in the region (control condition). Villages were stratified into 3 strata by altitude, distance to the clinic, and size; in each stratum, the 5 villages were randomly assigned to one of 5 treatment sequences. Children aged 2 months to 5 years presenting to CHW with fever and cough were eligible. CHW conducted follow-up assessments 7 days after the initial visit. Our primary outcome was the proportion of children who were given or prescribed an antibiotic at the initial visit. Our secondary outcomes were (1) persistent fever on day 7; (2) development of prespecified danger signs; (3) unexpected visits to the CHW; (4) hospitalizations; (5) deaths; (6) lack of perceived improvement per the child’s caregiver on day 7; and (7) clinical failure, a composite outcome of persistence of fever on day 7, development of danger signs, hospitalization, or death. The 65 participating CHW enrolled 1,280 children, 1,220 (95.3%) of whom had sufficient data. Approximately 48% (587/1,220) and 52% (633/1,220) were enrolled during control (iCCM SCJA) and intervention periods (STAR SCJA), respectively. The observed percentage of children who were given or prescribed antibiotics at the initial visit was 91.8% (539/587) in the control periods as compared to 70.8% (448/633) during the intervention periods (adjusted prevalence difference −24.6%, 95% CI: −36.1%, −13.1%). The odds of antibiotic prescription by the CHW were over 80% lower in the intervention as compared to the control periods (OR 0.18, 95% CI: 0.06, 0.49). The frequency of clinical failure (iCCM SCJA 3.9% (23/585) v. STAR SCJA 1.8% (11/630); OR 0.41, 95% CI: 0.09, 1.83) and lack of perceived improvement by the caregiver (iCCM SCJA 2.1% (12/584) v. STAR SCJA 3.5% (22/627); OR 1.49, 95% CI: 0.37, 6.52) was similar. There were no unexpected visits or deaths in either group within the follow-up period. Conclusions Incorporating CRP measurement into iCCM algorithms for evaluation of children with febrile ARI by CHW in rural Uganda decreased antibiotic use. There is evidence that this decrease was not associated with worse clinical outcomes, although the number of adverse events was low. These findings support expanded access to simple, point-of-care diagnostics to improve antibiotic stewardship in rural, resource-constrained settings where individuals with limited medical training provide a substantial proportion of care. Trial registration ClinicalTrials.gov NCT05294510. The study was reviewed and approved by the University of North Carolina Institutional Review Board (#18–2803), Mbarara University of Science and Technology Research Ethics Committee (14/03-19), and Uganda National Council on Science and Technology (HS 2631).