WASHINGTON — The Centers for Medicare & Medicaid Services (CMS) is proposing a nearly 3.4% cutopens in a new tab or window to the “conversion factor” used to set the Medicare Physician Fee Schedule for 2024, and physician groups are none too happy about it.

“The proposed 2024 Medicare Physician Fee Schedule (PFS) raises significant concerns for medical groups related to its 3.4% reduction to the conversion factor, which further increases the gap between physician practice expenses and Medicare reimbursement rates,” Anders Gilberg, MGA, senior vice president for government affairs at the Medical Group Management Association here, said Thursday afternoon in a statementopens in a new tab or window. (Disclosure: Gilberg is a member of the MedPage Today editorial board.) “Medicare already largely fails to cover the cost of furnishing care to beneficiaries, and the proposed cut to the 2024 conversion factor compounds the problem.”

“While the ACR [American College of Rheumatology] appreciates CMS’ continued recognition of the value of complex care provided by rheumatologists and other cognitive care specialists … we are gravely concerned that the proposed rule’s physician payment cuts contained in CMS’ conversion factor would add to physicians’ uncertainty about their continued ability to provide the highest quality of care to Medicare patients,” ACR president Douglas White, MD, PhD, said in a statementopens in a new tab or window.

The conversion factor is the multiplier that Medicare applies to relative value units (RVUs) to calculate reimbursement for a particular service or procedure under Medicare’s fee-for-service system. The 2024 conversion factor of $32.74 includes both a 2.17% decrease required for budget neutrality reasons and a 1.25% increase that was included in last year’s Consolidated Appropriations Act (CAA); the CAA also increased the 2023 conversion factor.

Those two percentages — a 2.17% decrease partially offset by a 1.25% increase — would normally be considered a 0.92% decrease in physician pay, but the percentages were calculated based on the original conversion factor for 2023 — $33.06 — which was then increased to $33.88 by the raise from the CAA; comparing that number to this year’s $32.74 number results in the nearly 3.4% cut. (See p. 1191 of the proposed ruleopens in a new tab or window for more details.)

The American Medical Association (AMA) also panned the cut, with AMA president Jesse Ehrenfeld, MD, MPH, calling it “a critical reminder that patients and physicians desperately need Congress to develop a permanent solution that addresses the financial instability and threatens access to care.”

“When adjusted for inflation, Medicare physician payment already has effectively declined 26% from 2001 to 2023 before additional inflation and these cuts are factored in,” Ehrenfeld said in a statementopens in a new tab or window. “Physicians are one of the only providers without an automatic inflationary increase … Physicians need relief from this unsustainable journey.”

There was one group that applauded the agency, however. “CMS showed its commitment to supporting value-based care and growing participation in accountable care organizations (ACOs) in this proposed rule,” Clif Gaus, ScD, president and CEO of the National Association of ACOs (NAACOS), which represents accountable care organizations, said in a statementopens in a new tab or window. “It addresses several issues that NAACOS has been advocating for, including improvements in quality reporting, more fair benchmarking policies, a smooth transition to a new risk adjustment model, keeping advanced payments for new ACOs who transition to risk, [and] helping ACOs who serve high-cost beneficiaries and others.”

“NAACOS thanks CMS for its continued leadership on this issue and its willingness to address the barriers standing in the way of clinicians and health systems who want to provide higher quality, more cost-effective, coordinated care for patients,” he said.

The fee schedule’s effects, however, vary by specialty. In the 2024 fee schedule, the big loser is interventional radiology, whose fees are estimated to decrease by an estimated 4%. Other losers were nuclear medicine, vascular surgery, and diagnostic radiology, whose fees will decrease by 3%.

The American Society for Radiation Oncology (ASTRO) was not happy with an estimated 2% cut for radiation oncologists and radiation therapy centers. “ASTRO is disappointed that CMS once again undervalues the impact of radiation oncology and intends to cut reimbursement by an additional 2% in 2024 for this essential cornerstone of cancer care,” Geraldine Jacobson, MD, MPH, chair of the ASTRO board of directors, said in a statementopens in a new tab or window.

“Medicare spends less on all radiation therapy services than it does on just three top cancer drugs, although radiation is utilized by twice as many beneficiaries,” she added. “Despite this outsized value, CMS has cut radiation oncology physician fee schedule payments by over 20% in the last decade – more than nearly all other physician specialties.

On the other side of the ledger, the total allowed charges for family practice and endocrinology will increase by an estimated 3%. A number of other specialties will see an estimated 2% increase, including clinical social workers, clinical psychologists, general practitioners, rheumatologists, and nurse practitioners, according to CMS.

For its part, CMS touted several new services that would be covered under the fee schedule. “In alignment with the goal of the Biden-Harris Administration’s Cancer Moonshot for everyone with cancer to have access to covered patient navigation services, CMS is proposing payment for Principal Illness Navigation services to help patients navigate cancer treatment and treatment for other serious illnesses,” the agency said in a press releaseopens in a new tab or window. “These services are also designed to include care involving other peer support specialists, such as peer recovery coaches for individuals with substance use disorder.”

The proposed rule also calls for coverage of some dental services for cancer patients. “Access to oral and dental health services that promote health and wellness allows people with Medicare to achieve the best health possible,” the release continued. “In this proposed rule, CMS is … proposing that payment can be made for certain dental services prior to and during several different cancer treatments, including, but not limited to, chemotherapy.”

In this exclusive video, Harlan Krumholz, MD, SM, of the Yale School of Medicine and Yale New Haven Hospital in Connecticut, discusses uses of large language models like ChatGPT in healthcare settings and how to use new artificial intelligence (AI) technology responsibly.

Krumholz is the director of the Center for Outcomes Research and Evaluation, the Harold H. Hines Jr. Professor of Medicine, and a professor in the Institute for Social and Policy Studies, Investigative Medicine and of Public Health.

The following is a transcript of his remarks:

I’m always surprised that so many people have heard of ChatGPTopens in a new tab or window and other AI platforms but there are still a lot of people who haven’t tried it yet, so they really don’t know what the experience is like and maybe they’re not really familiar or clear about it.

Hi, I’m Harlan Krumholz from the Yale School of Medicine, and I just wanted to take a few minutes to talk about these new models and to provide a little context in case you’re one of those who hasn’t had a chance to really try them out yet.

These AI models, like ChatGPT, are called large language models. Sometimes you hear people offhand saying LLMs — large language models — it makes you sound like you’re in the know if you say that. Well, these are foundation models that are trained on massive, diverse, large datasets and can be applied for numerous downstream tasks.

For medicine, these can be used as chatbots for patients. What are chatbots? Chatbots are automated tools that can interact with patients to elicit information and even give advice without the need for a human being involved. They can be used for interactive note-taking or they can augment the performance of people doing procedures. They can generate reports like radiology reports, they’re helping basic scientists identify targets for drug development, they can be used for bedside decision support.

Sound too good to be true? Well, at least at this stage, it is a bit too good to be true. I mean, it’s a remarkable tool. I think we’re at a juncture in history; it’s a step function with what these are able to achieve compared with what I was seeing was able to be achieved with AI before this. Now, this is about taking unstructured data — not data that fits into a case report form or into a given field — but take unstructured data like notes and texts and be able to make sense of it and then be able to feed it back appropriately when people are asking questions.

Now, you may know that there are a lot of people who are raising warnings about this AI. They’re thinking that we’re moving too fast. There are even some people who think this could be the end of humanity. Now, lest you think that this is only about people who are untethered to the reality of the world, these are actually very smart people, very well-steeped in AI that are expressing concerns, and governments are stepping forward and wondering who should really be able to control these kind of tools and how they might be applied.

There’s another feature to these — well, let me say, it’s both a feature and a bug — that is, these models are capable of creativity. So you could say, “I want to write a note to someone and I want it to be done in the form of a Shakespearean sonnet.” Well, it can actually produce that, or in the style of anyone that you can think of. That’s creativity.

But every once in a while you’ll be asking it a question about reality — and believe it or not, these are called hallucinations of the AI — that is, it can provide an answer that may even seem reasonable, but actually it’s made up. This happened to a lawyer who was using it to develop references for a court caseopens in a new tab or window, and it turned out that some of the references were actually made-up references, quite to the embarrassment of the individual and perhaps to some professional harm.

So there’s a lot to sort out with these, and there are a range of possibilities. Like I said, it’s a juncture in history, but I urge you to give it a try. For example, in clinic this weekend — I do a clinic with medical students — we were taking some of the more perplexing patients and putting their symptoms into this. By the way, you just put in, “I have a patient with these symptoms.” You want to be careful by the way, this isn’t mostly HIPAA [Health Insurance Portability and Accountability Act] overseen, so we were being vague but still put in the symptoms. It generated a pretty good differential diagnosis.

This can be used for a wide variety of teaching, but you do need some expertise to know whether or not what it’s giving you is real and whether you can trust it and rely on it.

A recent New York Times articleopens in a new tab or window came out and I was quoted as saying, “You’d be crazy not to try this.” And I’ll say this, too, I really urge clinicians and healthcare professionals to become familiar with this kind of technology. Give it a try, take it for a ride. Get familiar with what’s coming out, because I think on the horizon you’re going to see this in medicine and you’re going to see this being applied in a wide variety of ways.

You’re already seeing Epic making an agreementopens in a new tab or window with OpenAI who developed this platform, ChatGPT, to be able to integrate it into Epic for many of the tedious tasks that need to be done — report generation and so forth — that that could actually make lives better for physicians and make the chart more complete.

Now, we talk a lot about ChatGPT, but just by the way, there are a lot of these large language models out there. ChatGPT is just one of them. And many people are suggesting that in future generations, these are only going to get more powerful and there will be competition among the tech companies and other newly emerging companies that are going to try to leverage the rapid advances. In the last 6 months, again by the way, people have said that there’s been more advances in the field of AI than they’d seen in a decade.

So, I think we’re on the cusp of a different moment in history. This issue in medicine is going to be very important. Also, what needs to be regulated? What is it that can come into medicine that doesn’t need to be regulated? And what can we really trust? As clinicians, we don’t really need to understand exactly how it works, but we need to know whether we can trust it. That’s going to take some additional time and testing. We’re not quite sure how it’s going to fit, but I’m sure in the end this will help transform medicine, hopefully for the betterment of patients. We need to be involved to ensure that there’s not unintended harm that occurs as new technology gets introduced.

But I’m optimistic about the possibilities and, again, I urge you to give them a try.

When timely angioplasty is unavailable to older ST-segment elevation myocardial infarction (STEMI) patients, a modified pharmaco-invasive reperfusion strategy could be reasonable, according to the STREAM-2 trial.

Half-dose tenecteplase (TNKase) produced ECG changes that were at least comparable to those after primary percutaneous coronary intervention (PCI) in a cohort presenting within 3 hours of STEMI symptom onset but unable to undergo primary PCI within 1 hour, reported a group led by Frans Van de Werf, MD, PhD, of KU Leuven, Belgium.

After last angiography, majority (≥50%) resolution of ST-segment elevation was achieved in 85.2% of those assigned pharmaco-invasive treatment with tenecteplase vs 78.4% of peers who had upfront primary PCI (P=0.05). Residual median sums of ST deviations measured 4.5 vs 5.5 mm (P=0.02).

The STREAM-2 trial results were published in Circulationopens in a new tab or window and were previously presented at the American College of Cardiologyopens in a new tab or window meeting earlier this year.

Although tenecteplase dosing was halved for safety reasons in this population of people 60 years and older, brain bleeds were nevertheless higher than expected, echoing the excess intracranial hemorrhages (ICHs) with standard-dose tenecteplase in the preceding STREAM-1 trialopens in a new tab or window.

Van de Werf and colleagues reported that in STREAM-2, there were 10 strokes in total: six ICHs occurred in the pharmaco-invasive arm (1.5%), zero ICHs in the primary PCI arm, three ischemic strokes in the pharmaco-invasive arm (0.75%), and one ischemic stroke in the primary PCI arm (0.5%).

They stressed that all six ICHs were in people under age 75 and three of them were protocol violations: two tenecteplase recipients got therapeutic doses of unfractionated heparin during rescue PCI despite full-dose IV and subcutaneous enoxaparin being given shortly before, and one person turned out to have uncontrolled hypertension.

“We cannot discriminate why the ICH rate we observed was higher than anticipated despite the use of half-dose tenecteplase, but major protocol violations in half of the cases were probably contributing factors,” study authors said, noting that this observation “reinforces the need for clear and timely communication regarding given treatments between various members of the health care team when rapid transitions in STEMI care unfold.”

In any case, the 30-day composite endpoint counting death, shock, heart failure, or reinfarction was equal between groups (12.8% of tenecteplase arm vs 13.3% of primary PCI group, RR 0.96, 95% CI 0.62-1.48).

“In summary, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided, a pharmaco-invasive treatment as used in this trial is an effective reperfusion strategy in older, early presenting patients with STEMI,” Van de Werf’s team wrote. With primary PCI, the two “reperfusion therapies appear to be legitimate options in appropriately selected patients within a global context in which it is not possible to achieve timely PCI.”

Current STEMI guidelines recommend primary PCI for reperfusion of STEMI when performed within 2 hours after first medical contact — an unattainable goal for many patients presenting initially to non-PCI-capable hospitals. In this case, a pharmaco-invasive strategy is an endorsed alternative.

STREAM-2 was an open-label trial conducted in 49 centers in 10 countries. Participants averaged 70.5 years of age and nearly one-third were women. The median Thrombolysis In Myocardial Infarction (TIMI) risk score was 4.

STEMI patients were randomly assigned 2:1 to half-dose tenecteplase followed by coronary angiography and PCI if indicated (n=401) or upfront primary PCI (n=203).

Overall median times from symptom onset to randomization were 97 minutes for pharmaco-invasive and 92 minutes for primary PCI patients. Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively.

Whereas patients randomly assigned to pharmaco-invasive treatment received tenecteplase within 10 minutes no matter their randomization location, the time to sheath insertion was shorter for patients randomized to PCI while they were in an ambulance vs at a community hospital (median 65 vs 110 minutes).

For 42.2% patients randomly assigned to tenecteplase, urgent angiography was performed for possible rescue PCI at a median time of 142 minutes from randomization.

TIMI flow grade 3 at last angiography was approximately 87% in both groups.

The incidence of major non-intracranial bleeding was below 1.5% across study arms.

“The use of half-dose tenecteplase with improved antithrombotic treatment in the pharmaco-invasive strategy, more frequent use of radial access (>90% in both groups), and advances in interventional technologies may have contributed to the lower-than-anticipated and comparable clinical efficacy outcomes and low incidence of major non-intracranial bleeding in our higher-risk population,” the investigators posited.

It’s widely known that length of stay is one of the most important determinants of success in substance use disorder (SUD) treatment. Data has proven that the longer we can keep patients engaged, the betteropens in a new tab or window their long-term prognosis.

Unfortunately, it’s also one of the hardest factors for providers to overcome. Between the difficulties of withdrawal and the overwhelming desire for substances driven by the disease, far too many patients choose to walk away. In fact, research shows the rate of patients leaving against medical adviceopens in a new tab or window (AMA) has increased substantiallyopens in a new tab or window over the last several years, from 10-15% in 2017 up to 23% in 2019.

If we’re lucky, we get them back in treatment before tragedy strikes. According to the literature, over 35% of patients who leave healthcare facilities AMA return within 30 days, and 16% get readmitted. Sadly, many don’t make it back. Clearly it would be far better for them to stay the first time around.

Anecdotally, the variables thought to drive AMA discharge have focused on demographics: patients who are young, male, and local are presumed to be at greater risk. However, data show otherwise. In fact, demographics have very little, if anything at all, to do with it. Instead, the three main variables that are associated with AMA discharge are psychosocial. Here’s what providers can do to help patients overcome those obstacles.

Life Circumstances

Many patients believe the circumstances in their life make it impossible for them to stay in treatment. For example, I had one patient with a wife and three children whose utility company was prepared to cut off service to their home for nonpayment. The patient felt strongly that his wife couldn’t function without him while he was in rehab. But is that accurate? Or is that merely his perception? Could someone else in the family step in to help while he got treatment?

As providers, we must help patients determine if these circumstances are accurate, and if not, help them see a more evidence-based reality. Of course, life circumstances can also contribute to the SUD condition. Difficult family dynamics, trauma, co-dependence, and co-occurring mental health issues can all play a role in the context that contributes to SUD. Sometimes separationopens in a new tab or window from those circumstances can be the best course of action.

That’s why it’s essential to conduct biopsychosocial assessments upon intake to get to the heart of these conditions. Start by asking questions about the patients’ social and family dynamics and what brought them to treatment. This evaluation can help get to the “why” behind their substance use and their desire for treatment. Cognitive interpersonal psychotherapy can help patients reframe their point of view on their circumstances, help them see how they may have contributed to the SUD, and ultimately, how completing treatment can help them stop using and provide coping skills to deal with difficult circumstances going forward.

Motivation

Intrinsic motivation is essential for successful treatment. Very rarely will external motivation be effective, including ultimatums or threats of incarceration, job loss, or divorce. Patients must learn to visualize sobriety, what it feels like for them, and what it can mean for their future. They have to want it and see it as a real possibility.

When external motivators are the driving force behind seeking treatment, the use of motivational interviewing can help patients to shift their “why.” This technique helps patients connect the things they care about and their future goals with sobriety, and boost their confidence in believing they can achieve those goals.

I had one patient, a young man, who had been in and out of our facility several times. His mother and brothers would force him to come, and he made it clear he was only here to detox, didn’t want group therapy, and would go right back to using in short order. On his most recent admission, we talked about the importance of group therapy and helped him develop a better understanding of his disease and what recovery could actually do for him beyond detox. This time, it clicked. Instead of being coerced into treatment, he asked to stay longer, doing intense outpatient therapy every morning and going to work in his family’s auto shop every afternoon. It has made a huge difference in his prognosis.

Readiness

Patients who aren’t ready to acknowledge the negative impact substances have had on their lives are at greater risk of AMA discharge. They might believe they have their substance use under control or can get it under control on their own. To avoid leaving treatment AMA, they have to first recognize the problems their untreated disease has caused in their relationships, financial situation, and personal health and safety, and understand that it is nearly impossible to overcome addiction on their own.

For as much as we’ve made progress in educating the public that addiction is a disease, a surprising number of SUD patients still don’t see it that way. As part of the process, we have to help them see SUD as a chronic conditionopens in a new tab or window, like diabetes or cancer, that has to be managed long-term through lifestyle change. The goal of treatment is to put that disease in remission and teach them skills to help keep it that way.

Helping patients know what to expect in treatment is a key factor in readiness and avoiding AMA. The first few days of treatment are tough. Patients are often still under the influence for several days after admission, which makes them much more likelyopens in a new tab or window to discharge AMA as substances cloud their judgment. Providers must explain the impact substances have on their brain and why the urge to leave likely isn’t valid — it’s the substance talking.

Providers should explain the physical challenges of detox and withdrawal. The discomfort, especially when patients are unprepared for it, can be a huge driver in AMA discharge when patients know they can leave, use again, and feel “better” immediately. Employing medication-assisted treatment (MAT), especially for alcohol and opioid use disorder, can substantially loweropens in a new tab or window the likelihood of AMA discharge.

Knowing that these psychosocial variables are the most important factors in AMA discharge means that we, as providers, can actually help patients to overcome them. We obviously can’t change patients’ age, gender, or any other demographic, but we can — through targeted therapy — help them change their way of thinking about the disease to give them the best chance of success through holistic treatment and targeted interventions.

Jesus Perez, PsyD, is a licensed psychologist and clinical director of Recovery First Treatment Centeropens in a new tab or window, an American Addiction Centers facilityopens in a new tab or window.

The range of COVID-19 symptoms varies-; some feel a mild cold, others are hospitalized, while others perish. Many studies have linked the severity of COVID-19 symptoms with an individual’s biological factors, but less is known about the impact of non-biological factors, such as the environment in which people live.

A new study that published on June 14, 2023, in the journal PLoS ONE, is the first to show that the neighborhood-built environment might pose an independent risk determining the individuals hospitalized due to COVID-19 illness.

The authors found that in a cohort of more than 18,000 individuals with SARS-CoV-2 infections, living in multi-family building, living in a neighborhood with higher air pollution (PM2.5) levels and living in a neighborhood with lower walkability and bike-ability were associated with a greater incidence rate of hospitalization, even when controlling for socioeconomic vulnerability and individual-level demographic and medical characteristics. Neighborhoods with higher public transit quality and access were also associated with a higher incidence rate of hospitalization.

The study identified differences between the two largest ethnic groups in the region. Higher PM2.5 levels posed a higher rate of hospitalization for Latinx individuals, and density and overcrowding showed stronger associations for non-Hispanic White individuals.

The findings could help inform public health and urban planning initiatives in lowering the risk of hospitalizations linked to COVID-19 and other respiratory pathogens.

“For urban planners, the findings underline what we’re already trying to do to build healthier communities-;create more walkability, bike-ability and infrastructure that will reduce air pollution,” said Alessandro Rigolon, associate professor at the University of Utah and lead author of the study. “From a public health perspective, the findings can help testing and vaccination campaigns target areas with higher air pollution or multi-family housing.”

The study also exposed how urban policies from the past continue impact the daily lives of many communities.

“We found much higher rates of COVID-19 hospitalizations along the I-25 and I-70 corridors and in the industrial areas of North Denver,” said Jeremy Németh, professor at the University of Colorado Denver and co-author of the study. “These are the same areas that have experienced decades of disinvestment and increased air pollution due to racist land-use policies levied on our cities in the early 20th century.”

Neighborhood-built environments

The study analyzed the neighborhood characteristics in the Denver Metro Area associated with hospitalizations of 18,042 people who tested positive for SARS-CoV-2 between May and December in 2020, before vaccines became extensively available. Researchers from two of the Denver Metro Area’s major health care systems, Denver Health and University of Colorado Hospital, reviewed more than 30,000 cases of eligible individuals. They limited the cohort to those living in the greater metro area, and matched available health record data for each case. Variables pulled from the medical record included age and body mass index (BMI), evidence of tobacco use, hypertension, chronic lung disease, some forms of cardiovascular disease and chronic kidney disease. Researchers at the University of Colorado Denver then converted addresses of people in the final cohort to their geospatial coordinates and assigned environmental variables accordingly.

Ethical oversight and approval for the study was granted by the Colorado Multiple Institutional Review Board and all protected health information was anonymized prior to sharing.

“Very few studies are comprehensive like ours. We’re able to control for some individual level factors that, for people with COVID-19, would lead to higher chances of being hospitalized,” said Rigolon.

With biological factors largely accounted for, the authors identified four characteristics of a neighborhood that might contribute to COVID-19 hospitalization: density and overcrowding, including living in an overcrowded home or multi-family building; environmental hazards, such as air pollution levels (PM 2.5) and proximity to highways; environmental amenities, including access to parks; and mobility options, including public transit access, walkability and bike-ability.

The authors were unsurprised that individuals with compromised lung and immune systems who face chronic air pollution would be unable to respond as well to the respiratory disease and would be more likely to need hospitalization after contracting COVID-19. Their finding that higher PM2.5 levels impacted Latinx individuals more than non-Hispanic White individuals underscores a worldwide problem-;air pollution disproportionately affects People of Color. While findings support making existing neighborhoods more walkable and bikeable, the authors emphasized that future planning efforts to reduce emissions should center the principles of environmental justice. Since walkability was particularly protective in Latinx communities, the authors suggest that cities should prioritize investing to make Latinx-dominant neighborhoods pedestrian-friendly.

The result for density and overcrowding underscore the need for vaccination and testing efforts to focus on areas with multi-family housing to mitigate risk of severe disease. Because living in transit-rich neighborhoods was associated with higher risk of hospitalization from COVID-19, public health measures like educational campaigns and outreach in these areas are particularly important.

“So many health disparities track along geographic lines. We’ve long suspected that more than just pre-existing medical conditions were to blame for the disparities. It was interesting to work with the urban planning teams to pinpoint exactly which environmental factors were partially to blame for disproportionate rates of hospitalizations that we keep seeing. This will help public health leaders continue to advocate for healthier cities, and it helps inform outreach efforts to address COVID-19 and other respiratory illnesses,” said Sarah Rowan, associate professor of medicine at University of Colorado School of Medicine, Denver Health infectious diseases physician and the study’s senior author.

Neighborhoods in other areas, other diseases?

The authors would like to replicate this study in other regions such as in the Salt Lake Valley in Utah, which has similar environmental and population characteristics as the Denver Metro Area. They’d also like to expand to other respiratory diseases where people are hospitalized, such as the flu. Though it took multiple years to process the massive quantity of patient records, studies that can look at health outcomes and the built environment on an individual level are valuable.

“Urban planning was born out of public health concerns in the U.S. when cities were getting very crowded, very polluted and sanitation was an issue. It’s only natural that urban planners do research that involves public health,” said Rigolon.

Additional contributing authors include Brenn Anderson-Gregson, Ann Rae Miller and Priyanka deSouza of the Department of Urban and Regional Planning, University of Colorado Denver; Brian Montague and Kristine M. Erlandson of the Division of Infectious Diseases, University of Colorado School of Medicine; and Cory Hussain, University of Colorado School of Medicine and Denver Health.