Donna Zulman

All Publications

• Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA Zulman, D. M., Haverfield, M. C., Shaw, J. G., Brown-Johnson, C. G., Schwartz, R., Tierney, A. A., Zionts, D. L., Safaeinili, N., Fischer, M., Thadaney Israni, S., Asch, S. M., Verghese, A. 2020; 323 (1): 70–81

  Abstract

  Time constraints, technology, and administrative demands of modern medicine often impede the human connection that is central to clinical care, contributing to physician and patient dissatisfaction.To identify evidence and narrative-based practices that promote clinician presence, a state of awareness, focus, and attention with the intent to understand patients.Preliminary practices were derived through a systematic literature review (from January 1997 to August 2017, with a subsequent bridge search to September 2019) of effective interpersonal interventions; observations of primary care encounters in 3 diverse clinics (n = 27 encounters); and qualitative interviews with physicians (n = 10), patients (n = 27), and nonmedical professionals whose occupations involve intense interpersonal interactions (eg, firefighter, chaplain, social worker; n = 30). After evidence synthesis, promising practices were reviewed in a 3-round modified Delphi process by a panel of 14 researchers, clinicians, patients, caregivers, and health system leaders. Panelists rated each practice using 9-point Likert scales (-4 to +4) that reflected the potential effect on patient and clinician experience and feasibility of implementation; after the third round, panelists selected their "top 5" practices from among those with median ratings of at least +2 for all 3 criteria. Final recommendations incorporate elements from all highly rated practices and emphasize the practices with the greatest number of panelist votes.The systematic literature review (n = 73 studies) and qualitative research activities yielded 31 preliminary practices. Following evidence synthesis, 13 distinct practices were reviewed by the Delphi panel, 8 of which met criteria for inclusion and were combined into a final set of 5 recommendations: (1) prepare with intention (take a moment to prepare and focus before greeting a patient); (2) listen intently and completely (sit down, lean forward, avoid interruptions); (3) agree on what matters most (find out what the patient cares about and incorporate these priorities into the visit agenda); (4) connect with the patient's story (consider life circumstances that influence the patient's health; acknowledge positive efforts; celebrate successes); and (5) explore emotional cues (notice, name, and validate the patient's emotions).This mixed-methods study identified 5 practices that have the potential to enhance physician presence and meaningful connection with patients in the clinical encounter. Evaluation and validation of the outcomes associated with implementing the 5 practices is needed, along with system-level interventions to create a supportive environment for implementation.

  View details for DOI 10.1001/jama.2019.19003

  View details for PubMedID 31910284

• Effect of an Intensive Outpatient Program to Augment Primary Care for High-Need Veterans Affairs Patients: A Randomized Clinical Trial. JAMA internal medicine Zulman, D. M., Pal Chee, C., Ezeji-Okoye, S. C., Shaw, J. G., Holmes, T. H., Kahn, J. S., Asch, S. M. 2017; 177 (2): 166-175

  Abstract

  Many organizations are adopting intensive outpatient care programs for high-need patients, yet little is known about their effectiveness in integrated systems with established patient-centered medical homes.To evaluate how augmenting the Veterans Affairs (VA) medical home (Patient Aligned Care Teams [PACT]) with an Intensive Management program (ImPACT) influences high-need patients' costs, health care utilization, and experience.Randomized clinical trial at a single VA facility. Among 583 eligible high-need outpatients whose health care costs or hospitalization risk were in the top 5% for the facility, 150 were randomly selected for ImPACT; the remaining 433 received standard PACT care.The ImPACT multidisciplinary team addressed health care needs and quality of life through comprehensive patient assessments, intensive case management, care coordination, and social and recreational services.Primary difference-in-difference analyses examined changes in health care costs and acute and extended care utilization over a 16-month baseline and 17-month follow-up period. Secondary analyses estimated the intervention's effect on ImPACT participants (using randomization as an instrument) and for patients with key sociodemographic and clinical characteristics. ImPACT participants' satisfaction and activation levels were assessed using responses to quality improvement surveys administered at baseline and 6 months.Of 140 patients assigned to ImPACT, 96 (69%) engaged in the program (mean [SD] age, 68.3 [14.2] years; 89 [93%] male; mean [SD] number of chronic conditions, 10 [4]; 62 [65%] had a mental health diagnosis; 21 [22%] had a history of homelessness). After accounting for program costs, adjusted person-level monthly health care expenditures decreased similarly for ImPACT and PACT patients (difference-in-difference [SE] -$101 [$623]), as did acute and extended care utilization rates. Among respondents to the ImPACT follow-up survey (n = 54 [56% response rate]), 52 (96%) reported that they would recommend the program to others, and pre-post analyses revealed modest increases in satisfaction with VA care (mean [SD] increased from 2.90 [0.72] to 3.16 [0.60]; P = .04) and communication (mean [SD] increased from 2.99 [0.74] to 3.18 [0.60]; P = .03).Intensive outpatient care for high-need patients did not reduce acute care utilization or costs compared with standard VA care, although there were positive effects on experience among patients who participated. Implementing intensive outpatient care programs in integrated settings with well-established medical homes may not prevent hospitalizations or achieve substantial cost savings.clinicaltrials.gov Identifier: NCT02932228.

  View details for DOI 10.1001/jamainternmed.2016.8021

  View details for PubMedID 28027338

• Evolutionary Pressures on the Electronic Health Record: Caring for Complexity. JAMA Zulman, D. M., Shah, N. H., Verghese, A. 2016; 316 (9): 923-924

  View details for DOI 10.1001/jama.2016.9538

  View details for PubMedID 27532804

• How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Jenchura, E. C., Cohen, D. M., Lewis, E. T., Houston, T. K., Asch, S. M. 2015; 30 (8): 1063-1070

  Abstract

  Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear.To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology.After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants.Fifty-three individuals with ≥3 chronic conditions and experience using technology for health-related purposes.Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96 %), communicate with health care providers (92 %), track medical information (83 %), track medications (77 %), and support decision-making about treatment (55 %). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes.Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

  View details for DOI 10.1007/s11606-015-3222-9

  View details for Web of Science ID 000358359400012

  View details for PubMedCentralID PMC4510242

• Multimorbidity and healthcare utilisation among high-cost patients in the US Veterans Affairs Health Care System. BMJ open Zulman, D. M., Pal Chee, C., Wagner, T. H., Yoon, J., Cohen, D. M., Holmes, T. H., Ritchie, C., Asch, S. M. 2015; 5 (4)

  View details for DOI 10.1136/bmjopen-2015-007771

  View details for PubMedID 25882486

• Quality of care for patients with multiple chronic conditions: the role of comorbidity interrelatedness. Journal of general internal medicine Zulman, D. M., Asch, S. M., Martins, S. B., Kerr, E. A., Hoffman, B. B., Goldstein, M. K. 2014; 29 (3): 529-537

  Abstract

  Multimorbidity-the presence of multiple chronic conditions in a patient-has a profound impact on health, health care utilization, and associated costs. Definitions of multimorbidity in clinical care and research have evolved over time, initially focusing on a patient's number of comorbidities and the associated magnitude of required care processes, and later recognizing the potential influence of comorbidity characteristics on patient care and outcomes. In this article, we review the relationship between multimorbidity and quality of care, and discuss how this relationship may be mediated by the degree to which conditions interact with one another to generate clinical complexity (comorbidity interrelatedness). Drawing on established theoretical frameworks from cognitive engineering and biomedical informatics, we describe how interactions among conditions result in clinical complexity and may affect quality of care. We discuss how this comorbidity interrelatedness influences the value of existing quality guidelines and performance metrics, and describe opportunities to quantify this construct using data widely available through electronic health records. Incorporating comorbidity interrelatedness into conceptualizations of multimorbidity has the potential to enhance clinical and research efforts that aim to improve care for patients with multiple chronic conditions.

  View details for DOI 10.1007/s11606-013-2616-9

  View details for PubMedID 24081443

• Patient Interest in Sharing Personal Health Record Information A Web-Based Survey ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Turvey, C. L., Wagner, T. H., Woods, S. S., An, L. C. 2011; 155 (12): 805-U46

  Abstract

  Electronic personal health record (PHR) systems are proliferating but largely have not realized their potential for enhancing communication among patients and their network of care providers.To explore preferences about sharing electronic health information among users of the U.S. Department of Veterans Affairs (VA) PHR system, My HealtheVet.Web-based survey of a convenience sample.My HealtheVet Web site from 7 July through 4 October 2010.18 471 users of My HealtheVet.Interest in shared PHR access and preferences about who would receive access, the information that would be shared, and the activities that users would delegate.Survey respondents were predominantly men (92%) and aged 50 to 64 years (51%) or 65 years or older (39%); approximately 39% reported poor or fair health status. Almost 4 of 5 respondents (79%) were interested in sharing access to their PHR with someone outside of their health system (62% with a spouse or partner, 23% with a child, 15% with another family member, and 25% with a non-VA health care provider). Among those who selected a family member other than a spouse or partner, 47% lived apart from the specified person. Preferences about degree of access varied on the basis of the type of information being shared, the type of activity being performed, and the respondent's relationship with the selected person.The survey completion rate was 40.8%. Results might not be generalizable to all My HealtheVet users.In a large survey of PHR users in the VA system, most respondents were interested in sharing access to their electronic health information with caregivers and non-VA providers. Existing and evolving PHR systems should explore secure mechanisms for shared PHR access to improve information exchange among patients and the multiple persons involved in their health care.Veterans Health Administration and The Robert Wood Johnson Foundation Clinical Scholars Program.

  View details for DOI 10.1059/0003-4819-155-12-201112200-00002

  View details for Web of Science ID 000298280500014

  View details for PubMedID 22184687

• Examining the Evidence: A Systematic Review of the Inclusion and Analysis of Older Adults in Randomized Controlled Trials JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Sussman, J. B., Chen, X., Cigolle, C. T., Blaum, C. S., Hayward, R. A. 2011; 26 (7): 783-790

  Abstract

  Due to a shortage of studies focusing on older adults, clinicians and policy makers frequently rely on clinical trials of the general population to provide supportive evidence for treating complex, older patients.To examine the inclusion and analysis of complex, older adults in randomized controlled trials.A PubMed search identified phase III or IV randomized controlled trials published in 2007 in JAMA, NEJM, Lancet, Circulation, and BMJ. Therapeutic interventions that assessed major morbidity or mortality in adults were included. For each study, age eligibility, average age of study population, primary and secondary outcomes, exclusion criteria, and the frequency, characteristics, and methodology of age-specific subgroup analyses were reviewed.Of the 109 clinical trials reviewed in full, 22 (20.2%) excluded patients above a specified age. Almost half (45.6%) of the remaining trials excluded individuals using criteria that could disproportionately impact older adults. Only one in four trials (26.6%) examined outcomes that are considered highly relevant to older adults, such as health status or quality of life. Of the 42 (38.5%) trials that performed an age-specific subgroup analysis, fewer than half examined potential confounders of differential treatment effects by age, such as comorbidities or risk of primary outcome. Trials with age-specific subgroup analyses were more likely than those without to be multicenter trials (97.6% vs. 79.1%, p < 0.01) and funded by industry (83.3% vs. 62.7%, p < 0.05). Differential benefit by age was found in seven trials (16.7%).Clinical trial evidence guiding treatment of complex, older adults could be improved by eliminating upper age limits for study inclusion, by reducing the use of eligibility criteria that disproportionately affect multimorbid older patients, by evaluating outcomes that are highly relevant to older individuals, and by encouraging adherence to recommended analytic methods for evaluating differential treatment effects by age.

  View details for DOI 10.1007/s11606-010-1629-x

  View details for Web of Science ID 000291701200020

  View details for PubMedID 21286840

• Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA network open Chang, E. T., Zulman, D. M., Nelson, K. M., Rosland, A., Ganz, D. A., Fihn, S. D., Piegari, R., Rubenstein, L. V. 2020; 3 (6): e208120

  Abstract

  Importance: Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described.Objective: To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA).Design, Setting, and Participants: This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019.Exposures: Risk of hospitalization and assignment to general vs specialized primary care.Main Outcome and Measures: High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care).Results: The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n=351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P<.001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P<.001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P<.001). Use of intensive supplementary outpatient services was low overall.Conclusions and Relevance: The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.

  View details for DOI 10.1001/jamanetworkopen.2020.8120

  View details for PubMedID 32597993

• Patient Perceptions of Video Visits Using Veterans Affairs Telehealth Tablets: Survey Study. Journal of medical Internet research Slightam, C., Gregory, A. J., Hu, J., Jacobs, J., Gurmessa, T., Kimerling, R., Blonigen, D., Zulman, D. M. 2020; 22 (4): e15682

  Abstract

  BACKGROUND: Video-based health care can help address access gaps for patients and is rapidly being offered by health care organizations. However, patients who lack access to technology may be left behind in these initiatives. In 2016, the US Department of Veterans Affairs (VA) began distributing video-enabled tablets to provide video visits to veterans with health care access barriers.OBJECTIVE: This study aimed to evaluate veterans' experiences with VA-issued tablets and identify patient characteristics associated with preferences for video visits vs in-person care.METHODS: A baseline survey was sent to the tablet recipients, and a follow-up survey was sent to the respondents 3 to 6 months later. Multivariate logistic regression was used to identify patient characteristics associated with preferences for care, and we examined qualitative themes around care preferences using standard content analysis methods for coding the data collected in the open-ended questions.RESULTS: Patient-reported access barriers centered around transportation and health-related challenges, outside commitments, and feeling uncomfortable or uneasy at the VA. Satisfaction with the tablet program was high, and in the follow-up survey, approximately two-thirds of tablet recipients preferred care via a tablet (194/604, 32.1%) or expressed that video-based and in-person care were "about the same" (216/604, 35.7%), whereas one-third (192/604, 31.7%) indicated a preference for in-person care. Patients were significantly more likely to report a preference for video visits (vs a preference for in-person visits or rating them "about the same") if they felt uncomfortable in a VA setting, reported a collaborative communication style with their doctor, had a substance use disorder diagnosis, or lived in a place with better broadband coverage. Patients were less likely to report a preference for video visits if they had more chronic conditions. Qualitative analyses identified four themes related to preferences for video-based care: perceived improvements in access to care, perceived differential quality of care, feasibility of obtaining necessary care, and technology-related challenges.CONCLUSIONS: Many recipients of VA-issued tablets report that video care is equivalent to or preferred to in-person care. Results may inform efforts to identify good candidates for virtual care and interventions to support individuals who experience technical challenges.

  View details for DOI 10.2196/15682

  View details for PubMedID 32293573

• Measures of care fragmentation: Mathematical insights from population genetics. Health services research Rosenberg, N. A., Zulman, D. M. 2020

  Abstract

  OBJECTIVE: To identify novel properties of health care fragmentation measures, drawing on insights from mathematically equivalent measures of genetic diversity.STUDY DESIGN: We describe mathematical relationships between two measures: (a) Breslau's Usual Provider of Care (UPC), the proportion of care with the most frequently visited provider, analogous to the "frequency of the most frequent allele" at a genetic locus; and (b) Bice-Boxerman's Continuity of Care Index (COCI), a measure of care dispersion across multiple providers, analogous to "Nei's estimator of homozygosity" in genetics.PRINCIPAL FINDINGS: Just as the frequency of the most frequent allele places a tight constraint on homozygosity, the proportion of care with the most frequently visited provider (UPC) places lower and upper bounds on dispersion of care (COCI), and vice versa. This property presents the possibility of a normalized COCI given UPC (NCGU) measure, which reflects a bounded range of care dispersion dependent on the number of visits with the most frequently visited provider. Mathematical aspects of UPC and COCI also suggest thresholds for the minimal number of patient visits to use when studying fragmentation.CONCLUSIONS: Applying knowledge from population genetics elucidated relationships between care fragmentation measures and produced novel insights for care fragmentation studies.

  View details for DOI 10.1111/1475-6773.13263

  View details for PubMedID 31970757

• Can Patient-Provider Interpersonal Interventions Achieve the Quadruple Aim of Healthcare? A Systematic Review. Journal of general internal medicine Haverfield, M. C., Tierney, A., Schwartz, R., Bass, M. B., Brown-Johnson, C., Zionts, D. L., Safaeinili, N., Fischer, M., Shaw, J. G., Thadaney, S., Piccininni, G., Lorenz, K. A., Asch, S. M., Verghese, A., Zulman, D. M. 2020

  Abstract

  Human connection is at the heart of medical care, but questions remain as to the effectiveness of interpersonal interventions. The purpose of this review was to characterize the associations between patient-provider interpersonal interventions and the quadruple aim outcomes (population health, patient experience, cost, and provider experience).We sourced data from PubMed, EMBASE, and PsycInfo (January 1997-August 2017). Selected studies included randomized controlled trials and controlled observational studies that examined the association between patient-provider interpersonal interventions and at least one outcome measure of the quadruple aim. Two abstractors independently extracted information about study design, methods, and quality. We characterized evidence related to the objective of the intervention, type and duration of intervention training, target recipient (provider-only vs. provider-patient dyad), and quadruple aim outcomes.Seventy-three out of 21,835 studies met the design and outcome inclusion criteria. The methodological quality of research was moderate to high for most included studies; 67% of interventions targeted the provider. Most studies measured impact on patient experience; improvements in experience (e.g., satisfaction, patient-centeredness, reduced unmet needs) often corresponded with a positive impact on other patient health outcomes (e.g., quality of life, depression, adherence). Enhanced interpersonal interactions improved provider well-being, burnout, stress, and confidence in communicating with difficult patients. Roughly a quarter of studies evaluated cost, but the majority reported no significant differences between intervention and control groups. Among studies that measured time in the clinical encounter, intervention effects varied. Interventions with lower demands on provider time and effort were often as effective as those with higher demands.Simple, low-demand patient-provider interpersonal interventions may have the potential to improve patient health and patient and provider experience, but there is limited evidence that these interventions influence cost-related outcomes.

  View details for DOI 10.1007/s11606-019-05525-2

  View details for PubMedID 31919725

• "They are interrelated, one feeds off the other": A taxonomy of perceived disease interactions derived from patients with multiple chronic conditions. Patient education and counseling Zulman, D. M., Slightam, C. A., Brandt, K., Lewis, E. T., Asch, S. M., Shaw, J. G. 2019

  Abstract

  OBJECTIVE: To understand patients' experiences with condition interactions and develop a taxonomy to inform care for patients with multiple chronic conditions.METHODS: We conducted qualitative and quantitative analysis of free-text data from patient surveys in which respondents were asked to indicate their most bothersome chronic condition and describe how their other conditions affect their self-care for that condition. Using standard content analysis, we developed a taxonomy comprising how patients perceive interactions among their conditions, and examined cross-cutting themes that reflect qualities of these interactions.RESULTS: Among 383 eligible survey respondents, the mean (SD) number of chronic conditions was 4 (2); common conditions included hypertension (60%), chronic pain (49%), arthritis (41%), depression (32%), diabetes (29%), and post-traumatic stress disorder (26%). Patients' perceived condition interactions took four broad forms: 1) unidirectional interactions among conditions and/or treatments, 2) cyclical or multidimensional interactions, 3) uncertain or indistinct interactions, and 4) no perceived interaction. Cross-cutting themes included beliefs about causal relationships between conditions, identification of interactions as negative vs. positive, and interactions between physical and mental health.CONCLUSION: This study presents a novel taxonomy of condition interactions from the patient perspective.PRACTICE IMPLICATIONS: Understanding perceived condition interactions may support patient self-management and shared decision-making efforts.

  View details for DOI 10.1016/j.pec.2019.11.020

  View details for PubMedID 31787406

• What is clinician presence? A qualitative interview study comparing physician and non-physician insights about practices of human connection. BMJ open Brown-Johnson, C., Schwartz, R., Maitra, A., Haverfield, M. C., Tierney, A., Shaw, J. G., Zionts, D. L., Safaeinili, N., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019; 9 (11): e030831

  Abstract

  OBJECTIVE: We sought to investigate the concept and practices of 'clinician presence', exploring how physicians and professionals create connection, engage in interpersonal interaction, and build trust with individuals across different circumstances and contexts.DESIGN: In 2017-2018, we conducted qualitative semistructured interviews with 10 physicians and 30 non-medical professionals from the fields of protective services, business, management, education, art/design/entertainment, social services, and legal/personal services.SETTING: Physicians were recruited from primary care clinics in an academic medical centre, a Veterans Affairs clinic, and a federally qualified health centre.PARTICIPANTS: Participants were 55% men and 45% women; 40% were non-white.RESULTS: Qualitative analyses yielded a definition of presence as a purposeful practice of awareness, focus, and attention with the intent to understand and connect with individuals/patients. For both medical and non-medical professionals, creating presence requires managing and considering time and environmental factors; for physicians in particular, this includes managing and integrating technology. Listening was described as central to creating the state of being present. Within a clinic, presence might manifest as a physician listening without interrupting, focusing intentionally on the patient, taking brief re-centering breaks throughout a clinic day, and informing patients when attention must be redirected to administrative or technological demands.CONCLUSIONS: Clinician presence involves learning to step back, pause, and be prepared to receive a patient's story. Building on strategies from physicians and non-medical professionals, clinician presence is best enacted through purposeful intention to connect, conscious navigation of time, and proactive management of technology and the environment to focus attention on the patient. Everyday practice or ritual supporting these strategies could support physician self-care as well as physician-patient connection.

  View details for DOI 10.1136/bmjopen-2019-030831

  View details for PubMedID 31685506

• Opportunity or Burden? A Behavioral Framework for Patient Engagement. Medical care Kimerling, R., Lewis, E. T., Javier, S. J., Zulman, D. M. 2019

  Abstract

  BACKGROUND: Engaging patients as partners in their care is clinically appealing, yet challenging to implement, and we lack a measurement framework that is applicable to vulnerable populations. To address this gap, we conducted a qualitative study to refine a conceptual framework that reflects an individual's propensity to engage with care.OBJECTIVES: Our objectives were to refine the framework's domains of engagement behavior; identify key behaviors within each domain that describe engagement with providers, health systems or settings; and illustrate examples for each behavior where higher self-efficacy describes an opportunity to enhance engagement, and lower self-efficacy describes difficulties with engagement that risk burden.RESEARCH DESIGN AND SAMPLE: We elicited patient perspectives by conducting individual semistructured interviews with veterans receiving care for mental health and/or chronic conditions from the Veterans Health Administration. Data were analyzed using the framework method.RESULTS: The resulting engagement framework encompassed 4 interrelated domains: Self-Management, Health Information Use, Collaborative Communication, and Healthcare Navigation. The propensity to engage with care was conceptualized as the cumulative self-efficacy to engage in behaviors across these domains. Results emphasize the collaborative nature of engagement behaviors and the impact of veteran cultural influences via perceptions of collective efficacy.CONCLUSIONS: This framework can be applied to judgments regarding a patient's propensity to engage in care. Because self-efficacy is an individual's context-specific judgment of their capabilities, this framework may inform health care and social service interventions that aim to engage patients. This maybe especially useful for public sector settings and populations with social risks.

  View details for DOI 10.1097/MLR.0000000000001240

  View details for PubMedID 31688570

• Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter JOURNAL OF GERIATRIC PSYCHIATRY AND NEUROLOGY Schwartz, R., Trivedi, R., Gray, C., Lorenz, K. A., Zulman, D. 2019; 32 (5): 246–56

  View details for DOI 10.1177/0891988719845509

  View details for Web of Science ID 000480256300002

• Increasing Mental Health Care Access, Continuity, and Efficiency for Veterans Through Telehealth With Video Tablets. Psychiatric services (Washington, D.C.) Jacobs, J. C., Blonigen, D. M., Kimerling, R., Slightam, C., Gregory, A. J., Gurmessa, T., Zulman, D. M. 2019: appips201900104

  Abstract

  OBJECTIVE: In 2016, the Veterans Health Administration (VHA) began distributing video-enabled tablets to veterans with access barriers. This study evaluated the implementation of this initiative for veterans with mental health conditions, including the impact of tablet receipt on access to and continuity of mental health care, missed opportunities for care, and use of urgent care.METHODS: A retrospective matched cohort study was conducted, matching tablet recipients with diagnoses of mental disorders (N=728) to a comparison group (N=1,020) on the basis of sociodemographic characteristics, mental health utilization and diagnoses, and wireless coverage. A difference-in-differences approach was used to compare 6-month pre-post changes in number of psychotherapy and medication management visits, continuity of psychotherapy based on VHA's quality metric for mental health care continuity, missed opportunity rate (i.e., the proportion of mental health appointments that were missed or canceled), and probability of any and number of emergency department (ED) or urgent care visits.RESULTS: Compared with the matched control group, tablet recipients experienced an increase of 1.94 (p<0.001) psychotherapy encounters, an increase of 1.05 (p<0.001) medication management visits, an 18.54 percentage point (p<0.001) increase in their likelihood of receiving recommended mental health care necessary for continuity of care, and a 20.24 percentage point (p<.001) decrease in their missed opportunity rate in the 6-month period following receipt of tablets (or the index date for the matched sample). No significant differences in ED or urgent care use were found.CONCLUSIONS: Distributing video-enabled tablets to veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency by decreasing missed opportunities for care.

  View details for DOI 10.1176/appi.ps.201900104

  View details for PubMedID 31378193

• Using Predictive Analytics to Guide Patient Care and Research in a National Health System JOURNAL OF GENERAL INTERNAL MEDICINE Nelson, K. M., Chang, E. T., Zulman, D. M., Rubenstein, L. V., Kirkland, F. D., Fihn, S. D. 2019; 34 (8): 1379–80

  View details for DOI 10.1007/s11606-019-04961-4

  View details for Web of Science ID 000477976700008

• High-Need Patients' Goals and Goal Progress in a Veterans Affairs Intensive Outpatient Care Program. Journal of general internal medicine Hsu, K. Y., Slightam, C., Shaw, J. G., Tierney, A., Hummel, D. L., Goldstein, M. K., Chang, E. T., Boothroyd, D., Zulman, D. M. 2019

  Abstract

  BACKGROUND: Healthcare systems nationwide are implementing intensive outpatient care programs to optimize care for high-need patients; however, little is known about these patients' personal goals and factors associated with goal progress.OBJECTIVE: To describe high-need patients' goals, and to identify factors associated with their goal progress DESIGN: Retrospective cohort study PARTICIPANTS: A total of 113 high-need patients participated in a single-site Veterans Affairs intensive outpatient care program.MAIN MEASURES: Two independent reviewers examined patients' goals recorded in the electronic health record, categorized each goal into one of three domains (medical, behavioral, or social), and determined whether patients attained goal progress during program participation. Logistic regression was used to determine factors associated with goal progress.RESULTS: The majority (n=72, 64%) of the 113 patients attained goal progress. Among the 100 (88%) patients with at least one identified goal, 58 set goal(s) in the medical domain; 60 in the behavioral domain; and 52 in the social domain. Within each respective domain, 41 (71%) attained medical goal progress; 34 (57%) attained behavioral goal progress; and 32 (62%) attained social goal progress. Patients with mental health condition(s) (aOR 0.3; 95% CI 0.1-0.9; p=0.03) and those living alone (aOR 0.4; 95% CI 0.1-1.0; p=0.05) were less likely to attain goal progress. Those with mental health condition(s) and those who were living alone were least likely to attain goal progress (interaction aOR 0.1 compared to those with neither characteristic; 95% CI 0.0-0.7; p=0.02).CONCLUSIONS: Among high-need patients participating in an intensive outpatient care program, patient goals were fairly evenly distributed across medical, behavioral, and social domains. Notably, individuals living alone with mental health conditions were least likely to attain progress. Future care coordination interventions might incorporate strategies to address this gap, e.g., broader integration of behavioral and social service components.

  View details for DOI 10.1007/s11606-019-05010-w

  View details for PubMedID 31140094

• Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial. Journal of general internal medicine Zulman, D. M., Chang, E. T., Wong, A., Yoon, J., Stockdale, S. E., Ong, M. K., Rubenstein, L. V., Asch, S. M. 2019

  Abstract

  BACKGROUND: Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home.OBJECTIVE: Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction.DESIGN: Cross-sectional analysis of patient survey data from a five-site randomized quality improvement study.PARTICIPANTS: Two thousand five hundred sixty-six Veterans with hospitalization risk scores ≥90th percentile and recent acute care.INTERVENTION: PIM offered patients intensive care coordination, including home visits, accompaniment to specialists, acute care follow-up, and case management from a team staffed by primary care providers, social workers, psychologists, nurses, and/or other support staff.MAIN MEASURES: Patient-reported experiences with care coordination (e.g., health goal assessment, test and appointment follow-up, Patient Assessment of Chronic Illness Care (PACIC)), access to healthcare services, provider relationships, and satisfaction.KEY RESULTS: Seven hundred fifty-nine PIM and 768 PACT patients responded to the survey (response rate 60%). Patients randomized to PIM were more likely than those in PACT to report that they were asked about their health goals (AOR=1.26; P=0.046) and that they have a VA provider whom they trust (AOR=1.35; P=0.005). PIM patients also had higher mean (SD) PACIC scores compared with PACT patients (2.91 (1.31) vs. 2.75 (1.25), respectively; P=0.022) and were more likely to report 10 out of 10 on satisfaction with primary care (AOR=1.25; P=0.048). However, other effects on coordination, access, and satisfaction did not achieve statistical significance.CONCLUSIONS: Augmenting VA's patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients' experiences with care coordination and provider relationships, but did not have a significant impact on most patient-reported access and satisfaction measures.

  View details for DOI 10.1007/s11606-019-04965-0

  View details for PubMedID 31098977

• Coordinating Care Across VA Providers and Settings: Policy and Research Recommendations from VA's State of the Art Conference. Journal of general internal medicine Cordasco, K. M., Frayne, S. M., Kansagara, D., Zulman, D. M., Asch, S. M., Burke, R. E., Post, E. P., Fihn, S. D., Klobucar, T., Meyer, L. J., Kirsh, S. R., Atkins, D. 2019

  Abstract

  Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran.

  View details for DOI 10.1007/s11606-019-04970-3

  View details for PubMedID 31098966

• Using Predictive Analytics to Guide Patient Care and Research in a National Health System. Journal of general internal medicine Nelson, K. M., Chang, E. T., Zulman, D. M., Rubenstein, L. V., Kirkland, F. D., Fihn, S. D. 2019

  View details for PubMedID 31011959

• Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields Journal of General Internal Medicine Schwartz, R., Haverfield, M. C., Brown-Johnson, C., Maitra, A., Tierney, A., Bharadwaj, S., Shaw, J. G., Azimpour, F., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019

  Abstract

  While barriers to physician wellness have been well detailed, concrete solutions are lacking.We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

  View details for DOI 10.1007/s11606-019-04913-y

• Neurologist Strategies for Optimizing the Parkinson's Disease Clinical Encounter. Journal of geriatric psychiatry and neurology Schwartz, R., Trivedi, R., Gray, C., Lorenz, K. A., Zulman, D. 2019: 891988719845509

  Abstract

  For patients with Parkinson's disease (PD), effective communication during neurology encounters is critical to ensuring the treatment plan maximizes quality of life. However, few research studies have engaged neurologists as key experts in identifying opportunities to optimize the clinical encounter. In this study, 16 neurologists from 4 clinic sites participated in hour-long semistructured interviews targeting opportunities to better address patients' quality of life needs.Neurologists identified opportunities to meet needs across 4 domains: (1) PD patient education materials and self-management tools to facilitate clinical communication; (2) techniques for improving clinical communication, including strategies for eliciting nonmotor symptoms and contextualizing symptoms to better meet patient quality of life needs; (3) addressing system-level barriers, including time constraints and the lack of an identified specialist referral network; and (4) training in how to lead difficult conversations.Neurologists identified specific barriers, and proposed solutions, to improving care delivery for patients with PD. Integrating practice tools to address quality of life needs, training neurologists in communication around end-of-life care, and strengthening referral networks for rehabilitation and psychosocial support hold promise for improving quality of life for patients with PD.

  View details for PubMedID 31046525

• Virtual Savings: Patient-Reported Time and Money Savings from a VA National Telehealth Tablet Initiative. Telemedicine journal and e-health : the official journal of the American Telemedicine Association Jacobs, J. C., Hu, J., Slightam, C., Gregory, A., Zulman, D. M. 2019

  Abstract

  Virtual care holds promise for offering services to Veterans Affairs (VA) patients who have barriers to accessing care. In 2016, the VA began issuing video-enabled tablets to Veterans with geographic, clinical, and/or social barriers to in-person care. To complement a national evaluation of system-level implementation and effectiveness of these tablets, we sought to understand whether the VA-issued tablets generated money and/or time savings for patients. We distributed a survey to 2,120 Veterans who received tablets and administered a follow-up survey 3-6 months later. The final analysis included 594 and 399 patients who responded to questions about money and time savings, respectively. We used poststratification survey weighting methods to address potential selection and nonresponse bias. In multinomial logistic regressions and logistic regressions, we examined patient characteristics associated with reported money and time savings. A majority of survey respondents reported that the tablets saved them money (89%) and time (71%). Respondents were more likely to report monetary savings if they lived at a greater distance from the VA, if they experienced travel barriers, and if they did not have a mental health condition. Respondents were more likely to report time savings if they were <45 or ≥65 years of age, employed, and reported more overall technology experience. Findings may inform policy decisions regarding patient targeting and training as VA aims to expand its use of video telehealth technology.

  View details for DOI 10.1089/tmj.2019.0179

  View details for PubMedID 31880502

• Transdisciplinary Strategies for Physician Wellness: Qualitative Insights from Diverse Fields. Journal of general internal medicine Schwartz, R., Haverfield, M. C., Brown-Johnson, C., Maitra, A., Tierney, A., Bharadwaj, S., Shaw, J. G., Azimpour, F., Thadaney Israni, S., Verghese, A., Zulman, D. M. 2019

  Abstract

  While barriers to physician wellness have been well detailed, concrete solutions are lacking.We looked to professionals across diverse fields whose work requires engagement and interpersonal connection with clients. The goal was to identify effective strategies from non-medical fields that could be applied to preserve physician wellness.We conducted semi-structured interviews with 30 professionals outside the field of clinical medicine whose work involves fostering effective connections with individuals.Professionals from diverse professions, including the protective services (e.g., police officer, firefighter), business/finance (e.g., restaurateur, salesperson), management (e.g., CEO, school principal), education, art/design/entertainment (e.g., professional musician, documentary filmmaker), community/social services (e.g., social worker, chaplain), and personal care/services (e.g., massage therapist, yoga instructor).Interviews covered strategies that professionals use to initiate and maintain relationships, practices that cultivate professional fulfillment and preserve wellness, and techniques that facilitate emotional presence during interactions. Data were coded using an inductive thematic analysis approach.Professionals identified self-care strategies at both institutional and individual levels that support wellness. Institutional-level strategies include scheduling that allows for self-care, protected time to connect with colleagues, and leadership support for debriefing after traumatic events. Individual strategies include emotionally protective distancing techniques and engagement in a bidirectional exchange that is central to interpersonal connection and professional fulfillment.In this exploratory study, the purposive sampling technique and single representative per occupation could limit the generalizability of findings.Across diverse fields, professionals employ common institutional and personal wellness strategies that facilitate meaningful engagement, support collegiality, and encourage processing after intense events. The transdisciplinary nature of these wellness strategies highlights universal underpinnings that support wellbeing in those engaging in people-oriented professions.

  View details for PubMedID 31037542

• Incorporating Theory into Practice: Reconceptualizing Exemplary Care Coordination Initiatives from the US Veterans Health Delivery System. Journal of general internal medicine McDonald, K. M., Singer, S. J., Gorin, S. S., Haggstrom, D. A., Hynes, D. M., Charns, M. P., Yano, E. M., Lucatorto, M. A., Zulman, D. M., Ong, M. K., Axon, R. N., Vogel, D., Upton, M. 2019

  Abstract

  This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation.

  View details for DOI 10.1007/s11606-019-04969-w

  View details for PubMedID 31098965

• What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION Chang, E. T., Raja, P., Stockdale, S. E., Katz, M. L., Zulman, D. M., Eng, J. A., Hedrick, K. H., Jackson, J. L., Pathak, N., Watts, B., Patton, C., Schectman, G., Asch, S. M. 2018; 6 (4): 231–37

  Abstract

  Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.

  View details for PubMedID 29102480

• Persistence of High Health Care Costs among VA Patients HEALTH SERVICES RESEARCH Yoon, J., Chee, C., Su, P., Almenoff, P., Zulman, D. M., Wagner, T. H. 2018; 53 (5): 3898–3916

  Abstract

  To examine high-cost patients in VA and factors associated with persistence in high costs over time.Secondary data for FY2008-2012.We obtained VA and Medicare utilization and cost records for VA enrollees and drew a 20 percent random sample (N = 1,028,568).We identified high-cost patients, defined as those in the top 10 percent of combined VA and Medicare costs, and determined the number of years they remained high cost over 4 years. We compared sociodemographics, clinical characteristics, and baseline utilization by number of high-cost years and conducted a discrete time survival analysis to predict high-cost persistence.Among 105,703 patients with the highest 10 percent of costs at baseline, 68 percent did not remain high cost in subsequent years, 32 percent had high costs after 1 year, and 7 percent had high costs in all four follow-up years. Mortality, which was 47 percent by end of follow-up, largely explained low persistence. The largest percentage of patients who persisted as high cost until end of follow-up was for spinal cord injury (16 percent).Most high-cost patients did not remain high cost in subsequent years, which poses challenges to providers and payers to manage utilization of these patients.

  View details for PubMedID 29862504

  View details for PubMedCentralID PMC6153161

• Engaging High-Need Patients in Intensive Outpatient Programs: A Qualitative Synthesis of Engagement Strategies. Journal of general internal medicine Zulman, D. M., O'Brien, C. W., Slightam, C., Breland, J. Y., Krauth, D., Nevedal, A. L. 2018

  Abstract

  BACKGROUND: Intensive outpatient programs address the complex medical, social, and behavioral needs of individuals who account for disproportionate healthcare costs. Despite their promise, the impact of these programs is often diminished due to patient engagement challenges (i.e., low rates of patient participation and partnership in care).OBJECTIVE: The objective of this study was to identify intensive outpatient program features and strategies that increase high-need patient engagement in these programs.DESIGN: Qualitative study.PARTICIPANTS: Twenty program leaders and clinicians from 12 intensive outpatient programs in academic, county, Veterans Affairs, community, and private healthcare settings.APPROACH: A questionnaire and semi-structured interviews were used to identify common barriers to patient engagement in intensive outpatient programs and strategies employed by programs to address these challenges. We used content analysis methods to code patient engagement barriers and strategies and to identify program features that facilitate patient engagement.KEY RESULTS: The most common barriers to patient engagement in intensive outpatient programs included physical symptoms/limitations, mental illness, care fragmentation across providers and services, isolation/lack of social support, financial insecurity, and poor social and neighborhood conditions. Patient engagement strategies included concrete services to support communication and use of recommended services, activities to foster patient trust and relationships with program staff, and counseling to build insight and problem-solving capabilities. Program features that were identified as enhancing engagement efforts included: 1) multidisciplinary teams with diverse skills, knowledge, and personalities to facilitate relationship building; 2) adequate staffing and resources to handle the demands of high-need patients; and 3) a philosophy that permitted flexibility and patient-centeredness.CONCLUSIONS: Promising clinical, interpersonal, and population-based approaches to engaging high-need patients frequently deviate from standard practice and require creative and proactive staff with adequate time, resources, and flexibility to address patients' needs on patients' terms.

  View details for PubMedID 30097977

• Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study HEALTH SERVICES RESEARCH Rosland, A., Wong, E., Maciejewski, M., Zulman, D., Piegari, R., Fihn, S., Nelson, K. 2018; 53 (4): 2503–22

  Abstract

  To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality.Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010.Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012.Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013.In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP < 160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics.Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.

  View details for PubMedID 29154464

  View details for PubMedCentralID PMC6052009

• Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization A Randomized Quality Improvement Trial ANNALS OF INTERNAL MEDICINE Yoon, J., Chang, E., Rubenstein, L., Park, A., Zulman, D. M., Stockdale, S., Ong, M. K., Atkins, D., Schectman, G., Asch, S. M. 2018; 168 (12): 846-+

  Abstract

  Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization.To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients.Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526).5 U.S. Department of Veterans Affairs (VA) medical centers.Primary care patients at high risk for hospitalization who had a recent acute care episode.Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts.Utilization and costs (including intensive management program expenses) 12 months before and after randomization.2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization.Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed.High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs.Veterans Health Administration Primary Care Services.

  View details for PubMedID 29868706

• Development of a web-based toolkit to support improvement of care coordination in primary care TRANSLATIONAL BEHAVIORAL MEDICINE Ganz, D. A., Barnard, J. M., Smith, N. Y., Miake-Lye, I. M., Delevan, D. M., Simon, A., Rose, D. E., Stockdale, S. E., Chang, E. T., Noel, P. H., Finley, E. P., Lee, M. L., Zulman, D. M., Cordasco, K. M., Rubenstein, L. V. 2018; 8 (3): 492–502

  Abstract

  Promising practices for the coordination of chronic care exist, but how to select and share these practices to support quality improvement within a healthcare system is uncertain. This study describes an approach for selecting high-quality tools for an online care coordination toolkit to be used in Veterans Health Administration (VA) primary care practices. We evaluated tools in three steps: (1) an initial screening to identify tools relevant to care coordination in VA primary care, (2) a two-clinician expert review process assessing tool characteristics (e.g. frequency of problem addressed, linkage to patients' experience of care, effect on practice workflow, and sustainability with existing resources) and assigning each tool a summary rating, and (3) semi-structured interviews with VA patients and frontline clinicians and staff. Of 300 potentially relevant tools identified by searching online resources, 65, 38, and 18 remained after steps one, two and three, respectively. The 18 tools cover five topics: managing referrals to specialty care, medication management, patient after-visit summary, patient activation materials, agenda setting, patient pre-visit packet, and provider contact information for patients. The final toolkit provides access to the 18 tools, as well as detailed information about tools' expected benefits, and resources required for tool implementation. Future care coordination efforts can benefit from systematically reviewing available tools to identify those that are high quality and relevant.

  View details for PubMedID 29800397

• Engaging high-risk patients in intensive care coordination programs: the engagement through CARInG framework TRANSLATIONAL BEHAVIORAL MEDICINE O'Brien, C. W., Breland, J. Y., Slightam, C., Nevedal, A., Zulman, D. M. 2018; 8 (3): 351–56

  Abstract

  Intensive outpatient care programs (IOCPs) have shown promise for high-risk patients who account for disproportionate acute care utilization and costs. These programs typically address medical, behavioral, and social needs through intensive case management, health care navigation, coordination, and access to a range of social and community services. However, the value of these programs is often limited by patient engagement challenges (i.e., difficulty engaging patients in self-care, decision-making, and follow-up with recommended services). The purpose of this study was to develop a framework for engaging high-risk patients with complex medical, behavioral, and social needs in IOCPs. We conducted a qualitative study with 20 leaders and clinicians (e.g., physicians, nurses, psychologists, case workers) from 12 IOCPs affiliated with diverse settings (academic hospitals, county healthcare systems, Veterans Affairs facilities, community health centers, and private health systems). After completing a brief survey, participants were asked to describe how their program conceptualizes patient engagement and to describe characteristics of highly engaged patients. We used conventional content analysis methods to analyze qualitative data. Three domains of engagement were identified and are summarized in the Engagement Through CARInG Framework: Communication and actions to improve health; Relationships built on trust in IOCP staff; and Insight and goal-setting ability. Qualitative findings illustrate the spectrum and interrelatedness of these domains. The Engagement Through CARInG Framework can guide interventions that aim to enhance self-care and improve care coordination for high-risk patients with complex medical, behavioral, and social needs.

  View details for PubMedID 29800395

• An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation CONTEMPORARY CLINICAL TRIALS Chang, E. T., Zulman, D. M., Asch, S. M., Stockdale, S. E., Yoon, J., Ong, M. K., Lee, M., Simon, A., Atkins, D., Schectman, G., Kirsh, S. R., Rubenstein, L. V., PIM Executive Comm Demonstrati 2018; 69: 65–75

  Abstract

  Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization.Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement.VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor.This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.

  View details for PubMedID 29698772

• FOSTERING PATIENT-PROVIDER CONNECTION DURING CLINICAL ENCOUNTERS: INSIGHTS FROM NON-MEDICAL PROFESSIONALS Schwartz, R., Brown-Johnson, C., Haverfield, M. C., Tierney, A. A., Bharadwaj, S., Zionts, D. L., Romero, I., Piccininni, G., Shaw, J. G., Thadaney, S., Azimpour, F., Verghese, A., Zulman, D. M. SPRINGER. 2018: S200

  View details for Web of Science ID 000442641400264

• A Natural Language Processing System That Links Medical Terms in Electronic Health Record Notes to Lay Definitions: System Development Using Physician Reviews JOURNAL OF MEDICAL INTERNET RESEARCH Chen, J., Druhl, E., Ramesh, B., Houston, T. K., Brandt, C. A., Zulman, D. M., Vimalananda, V. G., Malkani, S., Yu, H. 2018; 20 (1): e26

  Abstract

  Many health care systems now allow patients to access their electronic health record (EHR) notes online through patient portals. Medical jargon in EHR notes can confuse patients, which may interfere with potential benefits of patient access to EHR notes.The aim of this study was to develop and evaluate the usability and content quality of NoteAid, a Web-based natural language processing system that links medical terms in EHR notes to lay definitions, that is, definitions easily understood by lay people.NoteAid incorporates two core components: CoDeMed, a lexical resource of lay definitions for medical terms, and MedLink, a computational unit that links medical terms to lay definitions. We developed innovative computational methods, including an adapted distant supervision algorithm to prioritize medical terms important for EHR comprehension to facilitate the effort of building CoDeMed. Ten physician domain experts evaluated the user interface and content quality of NoteAid. The evaluation protocol included a cognitive walkthrough session and a postsession questionnaire. Physician feedback sessions were audio-recorded. We used standard content analysis methods to analyze qualitative data from these sessions.Physician feedback was mixed. Positive feedback on NoteAid included (1) Easy to use, (2) Good visual display, (3) Satisfactory system speed, and (4) Adequate lay definitions. Opportunities for improvement arising from evaluation sessions and feedback included (1) improving the display of definitions for partially matched terms, (2) including more medical terms in CoDeMed, (3) improving the handling of terms whose definitions vary depending on different contexts, and (4) standardizing the scope of definitions for medicines. On the basis of these results, we have improved NoteAid's user interface and a number of definitions, and added 4502 more definitions in CoDeMed.Physician evaluation yielded useful feedback for content validation and refinement of this innovative tool that has the potential to improve patient EHR comprehension and experience using patient portals. Future ongoing work will develop algorithms to handle ambiguous medical terms and test and evaluate NoteAid with patients.

  View details for PubMedID 29358159

• "It's a disease of families": Neurologists' insights on how to improve communication and quality of life for families of Parkinson's disease patients. Chronic illness Schwartz, R., Zulman, D., Gray, C., Goldstein, M. K., Trivedi, R. 2018: 1742395318799852

  Abstract

  Objectives Parkinson's disease presents an evolving challenge for patients and families due to an unpredictable disease trajectory and symptoms that complicate social interactions. In this study, we explore neurologists' perspectives on the challenges Parkinson's disease presents for families and the strategies they use to improve communication and quality of life. Methods We conducted hour-long semi-structured interviews with 16 neurologists at 4 care delivery institutions in the San Francisco Bay Area, focusing on techniques neurologists use to support families through the Parkinson's disease journey. Results Neurologists identified strategies for addressing caregiver-patient disagreements around symptom accuracy and negotiating driving safety. Family education is needed to contextualize patient symptoms and to identify psychosocial support resources. Unmet caregiver needs remain, particularly in the form of psychosocial support, respite care and support for unequal gender dynamics in the Parkinson's disease caregiving experience. Discussion Family members of Parkinson's disease patients face unique caregiving and interpersonal challenges due to the nature of the disease. Targeted education and structural support are needed to alleviate current burdens and allow for improved patient- and family-centered care.

  View details for PubMedID 30208725

• Adjustment for Variable Adherence Under Hierarchical Structure: Instrumental Variable Modeling Through Compound Residual Inclusion MEDICAL CARE Holmes, T. H., Zulman, D. M., Kushida, C. A. 2017; 55 (12): E120–E130

  Abstract

  Variable adherence to assigned conditions is common in randomized clinical trials.A generalized modeling framework under longitudinal data structures is proposed for regression estimation of the causal effect of variable adherence on outcome, with emphasis upon adjustment for unobserved confounders.A nonlinear, nonparametric random-coefficients modeling approach is described. Estimates of local average treatment effects among compliers can be obtained simultaneously for all assigned conditions to which participants are randomly assigned within the trial. Two techniques are combined to address time-varying and time-invariant unobserved confounding-residual inclusion and nonparametric random-coefficients modeling. Together these yield a compound, 2-stage residual inclusion, instrumental variables model.The proposed method is illustrated through a set of simulation studies to examine small-sample bias and in application to neurocognitive outcome data from a large, multicenter, randomized clinical trial in sleep medicine for continuous positive airway pressure treatment of obstructive sleep apnea.Results of simulation studies indicate that, relative to a standard comparator, the proposed estimator reduces bias in estimates of the causal effect of variable adherence. Bias reductions were greatest at higher levels of residual variance and when confounders were time varying.The proposed modeling framework is flexible in the distributions of outcomes that can be modeled, applicable to repeated measures longitudinal structures, and provides effective reduction of bias due to unobserved confounders.

  View details for PubMedID 29135775

  View details for PubMedCentralID PMC4942413

• Intensive Outpatient Program Effects on High-need Patients' Access, Continuity, Coordination, and Engagement. Medical care Wu, F. M., Slightam, C. A., Wong, A. C., Asch, S. M., Zulman, D. M. 2017

  Abstract

  OBJECTIVE: The intensive and varied services required by high-need patients have inspired a number of new care delivery models; however, evidence of their effectiveness is mixed. This study evaluated whether augmenting a patient-centered medical home (PCMH) with intensive outpatient management enhances high-need patients' care processes.RESEARCH DESIGN: Retrospective analysis using differences-in-differences and chi tests.SUBJECTS: Of 545 high-need patients receiving PCMH care, 140 were previously randomly selected for the intensive outpatient management program; the remaining received usual care.MEASURES: We evaluated program effects on care continuity (proportion of primary care visits with assigned primary care physician); access (proportion of telephone visits out of all primary care encounters, missed appointment rate); care coordination (rate of follow-up after hospital discharge, new telehealth enrollment); and patient engagement (rates of online personal health record registration, advance directive completion).RESULTS: Compared with patients receiving usual care, patients enrolled in intensive management experienced a 5.9% increase in proportion of primary care visits with an assigned primary care physician (P<0.001) and a 17.9% increase in proportion of telephone-based visits (P<0.001). Patients in the program had 7.5% higher rates of telehealth referral (P=0.01), 17.2% higher rates of advance directive completion (P<0.01), and 9.3% higher rates of personal health record registration (P=0.02). There was no effect on missed appointments or posthospital discharge visit rates.CONCLUSIONS: Augmenting a PCMH with intensive outpatient management may have positive effects on primary care processes related to continuity, access, coordination, and patient engagement.

  View details for DOI 10.1097/MLR.0000000000000833

  View details for PubMedID 29087980

• The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study: study protocol for a randomized trial. Trials Heisler, M., Burgess, J., Cass, J., Chardos, J. F., Guirguis, A. B., Jeffery, S. M., Strohecker, L. A., Tremblay, A. S., Wu, W., Zulman, D. M. 2017; 18 (1): 239-?

  Abstract

  Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found in efficacy trials to help adults with diabetes improve their self-management and achieve short-term gains in clinical and patient-centered outcomes. In order to translate this evidence to system-level interventions, there is a need for large-scale, pragmatic trials that examine the effectiveness, implementation, and costs of SMAs and reciprocal peer support across diverse settings.The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study is a multisite, cluster randomized trial that is evaluating the effectiveness and implementation of SMAs with and without an additional reciprocal Peer-to-Peer (P2P) support program, when compared to usual care. The P2P program comprises periodic peer support group sessions and telephone contact between SMA participant pairs to promote more effective diabetes self-management. We will examine outcomes across three different treatment groups: (1) SMAs, (2) SMAs plus P2P, and (3) usual care. We will collect and analyze data over a 2.5-year implementation period at five geographically diverse Veterans Affairs (VA) health systems. The primary outcome is the relative change in hemoglobin A1c over time. Secondary outcomes are changes in systolic blood pressure, antihypertensive medication use, statin use, and insulin initiation over the study period. The unit of analysis is the individual, adjusted by the individual's SMA group (the cluster). We will use mixed methods to rigorously evaluate processes and costs of implementing these programs in each of the clinic settings.We hypothesize that patients will experience improved outcomes immediately following participation in SMAs and that augmenting SMAs with reciprocal peer support will help to maintain these gains over time. The results of this study will be among the first to examine the effects of diabetes SMAs alone and in conjunction with P2P in a range of real-life clinical settings. In addition, the study will provide important information on contextual factors associated with successful program implementation.ClinicalTrials.gov, ID: NCT02132676 . Registered on 21 August 2013.

  View details for DOI 10.1186/s13063-017-1959-7

  View details for PubMedID 28549471

• Comparative Effectiveness of Wellness Programs: Impact of Incentives on Healthcare Costs for Obese Enrollees. American journal of preventive medicine Zivin, K., Sen, A., Plegue, M. A., Maciejewski, M. L., Segar, M. L., AuYoung, M., Miller, E. M., Janney, C. A., Zulman, D. M., Richardson, C. R. 2017; 52 (3): 347-352

  Abstract

  Employee wellness programs show mixed effectiveness results. This study examined the impact of an insurer's lifestyle modification program on healthcare costs of obese individuals.This nonrandomized comparative effectiveness study evaluated changes in healthcare costs for participants in two incentivized programs, an Internet-mediated pedometer-based walking program (WalkingSpree, n=7,594) and an in-person weight-loss program (Weight Watchers, n=5,764). The primary outcome was the change in total healthcare costs from the baseline year to the year after program participation. Data were collected from 2009 to 2011 and the analysis was done in 2014-2015.After 1 year, unadjusted mean costs decreased in both programs, with larger decreases for Weight Watchers participants than WalkingSpree participants (-$1,055.39 vs -$577.10, p=0.019). This difference was driven by higher rates of women in Weight Watchers, higher baseline total costs among women, and a greater decrease in costs for women in Weight Watchers (-$1,037.60 vs -$388.50, p=0.014). After adjustment for baseline costs, there were no differences by program or gender.Comparable cost reductions in both programs suggest that employers may want to offer more than one choice of incentivized wellness program with monitoring to meet the diverse needs of employees.

  View details for DOI 10.1016/j.amepre.2016.10.006

  View details for PubMedID 27866825

• "I had to change so much in my life to live with my new limitations": Multimorbid patients' descriptions of their most bothersome chronic conditions. Chronic illness Slightam, C. A., Brandt, K., Jenchura, E. C., Lewis, E. T., Asch, S. M., Zulman, D. M. 2017: 1742395317699448-?

  Abstract

  Objective To characterize diseases that are described as most bothersome by individuals with multiple chronic conditions and to identify themes that characterize their experiences with their most bothersome condition. Methods In a survey of patients at an academic center and a Veterans Affairs hospital, we asked individuals with multiple chronic conditions to identify their most bothersome chronic condition and describe why it is challenging. Standard content analysis methods were used to code responses and identify themes reflecting characteristics of most bothersome conditions. Results The most commonly cited bothersome conditions were chronic pain (52%), diabetes (43%), post-traumatic stress disorder (25%), heart failure (24%), and lung problems (20%). Conditions were described as most bothersome due to: (a) impact on function and quality of life (e.g. active symptoms, activity limitations), (b) health consequences or sequelae (e.g. risk of complications), and (c) challenges associated with treatment or self-management. Patterns of theme dominance varied for conditions with different characteristics. Discussion The conditions that patients with multiple chronic conditions identify as most bothersome vary depending on individuals' diseases and their health-related preferences and priorities. Ascertaining patients' most bothersome conditions and associated challenges, stress, and frustrations may help ensure that management decisions are aligned with patient preferences and priorities.

  View details for DOI 10.1177/1742395317699448

  View details for PubMedID 28449592

• Alternative Strategies to Inpatient Hospitalization for Acute Medical Conditions: A Systematic Review. JAMA internal medicine Conley, J., O'Brien, C. W., Leff, B. A., Bolen, S., Zulman, D. 2016; 176 (11): 1693-1702

  Abstract

  Determining innovative approaches that better align health needs to the appropriate setting of care remains a key priority for the transformation of US health care; however, to our knowledge, no comprehensive assessment exists of alternative management strategies to hospital admission for acute medical conditions.To examine the effectiveness, safety, and cost of managing acute medical conditions in settings outside of a hospital inpatient unit.MEDLINE, Scopus, CINAHL, and the Cochrane Database of Systematic Reviews (January 1995 to February 2016) were searched for English-language systematic reviews that evaluated alternative management strategies to hospital admission. Two investigators extracted data independently on trial design, eligibility criteria, clinical outcomes, patient experience, and health care costs. The quality of each review was assessed using the revised AMSTAR tool (R-AMSTAR) and the strength of evidence from primary studies was graded according to the Oxford Centre for Evidence-Based Medicine.Twenty-five systematic reviews (representing 123 primary studies) met inclusion criteria. For outpatient management strategies, several acute medical conditions had no significant difference in mortality, disease-specific outcomes, or patient satisfaction compared with inpatient admission. For quick diagnostic units, the evidence was more limited but did demonstrate low mortality rates and high patient satisfaction. For hospital-at-home, a variety of acute medical conditions had mortality rates, disease-specific outcomes, and patient and caregiver satisfaction that were either improved or no different compared with inpatient admission. For observation units, several acute medical conditions were found to have no difference in mortality, a decreased length of stay, and improved patient satisfaction compared to inpatient admission; results for some conditions were more limited. Across all alternative management strategies, cost data were heterogeneous but showed near-universal savings when assessed.For low-risk patients with a range of acute medical conditions, evidence suggests that alternative management strategies to inpatient care can achieve comparable clinical outcomes and patient satisfaction at lower costs. Further study and application of such opportunities for health system redesign is warranted.

  View details for DOI 10.1001/jamainternmed.2016.5974

  View details for PubMedID 27695822

• How Veterans With Post-Traumatic Stress Disorder and Comorbid Health Conditions Utilize eHealth to Manage Their Health Care Needs: A Mixed-Methods Analysis JOURNAL OF MEDICAL INTERNET RESEARCH Whealin, J. M., Jenchura, E. C., Wong, A. C., Zulman, D. M. 2016; 18 (10): 175-190

  Abstract

  Mental health conditions are prevalent among US veterans and pose a number of self-management and health care navigation challenges. Post-Traumatic Stress Disorder (PTSD) with comorbid chronic medical conditions (CMCs) is especially common, in both returning Iraq or Afghanistan and earlier war-era veterans. Patient-facing electronic health (eHealth) technology may offer innovative strategies to support these individuals' needs.This study was designed to identify the types of eHealth tools that veterans with PTSD and comorbid CMCs use, understand how they currently use eHealth technology to self-manage their unique health care needs, and identify new eHealth resources that veterans feel would empower them to better manage their health care.A total of 119 veterans with PTSD and at least one CMC who have used the electronic personal health record system of the US Department of Veterans Affairs (VA) responded to a mailed survey about their chronic conditions and preferences related to the use of technology. After the survey, 2 focus groups, stratified by sex, were conducted with a subgroup of patients to explore how veterans with PTSD and comorbid CMCs use eHealth technology to support their complex health care needs. Focus groups were transcribed verbatim and analyzed using standard content analysis methods for coding textual data, guided by the "Fit between Individual, Task, and Technology" framework.Survey respondents had a mean age of 64.0 (SD 12.0) years, 85.1% (97/114) were male, 72.4% (84/116) were white, and 63.1% (70/111) had an annual household income of < US $50,000. Mean score on a measure of eHealth literacy was 27.7 (SD 9.8). Of the respondents, 44.6% (50/112) used health-related technology 1 to 3 times per month and 21.4% (24/112) used technology less than once per month. Veterans reported using technology most often to search for health information (78.9%, 90/114), communicate with providers (71.1%, 81/114), and track medications (64.9%, 74/114). Five major themes emerged that describe how eHealth technology influences veterans with PTSD and comorbid CMCs: (1) interactions with social support, (2) condition management, (3) access to and communication with providers, (4) information access, and (5) coordination of care.The "Fit between Individual, Task, and Technology" model provided a useful framework to examine the clinical tasks that arose for veterans and their resourceful adoption of eHealth tools. This study suggests that veterans who use the Web are eager to incorporate eHealth technology into their care and self-management activities. Findings illustrate a number of ways in which the VA and eHealth technology developers can refine existing applications, develop new resources, and better promote tools that address challenges experienced by veterans with PTSD and comorbid CMCs.

  View details for DOI 10.2196/jmir.5594

  View details for Web of Science ID 000387985700014

  View details for PubMedID 27784650

• Patient-Facing Mobile Apps to Treat High-Need, High-Cost Populations: A Scoping Review JMIR MHEALTH AND UHEALTH Singh, K., Drouin, K., Newmark, L. P., Filkins, M., Silvers, E., Bain, P. A., Zulman, D. M., Lee, J., Rozenblum, R., Pabo, E., Landman, A., Klinger, E. V., Bates, D. W. 2016; 4 (4)

  Abstract

  Self-management is essential to caring for high-need, high-cost (HNHC) populations. Advances in mobile phone technology coupled with increased availability and adoption of health-focused mobile apps have made self-management more achievable, but the extent and quality of the literature supporting their use is not well defined.The purpose of this review was to assess the breadth, quality, bias, and types of outcomes measured in the literature supporting the use of apps targeting HNHC populations.Data sources included articles in PubMed and MEDLINE (National Center for Biotechnology Information), EMBASE (Elsevier), the Cochrane Central Register of Controlled Trials (EBSCO), Web of Science (Thomson Reuters), and the NTIS (National Technical Information Service) Bibliographic Database (EBSCO) published since 2008. We selected studies involving use of patient-facing iOS or Android mobile health apps. Extraction was performed by 1 reviewer; 40 randomly selected articles were evaluated by 2 reviewers to assess agreement.Our final analysis included 175 studies. The populations most commonly targeted by apps included patients with obesity, physical handicaps, diabetes, older age, and dementia. Only 30.3% (53/175) of the apps studied in the reviewed literature were identifiable and available to the public through app stores. Many of the studies were cross-sectional analyses (42.9%, 75/175), small (median number of participants=31, interquartile range 11.0-207.2, maximum 11,690), or performed by an app's developers (61.1%, 107/175). Of the 175 studies, only 36 (20.6%, 36/175) studies evaluated a clinical outcome.Most apps described in the literature could not be located on the iOS or Android app stores, and existing research does not robustly evaluate the potential of mobile apps. Whereas apps may be useful in patients with chronic conditions, data do not support this yet. Although we had 2-3 reviewers to screen and assess abstract eligibility, only 1 reviewer abstracted the data. This is one limitation of our study. With respect to the 40 articles (22.9%, 40/175) that were assigned to 2 reviewers (of which 3 articles were excluded), inter-rater agreement was significant on the majority of items (17 of 30) but fair-to-moderate on others.

  View details for DOI 10.2196/mhealth.6445

  View details for Web of Science ID 000391888600003

  View details for PubMedID 27993761

  View details for PubMedCentralID PMC5206484

• Using Electronic Health Record Data to Measure Care Quality for Individuals with Multiple Chronic Medical Conditions. Journal of the American Geriatrics Society Bayliss, E. A., McQuillan, D. B., Ellis, J. L., Maciejewski, M. L., Zeng, C., Barton, M. B., Boyd, C. M., Fortin, M., Ling, S. M., Tai-Seale, M., Ralston, J. D., Ritchie, C. S., Zulman, D. M. 2016; 64 (9): 1839-1844

  Abstract

  To inform the development of a data-driven measure of quality care for individuals with multiple chronic conditions (MCCs) derived from an electronic health record (EHR).Qualitative study using focus groups, interactive webinars, and a modified Delphi process.Research department within an integrated delivery system.The webinars and Delphi process included 17 experts in clinical geriatrics and primary care, health policy, quality assessment, health technology, and health system operations. The focus group included 10 individuals aged 70-87 with three to six chronic conditions selected from a random sample of individuals aged 65 and older with three or more chronic medical conditions.Through webinars and the focus group, input was solicited on constructs representing high-quality care for individuals with MCCs. A working list was created of potential measures representing these constructs. Using a modified Delphi process, experts rated the importance of each possible measure and the feasibility of implementing each measure using EHR data.High-priority constructs reflected processes rather than outcomes of care. High-priority constructs that were potentially feasible to measure included assessing physical function, depression screening, medication reconciliation, annual influenza vaccination, outreach after hospital admission, and documented advance directives. High-priority constructs that were less feasible to measure included goal setting and shared decision-making, identifying drug-drug interactions, assessing social support, timely communication with patients, and other aspects of good customer service. Lower-priority domains included pain assessment, continuity of care, and overuse of screening or laboratory testing.High-quality MCC care should be measured using meaningful process measures rather than outcomes. Although some care processes are currently extractable from electronic data, capturing others will require adapting and applying technology to encourage holistic, person-centered care.

  View details for DOI 10.1111/jgs.14248

  View details for PubMedID 27385077

• Opportunities to Enhance Value-Related Research in the US Department of Veterans Affairs JOURNAL OF GENERAL INTERNAL MEDICINE Wagner, T. H., Burstin, H., Frakt, A. B., Krein, S. L., Lorenz, K., Maciejewski, M. L., Pizer, S. D., Weiner, M., Yoon, J., Zulman, D. M., Asch, S. M. 2016; 31: 78-83

  View details for DOI 10.1007/s11606-015-3538-5

  View details for Web of Science ID 000373159900014

  View details for PubMedCentralID PMC4803679

• Better health, less spending: Redesigning the transition from pediatric to adult healthcare for youth with chronic illness. Healthcare (Amsterdam, Netherlands) Vaks, Y., Bensen, R., Steidtmann, D., Wang, T. D., Platchek, T. S., Zulman, D. M., Malcolm, E., Milstein, A. 2016; 4 (1): 57-68

  Abstract

  Adolescents and young adults (AYA) with serious chronic illnesses face costly and dangerous gaps in care as they transition from pediatric to adult health systems. New, financially sustainable approaches to transition are needed to close these gaps. We designed a new transition model for adolescents and young adults with a variety of serious chronic conditions. Our explicit goal was to build a model that would improve the value of care for youth 15-25 years of age undergoing this transition. The design process incorporated a review, analysis, and synthesis of relevant clinical and health services research; stakeholder interviews; and observations of high-performing healthcare systems. We identified three major categories of solutions for a safer and lower cost transition to adult care: (1) building and supporting self-management during the critical transition; (2) engaging receiving care; and (3) providing checklist-driven guide services during the transition. We propose that implementation of a program with these interventions would have a positive impact on all three domains of the triple aim - improving health, improving the experience of care, and reducing per capita healthcare cost. The transition model provides a general framework as well as suggestions for specific interventions. Pilot tests to assess the model's ease of implementation, clinical effects, and financial impact are currently underway.

  View details for DOI 10.1016/j.hjdsi.2015.09.001

  View details for PubMedID 27001100

  View details for PubMedCentralID PMC4805882

• Key ingredients for implementing intensive outpatient programs within patient-centered medical homes: A literature review and qualitative analysis. Healthcare (Amsterdam, Netherlands) Breland, J. Y., Asch, S. M., Slightam, C., Wong, A., Zulman, D. M. 2016; 4 (1): 22-29

  Abstract

  Intensive outpatient programs aim to transform care while conserving resources for high-need, high-cost patients, but little is known about factors that influence their implementation within patient-centered medical homes (PCMHs).In this mixed-methods study, we reviewed the literature to identify factors affecting intensive outpatient program implementation, then used semi-structured interviews to determine how these factors influenced the implementation of an intensive outpatient program within the Veterans Affairs' (VA) PCMH. Interviewees included facility leadership and clinical staff who were involved in a pilot Intensive Management Patient Aligned Care Team (ImPACT) intervention for high-need, high-cost VA PCMH patents. We classified implementation factors in the literature review and qualitative analysis using the Consolidated Framework for Implementation Research (CFIR).The literature review (n=9 studies) and analyses of interviews (n=15) revealed key implementation factors in three CFIR domains. First, the Inner Setting (i.e., the organizational and PCMH environment), mostly enabled implementation through a culture of innovation, good networks and communication, and positive tension for change. Second, Characteristics of Individuals, including creativity, flexibility, and interpersonal skills, allowed program staff to augment existing PCMH services. Finally, certain Intervention Characteristics (e.g., adaptability) enabled implementation, while others (e.g., complexity) generated implementation barriers.Resources and structural features common to PCMHs can facilitate implementation of intensive outpatient programs, but program success is also dependent on staff creativity and flexibility, and intervention adaptations to meet patient and organizational needs.Established PCMHs likely provide resources and environments that permit accelerated implementation of intensive outpatient programs.V.

  View details for DOI 10.1016/j.hjdsi.2015.12.005

  View details for PubMedID 27001095

• Adjustment for Variable Adherence Under Hierarchical Structure: Instrumental Variable Modeling Through Compound Residual Inclusion. Medical care Holmes, T. H., Zulman, D. M., Kushida, C. A. 2016: -?

  Abstract

  Variable adherence to assigned conditions is common in randomized clinical trials.A generalized modeling framework under longitudinal data structures is proposed for regression estimation of the causal effect of variable adherence on outcome, with emphasis upon adjustment for unobserved confounders.A nonlinear, nonparametric random-coefficients modeling approach is described. Estimates of local average treatment effects among compliers can be obtained simultaneously for all assigned conditions to which participants are randomly assigned within the trial. Two techniques are combined to address time-varying and time-invariant unobserved confounding-residual inclusion and nonparametric random-coefficients modeling. Together these yield a compound, 2-stage residual inclusion, instrumental variables model.The proposed method is illustrated through a set of simulation studies to examine small-sample bias and in application to neurocognitive outcome data from a large, multicenter, randomized clinical trial in sleep medicine for continuous positive airway pressure treatment of obstructive sleep apnea.Results of simulation studies indicate that, relative to a standard comparator, the proposed estimator reduces bias in estimates of the causal effect of variable adherence. Bias reductions were greatest at higher levels of residual variance and when confounders were time varying.The proposed modeling framework is flexible in the distributions of outcomes that can be modeled, applicable to repeated measures longitudinal structures, and provides effective reduction of bias due to unobserved confounders.

  View details for PubMedID 26765149

  View details for PubMedCentralID PMC4942413

• Transforming Care for Complex Patients: Addressing Interconnected Medical, Social, and Behavioral Challenges. Journal of general internal medicine Zulman, D. M., Grant, R. W. 2016; 31 (3): 263–64

  View details for PubMedID 26631098

  View details for PubMedCentralID PMC4762822

• Health Care Utilization Patterns Among High-Cost VA Patients With Mental Health Conditions. Psychiatric services Hunter, G., Yoon, J., Blonigen, D. M., Asch, S. M., Zulman, D. M. 2015; 66 (9): 952-958

  Abstract

  To inform development of intensive management programs for high-cost patients, this study investigated the relationship between psychiatric diagnoses and patterns of health care utilization among high-cost patients in the Department of Veterans Affairs (VA) health care system.The costliest 5% of patients who received care in the VA in fiscal year 2010 were assigned to five mutually exclusive hierarchical groups on the basis of diagnosis codes: no mental health condition, serious mental illness, substance use disorder, posttraumatic stress disorder (PTSD), and depression. Multivariable linear regression was used to examine associations between diagnostic groups and use of mental health and non-mental health care and costs of care, with adjustment for sociodemographic characteristics. The proportion of costs generated by mental health care was estimated for each group.Among 261,515 high-cost VA patients, rates of depression, substance use disorder, PTSD, and serious mental illness were 29%, 20%, 17%, and 13%, respectively. Individuals in the serious mental illness and substance use disorder groups were younger and had fewer chronic general medical conditions and higher adjusted rates of mental health care utilization; they also had a greater proportion of costs generated by mental health care (41% and 31%, respectively) compared with individuals in the PTSD and depression groups (18% and 11%, respectively).Optimal management of high-risk, high-cost patients may require stratification by psychiatric diagnoses, with integrated care models for patients with multiple chronic conditions and comorbid mental health conditions and intensive mental health services for patients whose primary needs stem from mental health conditions.

  View details for DOI 10.1176/appi.ps.201400286

  View details for PubMedID 25930040

• Association Between Acute Medical Exacerbations and Consuming or Producing Web-Based Health Information: Analysis From Pew Survey Data JOURNAL OF MEDICAL INTERNET RESEARCH Gidwani, R., Zulman, D. 2015; 17 (6)

  Abstract

  The Internet is an increasingly important resource for individuals who seek information from both health professionals and peers. While the demographic and health characteristics of persons who use health information technology has been well described, less is known about the relationship between these health characteristics and level of engagement with health information technology. Even less is known about whether persons who produce Web-based health information differ in health status from persons who consume such content.We explored the health characteristics of persons who engage with the Internet for the purposes of consuming or producing Web-based health information, and specifically, whether healthier versus sicker persons engage with health information technology in different ways.We analyzed data from the 2012 Pew Health survey, a landline and cell phone survey of 3104 adults in the United States. Using multiple logistic regression with sampling weights, we examined the association between sociodemographic and health characteristics and the consumption or production of Web-based health information. Sociodemographic variables included age, sex, race, and education. Health characteristics included self-reported health status, presence of chronic condition(s), and having an acute medical exacerbation. Acute medical exacerbations were defined as an emergency department visit, hospitalization, or other serious medical emergency in the last 12 months.The majority of the sample reported good or excellent health (79.7%), although 50.3% reported having at least one chronic condition. About a fifth (20.2%) of the sample experienced an acute medical exacerbation in the past year. Education was the sociodemographic characteristic most strongly associated with consuming Web-based health information. The strongest health-related predictors of consuming Web-based health information were an acute medical exacerbation (OR 2.39, P<.001) and having a chronic condition (OR 1.54, P=.007). Having an acute medical exacerbation was the only predictor of producing Web-based health information (OR 1.97, P=.003). All participants, regardless of health status, were most interested in Web-based health information regarding diseases or medical problems. However, persons with acute medical exacerbations were more likely to seek Web-based health information regarding medical tests, procedures, and drugs compared to persons without acute medical exacerbations.Producers of Web-based health information differ from consumers of this information in important health characteristics that could skew the content of peer-generated Web-based health information and overrepresent the experiences of persons with acute medical exacerbations. Providers may have a role to play in directing patients towards high-quality, easy-to-understand online information, especially information regarding treatments and procedures.

  View details for DOI 10.2196/jmir.3801

  View details for Web of Science ID 000356819800012

  View details for PubMedID 26104000

• Racial Differences in Chronic Conditions and Sociodemographic Characteristics Among High-Utilizing Veterans. Journal of racial and ethnic health disparities Breland, J. Y., Chee, C. P., Zulman, D. M. 2015; 2 (2): 167-175

  Abstract

  African-Americans are disproportionally represented among high-risk, high-utilizing patients. To inform program development for this vulnerable population, the current study describes racial variation in chronic conditions and sociodemographic characteristics among high-utilizing patients in the Veterans Affairs Healthcare System (VA).We identified the 5 % most costly Veterans who used inpatient or outpatient care at the VA during fiscal year 2010 (N = 237,691) based on costs of inpatient and outpatient care, pharmacy services, and VA-sponsored contract care. Patient costs and characteristics were abstracted from VA outpatient and inpatient data files. Racial differences in sociodemographic characteristics (age, sex, marital support, homelessness, and health insurance status) were assessed with chi-square tests. Racial differences in 32 chronic condition diagnoses were calculated as relative risk ratios.African-Americans represented 21 % of high-utilizing Veterans. African-Americans had higher rates of homelessness (26 vs. 10 %, p < 0.001) and lower rates of supplemental health insurance (44 vs. 58 %, p < 0.001). The mean number of chronic conditions was similar across race. However, there were racial differences in the prevalence of specific chronic conditions, including a higher prevalence of HIV/AIDS (95 % confidence interval (CI) 4.86, 5.50) and schizophrenia (95 % CI 1.94, 2.07) and a lower prevalence of ischemic heart disease (95 % CI 0.57, 0.59) and bipolar disorder (95 % CI 0.78, 0.85) among African-American high-utilizing Veterans.Racial disparities among high-utilizing Veterans may differ from those found in the general population. Interventions should devote attention to social, environmental, and mental health issues in order to reduce racial disparities in this vulnerable population.

  View details for DOI 10.1007/s40615-014-0060-0

  View details for PubMedID 26863335

• The Effect of Medical Comorbidities on Male and Female Veterans' Use of Psychotherapy for PTSD. Medical care Breland, J. Y., Greenbaum, M. A., Zulman, D. M., Rosen, C. S. 2015; 53 (4): S120-7

  Abstract

  Posttraumatic stress disorder (PTSD) is associated with an increased risk for medical comorbidities that may prevent participation in psychotherapy. The present study investigated whether medical comorbidities were associated with lower initiation rates and fewer psychotherapy visits for PTSD. Because women are more likely to initiate psychotherapy after traumatic events, we also assessed whether relationships were weaker among women.Veterans (N=482, 47% women) recently diagnosed with PTSD completed a survey assessing demographics, mood, functional status, and interest in treatment. Data on medical comorbidities, psychotherapy visits, antidepressant prescriptions, and service connection were assessed longitudinally through administrative files. Logistic and negative binomial regressions assessed associations between number of medical comorbidities in the 2 years before the survey and the initiation and number of psychotherapy visits for PTSD in the year after the survey. All analyses were stratified by sex and controlled for survey and administrative variables.The relationship between medical comorbidities and number of psychotherapy visits was stronger among women than among men. A greater number of medical comorbidities was associated with significantly fewer psychotherapy visits in the total sample [incidence rate ratio: 0.91; 95% confidence interval (CI): 0.83, 1.00] and among women (incidence rate ratio: 0.87; 95% CI: 0.77, 0.99), but not among men (95% CI: 0.75, 1.01). Medical comorbidities were not associated with the initiation of psychotherapy among men or women.Addressing medical comorbidities may help individuals remain in psychotherapy for PTSD. Medical comorbidities may play a larger role in the number of psychotherapy visits among women than men.

  View details for DOI 10.1097/MLR.0000000000000284

  View details for PubMedID 25767965

• Automating Identification of Multiple Chronic Conditions in Clinical Practice Guidelines. AMIA Joint Summits on Translational Science proceedings AMIA Summit on Translational Science Leung, T. I., Jalal, H., Zulman, D. M., Dumontier, M., Owens, D. K., Musen, M. A., Goldstein, M. K. 2015; 2015: 456-460

  Abstract

  Many clinical practice guidelines (CPGs) are intended to provide evidence-based guidance to clinicians on a single disease, and are frequently considered inadequate when caring for patients with multiple chronic conditions (MCC), or two or more chronic conditions. It is unclear to what degree disease-specific CPGs provide guidance about MCC. In this study, we develop a method for extracting knowledge from single-disease chronic condition CPGs to determine how frequently they mention commonly co-occurring chronic diseases. We focus on 15 highly prevalent chronic conditions. We use publicly available resources, including a repository of guideline summaries from the National Guideline Clearinghouse to build a text corpus, a data dictionary of ICD-9 codes from the Medicare Chronic Conditions Data Warehouse (CCW) to construct an initial list of disease terms, and disease synonyms from the National Center for Biomedical Ontology to enhance the list of disease terms. First, for each disease guideline, we determined the frequency of comorbid condition mentions (a disease-comorbidity pair) by exactly matching disease synonyms in the text corpus. Then, we developed an annotated reference standard using a sample subset of guidelines. We used this reference standard to evaluate our approach. Then, we compared the co-prevalence of common pairs of chronic conditions from Medicare CCW data to the frequency of disease-comorbidity pairs in CPGs. Our results show that some disease-comorbidity pairs occur more frequently in CPGs than others. Sixty-one (29.0%) of 210 possible disease-comorbidity pairs occurred zero times; for example, no guideline on chronic kidney disease mentioned depression, while heart failure guidelines mentioned ischemic heart disease the most frequently. Our method adequately identifies comorbid chronic conditions in CPG recommendations with precision 0.82, recall 0.75, and F-measure 0.78. Our work identifies knowledge currently embedded in the free text of clinical practice guideline recommendations and provides an initial view of the extent to which CPGs mention common comorbid conditions. Knowledge extracted from CPG text in this way may be useful to inform gaps in guideline recommendations regarding MCC and therefore identify potential opportunities for guideline improvement.

  View details for PubMedID 26306285

• Using a Clinical Knowledge Base to Assess Comorbidity Interrelatedness Among Patients with Multiple Chronic Conditions. AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Zulman, D. M., Martins, S. B., Liu, Y., Tu, S. W., Hoffman, B. B., Asch, S. M., Goldstein, M. K. 2015; 2015: 1381-1389

  Abstract

  Decision support tools increasingly integrate clinical knowledge such as medication indications and contraindications with electronic health record (EHR) data to support clinical care and patient safety. The availability of this encoded information and patient data provides an opportunity to develop measures of clinical decision complexity that may be of value for quality improvement and research efforts. We investigated the feasibility of using encoded clinical knowledge and EHR data to develop a measure of comorbidity interrelatedness (the degree to which patients' co-occurring conditions interact to generate clinical complexity). Using a common clinical scenario-decisions about blood pressure medications in patients with hypertension-we quantified comorbidity interrelatedness by calculating the number of indications and contraindications to blood pressure medications that are generated by patients' comorbidities (e.g., diabetes, gout, depression). We examined properties of comorbidity interrelatedness using data from a decision support system for hypertension in the Veterans Affairs Health Care System.

  View details for PubMedID 26958279

• Partnered Research in Healthcare Delivery Redesign for High-Need, High-Cost Patients: Development and Feasibility of an Intensive Management Patient-Aligned Care Team (ImPACT) JOURNAL OF GENERAL INTERNAL MEDICINE Zulman, D. M., Ezeji-Okoye, S. C., Shaw, J. G., Hummel, D. L., Holloway, K. S., Smither, S. F., Breland, J. Y., Chardos, J. F., Kirsh, S., Kahn, J. S., Asch, S. M. 2014; 29: S861-S869

  Abstract

  We employed a partnered research healthcare delivery redesign process to improve care for high-need, high-cost (HNHC) patients within the Veterans Affairs (VA) healthcare system.Health services researchers partnered with VA national and Palo Alto facility leadership and clinicians to: 1) analyze characteristics and utilization patterns of HNHC patients, 2) synthesize evidence about intensive management programs for HNHC patients, 3) conduct needs-assessment interviews with HNHC patients (n = 17) across medical, access, social, and mental health domains, 4) survey providers (n = 8) about care challenges for HNHC patients, and 5) design, implement, and evaluate a pilot Intensive Management Patient-Aligned Care Team (ImPACT) for a random sample of 150 patients.HNHC patients accounted for over half (52 %) of VA facility patient costs. Most (94 %) had three or more chronic conditions, and 60 % had a mental health diagnosis. Formative data analyses and qualitative assessments revealed a need for intensive case management, care coordination, transitions navigation, and social support and services. The ImPACT multidisciplinary team developed care processes to meet these needs, including direct access to team members (including after-hours), chronic disease management protocols, case management, and rapid interventions in response to health changes or acute service use. Two-thirds of invited patients (n = 101) enrolled in ImPACT, 87 % of whom remained actively engaged at 9 months. ImPACT is now serving as a model for a national VA intensive management demonstration project.Partnered research that incorporated population data analysis, evidence synthesis, and stakeholder needs assessments led to the successful redesign and implementation of services for HNHC patients. The rigorous design process and evaluation facilitated dissemination of the intervention within the VA healthcare system.Employing partnered research to redesign care for high-need, high-cost patients may expedite development and dissemination of high-value, cost-saving interventions.

  View details for DOI 10.1007/s11606-014-3022-7

  View details for Web of Science ID 000345410200010

  View details for PubMedCentralID PMC4239286

• Better Health, Less Spending Delivery Innovation for Ischemic Cerebrovascular Disease STROKE Kalanithi, L., Tai, W., Conley, J., Platchek, T., Zulman, D., Milstein, A. 2014; 45 (10): 3105-?

  View details for DOI 10.1161/STROKEAHA.114.006236

  View details for Web of Science ID 000342794700056

  View details for PubMedID 25123221

• Blue Button use by patients to access and share health record information using the Department of Veterans Affairs' online patient portal. Journal of the American Medical Informatics Association Turvey, C., Klein, D., Fix, G., Hogan, T. P., Woods, S., Simon, S. R., Charlton, M., Vaughan-Sarrazin, M., Zulman, D. M., Dindo, L., Wakefield, B., Graham, G., Nazi, K. 2014; 21 (4): 657-663

  Abstract

  The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs' (VA) personal health record portal, My HealtheVet.An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers.Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans' self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button.This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.

  View details for DOI 10.1136/amiajnl-2014-002723

  View details for PubMedID 24740865

• Costs Associated With Multimorbidity Among VA Patients. Medical care Yoon, J., Zulman, D., Scott, J. Y., Maciejewski, M. L. 2014; 52: S31-6

  Abstract

  Multimorbidity (the presence of multiple chronic conditions) is associated with high levels of healthcare utilization and associated costs. We investigated the association between number of chronic conditions and costs of care for nonelderly and elderly Veterans Affairs (VA) patients, and estimated mean VA healthcare costs for the most prevalent and most costly combinations of 3 conditions (triads).We identified a cohort of 5,233,994 patients who received care within the VA system in fiscal year 2010. We estimated the costs of VA care for each patient using established methods and aggregated costs for inpatient care, outpatient care, prescription drugs, and contract care. Using ICD-9 diagnosis fields from all inpatient and outpatient records, we determined the prevalence of 28 chronic conditions and all condition triads. We then compared the condition-cost gradient, most prevalent triads, and most costly triads among nonelderly (below 65 y) and elderly (65 y and above) patients.Almost one third of nonelderly and slightly more than a third of elderly VA patients had ≥3 conditions, but these patients accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both nonelderly and elderly patients was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions that were present in the most costly triads included spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. Although patients with the most costly triads had average costs that were 3 times higher than average costs among patients with ≥3 conditions, the prevalence of these costly triads was extremely low (0.1%-0.4%).Patients with multiple chronic conditions account for a disproportionate share of VA healthcare expenditures. Interventions that aim to optimize care and contain costs for multimorbid patients need to incorporate strategies specific to the most prevalent and the most costly combinations of conditions.

  View details for DOI 10.1097/MLR.0000000000000061

  View details for PubMedID 24561756

• Better Health, Less Spending: Delivery Innovation for Ischemic Cerebrovascular Disease. Stroke; a journal of cerebral circulation Kalanithi, L., Tai, W., Conley, J., Platchek, T., Zulman, D., Milstein, A. 2014

  View details for PubMedID 25123221

• Implementation and evaluation of an incentivized Internet-mediated walking program for obese adults. Translational behavioral medicine Zulman, D. M., Damschroder, L. J., Smith, R. G., Resnick, P. J., Sen, A., Krupka, E. L., Richardson, C. R. 2013; 3 (4): 357-369

  Abstract

  In response to rising health care costs associated with obesity rates, some health care insurers are adopting incentivized technology-enhanced wellness programs. The purpose of this study is to evaluate the large-scale implementation of an incentivized Internet-mediated walking program for obese adults and to examine program acceptance, adherence, and impact. A mixed-methods evaluation was conducted to investigate program implementation, acceptance, and adherence rates, and physical activity rates among program participants. Program implementation was shaped by national and state policies, data security concerns, and challenges related to incentivizing participation. Among 15,397 eligible individuals, 6,548 (43 %) elected to participate in the walking program, achieving an average of 6,523 steps/day (SD 2,610 steps). Participants who uploaded step counts for 75 % of days for a full year (n = 2,885) achieved an average of 7,500 steps (SD 3,093). Acceptance and participation rates in this incentivized Internet-mediated walking program suggest that such interventions hold promise for engaging obese adults in physical activity.

  View details for DOI 10.1007/s13142-013-0211-6

  View details for PubMedID 24294324

• Implementation and evaluation of an incentivized Internet-mediated walking program for obese adults TRANSLATIONAL BEHAVIORAL MEDICINE Zulman, D. M., Damschroder, L. J., Smith, R. G., Resnick, P. J., Sen, A., Krupka, E. L., Richardson, C. R. 2013; 3 (4): 357-369

  Abstract

  In response to rising health care costs associated with obesity rates, some health care insurers are adopting incentivized technology-enhanced wellness programs. The purpose of this study is to evaluate the large-scale implementation of an incentivized Internet-mediated walking program for obese adults and to examine program acceptance, adherence, and impact. A mixed-methods evaluation was conducted to investigate program implementation, acceptance, and adherence rates, and physical activity rates among program participants. Program implementation was shaped by national and state policies, data security concerns, and challenges related to incentivizing participation. Among 15,397 eligible individuals, 6,548 (43 %) elected to participate in the walking program, achieving an average of 6,523 steps/day (SD 2,610 steps). Participants who uploaded step counts for 75 % of days for a full year (n = 2,885) achieved an average of 7,500 steps (SD 3,093). Acceptance and participation rates in this incentivized Internet-mediated walking program suggest that such interventions hold promise for engaging obese adults in physical activity.

  View details for DOI 10.1007/s13142-013-0211-6

  View details for Web of Science ID 000209413000005

  View details for PubMedCentralID PMC3830019

• Research Priorities in Geriatric Palliative Care: Multimorbidity JOURNAL OF PALLIATIVE MEDICINE Ritchie, C. S., Zulman, D. M. 2013; 16 (8): 843-847

  Abstract

  With global aging and scientific advances extending survival, the number of adults experiencing multiple chronic conditions has grown substantially and is projected to increase by another third between 2000 and 2030. Among the many challenges posed by multimorbidity, some of the most pressing include how to characterize and measure comorbid conditions, understand symptoms and illness burden, and provide person-centered care in the context of competing health care priorities and increasing complexity. In this white paper emanating from a National Institute on Aging supported conference to discuss research gaps at the geriatrics-palliative care interface, the authors review common definitions of multimorbidity; describe the association between multimorbidity and quality of life, functional status, quality of care, and health care utilization; note content and methodological gaps in multimorbidity evidence; and make recommendations regarding research priorities in this area of expanding public health impact.

  View details for DOI 10.1089/jpm.2013.9491

  View details for Web of Science ID 000322114600012

  View details for PubMedID 23777331

  View details for PubMedCentralID PMC3717194

• Facilitating out-of-home caregiving through health information technology: survey of informal caregivers' current practices, interests, and perceived barriers. Journal of medical Internet research Zulman, D. M., Piette, J. D., Jenchura, E. C., Asch, S. M., Rosland, A. 2013; 15 (7)

  Abstract

  Many patients with chronic conditions are supported by out-of-home informal caregivers-family members, friends, and other individuals who provide care and support without pay-who, if armed with effective consumer health information technology, could inexpensively facilitate their care.We sought to understand caregivers' use of, interest in, and perceived barriers to health information technology for out-of-home caregiving.We conducted 2 sequential Web-based surveys with a national sample of individuals who provide out-of-home caregiving to an adult family member or friend with a chronic illness. We queried respondents about their use of health information technology for out-of-home caregiving and used multivariable regression to investigate caregiver and care-recipient characteristics associated with caregivers' technology use for caregiving.Among 316 out-of-home caregiver respondents, 34.5% (109/316) reported using health information technology for caregiving activities. The likelihood of a caregiver using technology increased significantly with intensity of caregiving (as measured by number of out-of-home caregiving activities). Compared with very low intensity caregivers, the adjusted odds ratio (OR) of technology use was 1.88 (95% CI 1.01-3.50) for low intensity caregivers, 2.39 (95% CI 1.11-5.15) for moderate intensity caregivers, and 3.70 (95% CI 1.62-8.45) for high intensity caregivers. Over 70% (149/207) of technology nonusers reported interest in using technology in the future to support caregiving. The most commonly cited barriers to technology use for caregiving were health system privacy rules that restrict access to care-recipients' health information and lack of familiarity with programs or websites that facilitate out-of-home caregiving.Health information technology use for out-of-home caregiving is common, especially among individuals who provide more intense caregiving. Health care systems can address the mismatch between caregivers' interest in and use of technology by modifying privacy policies that impede information exchange.

  View details for DOI 10.2196/jmir.2472

  View details for PubMedID 23841987

  View details for PubMedCentralID PMC3713893

• Cardiac Risk Is Not Associated With Hypertension Treatment Intensification AMERICAN JOURNAL OF MANAGED CARE Sussman, J. B., Zulman, D. M., Hayward, R., Hofer, T. P., Kerr, E. A. 2012; 18 (8): 414-420

  Abstract

  Considering cardiovascular (CV) risk could make clinical care more efficient and individualized, but most practice guidelines focus on single risk factors. We sought to determine if hypertension treatment intensification (TI) is more likely in patients with elevated CV risk.Prospective cohort study of 856 US veterans with diabetes and elevated blood pressure (BP).We used multilevel logistic regression to compare TI across 3 CV risk groups: those with history of heart disease, a high-risk primary prevention group (10-year event risk >20% but no history of heart disease), and those with low/ medium CV risk (10-year event risk <20%).There were no significant differences in TI rates across risk groups, with adjusted odds ratios (ORs) of 1.19 (95% confidence interval 0.77-1.84) and 1.18 (0.76-1.83) for high-risk patients and those with a history of CVD, respectively, compared with those of low/medium risk. Several individual risk factors were associated with higher rates of TI: systolic BP, mean BP in the prior year, and higher glycated hemoglobin. Self-reported home BP <140/90 mm Hg was associated with lower rates of TI. Incorporating CV risk into TI decision algorithms could prevent an estimated 38% more cardiac events without increasing the number of treated patients.While an individual's BP alters clinical decisions about TI, overall CV risk does not appear to play a role in clinical decision making. Adoption of TI decision algorithms that incorporate CV risk could substantially enhance the efficiency and clinical utility of CV preventive care.

  View details for Web of Science ID 000309036300002

  View details for PubMedID 22928756

• Access to the Medical Record ANNALS OF INTERNAL MEDICINE Zulman, D. M., Nazi, K. M., Asch, S. M., Wagner, T. H. 2012; 156 (9): 668-668

  View details for DOI 10.1059/0003-4819-156-9-201205010-00016

  View details for Web of Science ID 000303403700011

  View details for PubMedID 22547480

• The influence of diabetes psychosocial attributes and self-management practices on change in diabetes status PATIENT EDUCATION AND COUNSELING Zulman, D. M., Rosland, A., Choi, H., Langa, K. M., Heisler, M. 2012; 87 (1): 74-80

  Abstract

  To examine the influence of diabetes psychosocial attributes and self-management on glycemic control and diabetes status change.Using data from the Health and Retirement Study, a nationally representative longitudinal study of U.S. adults >51 years, we examined cross-sectional relationships among diabetes psychosocial attributes (self-efficacy, risk awareness, care understanding, prioritization of diabetes, and emotional distress), self-management ratings, and glycemic control. We then explored whether self-management ratings and psychosocial attributes in 2003 predicted change in diabetes status in 2004.In multivariate analyses (N=1834), all diabetes psychosocial attributes were associated with self-management ratings, with self-efficacy and diabetes distress having the strongest relationships (adj coeff=8.1, p<0.01 and -4.1, p<0.01, respectively). Lower self-management ratings in 2003 were associated cross-sectionally with higher hemoglobin A1C (adj coeff=0.16, p<0.01), and with perceived worsening diabetes status in 2004 (adj OR=1.36, p<0.05), with much of this latter relationship explained by diabetes distress.Psychosocial attributes, most notably diabetes-related emotional distress, contribute to difficulty with diabetes self-management, poor glycemic control, and worsening diabetes status over time.Self-management and adherence interventions should target psychosocial attributes such as disease-related emotional distress.

  View details for DOI 10.1016/j.pec.2011.07.013

  View details for Web of Science ID 000303182000013

  View details for PubMedID 21840149

• Transfer of Information from Personal Health Records: A Survey of Veterans Using My HealtheVet TELEMEDICINE AND E-HEALTH Turvey, C. L., Zulman, D. M., Nazi, K. M., Wakefield, B. J., Woods, S. S., Hogan, T. P., Weaver, F. M., McInnes, K. 2012; 18 (2): 109-114

  Abstract

  Personal health records provide patients with ownership of their health information and allow them to share information with multiple healthcare providers. However, the usefulness of these records relies on patients understanding and using their records appropriately. My HealtheVet is a Web-based patient portal containing a personal health record administered by the Veterans Health Administration. The goal of this study was to explore veterans' interest and use of My HealtheVet to transfer and share information as well as to identify opportunities to increase veteran use of the My HealtheVet functions.Two waves of data were collected in 2010 through an American Customer Satisfaction Index Web-based survey. A random sample of veterans using My HealtheVet was invited to participate in the survey conducted on the My HealtheVet portal through a Web-based pop-up browser window.Wave One results (n=25,898) found that 41% of veterans reported printing information, 21% reported saving information electronically, and only 4% ever sent information from My HealtheVet to another person. In Wave Two (n=18,471), 30% reported self-entering medication information, with 18% sharing this information with their Veterans Affairs (VA) provider and 9.6% sharing with their non-VA provider.Although veterans are transferring important medical information from their personal health records, increased education and awareness are needed to increase use. Personal health records have the potential to improve continuity of care. However, more research is needed on both the barriers to adoption as well as the actual impact on patient health outcomes and well-being.

  View details for DOI 10.1089/tmj.2011.0109

  View details for Web of Science ID 000301041200006

  View details for PubMedID 22304439

• Adapting an in-person patient-caregiver communication intervention to a tailored web-based format PSYCHO-ONCOLOGY Zulman, D. M., Schafenacker, A., Barr, K. L., Moore, I. T., Fisher, J., McCurdy, K., Derry, H. A., Saunders, E. W., An, L. C., Northouse, L. 2012; 21 (3): 336-341

  Abstract

  Interventions that target cancer patients and their caregivers have been shown to improve patient-caregiver communication, support, and emotional well-being.To adapt an in-person communication intervention for cancer patients and caregivers to a web-based format, and to examine the usability and acceptability of the web-based program among representative users.A tailored, interactive web-based communication program for cancer patients and their family caregivers was developed based on an existing in-person, nurse-delivered intervention. The development process involved: (1) building a multidisciplinary team of content and web design experts, (2) combining key components of the in-person intervention with the unique tailoring and interactive features of a web-based platform, and (3) conducting focus groups and usability testing to obtain feedback from representative program users at multiple time points. Results: Four focus groups with 2-3 patient-caregiver pairs per group (n = 22 total participants) and two iterations of usability testing with four patient-caregiver pairs per session (n = 16 total participants) were conducted. Response to the program's structure, design, and content was favorable, even among users who were older or had limited computer and Internet experience. The program received high ratings for ease of use and overall usability (mean System Usability Score of 89.5 out of 100).Many elements of a nurse-delivered patient-caregiver intervention can be successfully adapted to a web-based format. A multidisciplinary design team and an iterative evaluation process with representative users were instrumental in the development of a usable and well-received web-based program.

  View details for DOI 10.1002/pon.1900

  View details for Web of Science ID 000300987400014

  View details for PubMedID 21830255

• Trust in the Internet as a Health Resource Among Older Adults: Analysis of Data from a Nationally Representative Survey JOURNAL OF MEDICAL INTERNET RESEARCH Zulman, D. M., Kirch, M., Zheng, K., An, L. C. 2011; 13 (1): 202-211

  Abstract

  Distrust in the Internet as a source of health information remains common among older adults. The influence of this distrust on Internet use for health-related purposes, however, is unclear.The objective of our study was to explore how older adults' trust in the Internet influences their online health-related activities, and to identify potential targets for improving health-related Internet resources for older adults.Data were obtained from a nationally representative, random digit-dial telephone survey of 1450 adults 50 years of age and older in the United States. A model was developed to conceptualize the hypothesized relationships among individual characteristics, distrust, and avoidance of the Internet as a health resource. Multivariate logistic regression analyses were conducted to examine the association between trust in online health information and use of the Internet for health-related purposes. Additional multivariate logistic regression analyses were conducted to identify the key characteristics associated with trust in online health information, adding sequentially the variables hypothesized to account for distrust among older adults: sociodemographic and health characteristics, inexperience and technical difficulties with the Internet, negative feelings toward the Internet, and lack of awareness about the sources providing the health information found online.The mean (SD) age of the study population was 63.7 (10.6) years. Of the 823 (56.8%) Internet users, 628 (76.3%) reported using the Internet as a health resource. Trust in the Internet as a source of health information was associated with using the Internet for a number of health activities, including searching for information about a specific health condition (adjusted OR 4.43, P < .001), purchasing prescription drugs (adjusted OR 2.61, P = .03), and talking with a health care provider about information found online (adjusted OR 2.54, P = .002). Older adults (age ≥ 65 years) were less likely to trust the Internet as a source of health information (OR 0.63, P = .04), even after adjusting for other sociodemographic characteristics and health and function. This age effect was only slightly attenuated (adjusted OR 0.69, P = .13) after adjusting for inexperience and technical difficulties with the Internet, but it disappeared entirely (adjusted OR 0.96, P = .91) after adjusting for other hypothesized contributors to distrust (including finding the Internet confusing because it provides "too much information," and lacking awareness about the source providing health information found online).Website design features that clearly identify the source and credibility of information and minimize confusion may build trust among older adults and offer an opportunity to increase the utility of the Internet as a health resource for this population.

  View details for DOI 10.2196/jmir.1552

  View details for Web of Science ID 000287447100016

  View details for PubMedID 21324832

• Patient-Provider Concordance in the Prioritization of Health Conditions Among Hypertensive Diabetes Patients 32nd Annual National Meeting of the Society-for-General-Internal-Medicine Zulman, D. M., Kerr, E. A., Hofer, T. P., Heisler, M., Zikmund-Fisher, B. J. SPRINGER. 2010: 408–14

  Abstract

  Many patients with diabetes have multiple other chronic conditions, but little is known about whether these patients and their primary care providers agree on the relative importance that they assign these comorbidities.To understand patterns of patient-provider concordance in the prioritization of health conditions in patients with multimorbidity.Prospective cohort study of 92 primary care providers and 1,169 of their diabetic patients with elevated clinic triage blood pressure (> or = 140/90) at nine Midwest VA facilities.We constructed a patient-provider concordance score based on responses to surveys in which patients were asked to rank their most important health concerns and their providers were asked to rank the most important conditions likely to affect that patient's health outcomes. We then calculated the change in predicted probability of concordance when the patient reported having poor health status, pain or depression, or competing demands (issues that were more pressing than his health), controlling for both patient and provider characteristics.For 714 pairs (72%), providers ranked the patient's most important concern in their list of three conditions. Both patients and providers ranked diabetes and hypertension most frequently; however, providers were more likely to rank hypertension as most important (38% vs. 18%). Patients were more likely than providers to prioritize symptomatic conditions such as pain, depression, and breathing problems. The predicted probability of patient-provider concordance decreased when a patient reported having poor health status (55% vs. 64%, p < 0.01) or non-health competing demands (46% vs. 62%, p < 0.01).Patients and their primary care providers often agreed on the most important health conditions affecting patients with multimorbidity, but this concordance was lower for patients with poor health status or non-health competing demands. Interventions that increase provider awareness about symptomatic concerns and competing demands may improve chronic disease management in these vulnerable patients.

  View details for DOI 10.1007/s11606-009-1232-1

  View details for Web of Science ID 000276721900010

  View details for PubMedID 20127197

• Optimizing Statin Treatment for Primary Prevention of Coronary Artery Disease ANNALS OF INTERNAL MEDICINE Hayward, R. A., Krumholz, H. M., Zulman, D. M., Timbie, J. W., Vijan, S. 2010; 152 (2): 69-?

  Abstract

  Although treating to lipid targets ("treat to target") is widely recommended for coronary artery disease (CAD) prevention, some have advocated administering fixed doses of statins based on a person's estimated net benefit ("tailored treatment").To examine how a tailored treatment approach to statin therapy compares with a treat-to-target approach.Simulated model of population-level effects of treat-to-target and tailored treatment approaches to statin therapy.Statin trials from 1994 to 2009 and nationally representative CAD risk factor data.U.S. persons aged 30 to 75 years with no history of myocardial infarction.Lifetime effects of 5 years of treatment.Societal and patient.Tailored treatment based on a person's 5-year CAD risk (simvastatin, 40 mg, for 5% to 15% CAD risk and atorvastatin, 40 mg, for CAD risk >15%) versus treat-to-target approaches that escalate statin dose per National Cholesterol Education Program [NCEP] III guidelines (including an intensive approach that advances treatment whenever intensification is optional by NCEP III criteria).Quality-adjusted life-years (QALYs).Compared with the standard NCEP III approach, the intensive NCEP III approach treated 15 million more persons and saved 570,000 more QALYs over 5 years. The tailored strategy treated a similar number of persons, as did the intensive NCEP III approach, but saved 500,000 more QALYs and treated fewer persons with high-dose statins.No circumstances were found in which a treat-to-target approach was preferable to tailored treatment.Model assumptions were based on available clinical data, which included few persons 75 years or older.A tailored treatment strategy prevents more CAD events while treating fewer persons with high-dose statins than low-density lipoprotein cholesterol-based target approaches. Results were robust, even with assumptions favoring a treat-to-target approach.Department of Veteran Affairs Health Services Research & Development Service's Quality Enhancement Research Initiative.

  View details for Web of Science ID 000273953000001

  View details for PubMedID 20083825

• The Relative Merits of Population-Based and Targeted Prevention Strategies MILBANK QUARTERLY Zulman, D. M., Vijan, S., Omenn, G. S., Hayward, R. A. 2008; 86 (4): 557-580

  Abstract

  Preventive medicine has historically favored reducing a risk factor by a small amount in the entire population rather than by a large amount in high-risk individuals. The use of multivariable risk prediction tools, however, may affect the relative merits of this strategy.This study uses risk factor data from the National Health and Nutrition Examination Survey III to simulate a population of more than 100 million Americans aged thirty or older with no history of CV disease. Three strategies that could affect CV events, CV mortality, and quality-adjusted life years were examined: (1) a population-based strategy that treats all individuals with a low- or moderate-intensity intervention (in which the low-intensity intervention represents a public health campaign with no demonstrable adverse effects), (2) a targeted strategy that treats individuals in the top 25 percent based on a single risk factor (LDL), and (3) a risk-targeted strategy that treats individuals in the top 25 percent based on overall CV risk (as predicted by a multivariable prediction tool). The efficiency of each strategy was compared while varying the intervention's intensity and associated adverse effects, and the accuracy of the risk prediction tool.The LDL-targeted strategy and the low-intensity population-based strategy were comparable for CV events prevented over five years (0.79 million and 0.75 million, respectively), as were the risk-targeted strategy and moderate-intensity population-based strategy (1.56 million and 1.87 million, respectively). The risk-targeted strategy, however, was more efficient than the moderate-intensity population-based strategy (number needed to treat [NNT] 19 vs. 62). Incorporating a small degree of treatment-related adverse effects greatly magnified the relative advantages of the risk-targeted approach over other strategies. Reducing the accuracy of the prediction tool only modestly decreased this greater efficiency.A population-based prevention strategy can be an excellent option if an intervention has almost no adverse effects. But if the intervention has even a small degree of disutility, a targeted approach using multivariable risk prediction can prevent more morbidity and mortality while treating many fewer people.

  View details for DOI 10.1111/j.1468-0009.2008.00534.x

  View details for Web of Science ID 000261104300003

  View details for PubMedID 19120980

• UCLA mobile clinic project JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Hastings, J., Zulman, D., Wali, S. 2007; 18 (4): 744-748

  Abstract

  We report on a man seeking care at the UCLA mobile clinic, illustrating and then discussing the challenges of caring for people who are homeless (especially mental illness and potential distrust of providers). Student-run free clinics can be beneficial but further research must examine how well such clinics meet homeless patients' needs.

  View details for Web of Science ID 000252211100004

  View details for PubMedID 17982203

• State Long Term Care Ombudsman Programs: Factors associated with perceived effectiveness GERONTOLOGIST Estes, C. L., Zulman, D. M., Goldberg, S. C., Ogawa, D. D. 2004; 44 (1): 104-115

  Abstract

  This article reports findings from a nationwide study on factors associated with the perceived effectiveness of state Long Term Care Ombudsman Programs (LTCOPs).Researchers conducted telephone interviews with ombudsmen from the 50 state programs as well as from Washington, DC, and Puerto Rico. Data from the National Ombudsman Reporting System were incorporated into the study, and statistical tests analyze associations between self-rated program effectiveness and adequacy of resources, organizational placement-autonomy, interorganizational relationships, and other variables.Several factors limit the perceived effectiveness of state LTCOPs, including insufficient funding and insufficient LTCOP autonomy caused by organizational placement. Despite these problem areas, state ombudsmen report that their programs meet statutorily mandated requirements with varying degrees of effectiveness. Findings show significant positive associations between program funding and paid and volunteer staff levels and between the ratio of long-term care beds per ombudsman and the percentage of nursing facilities visited. Sufficient funding is positively associated with perceived effectiveness of work with nursing facilities.Sufficient resources, sufficient organizational autonomy, and a supportive political and social environment are key elements in achieving varying types of perceived effectiveness in the state LTCOPs. Research is needed to extend this work to local ombudsman programs and to compare self-rated effectiveness with other outcome measures.

  View details for Web of Science ID 000189164000012

  View details for PubMedID 14978326

• Visual impairment and patterns of winter seasonal depression: Seeing the light? JOURNAL OF VISUAL IMPAIRMENT & BLINDNESS Oren, D. A., Zulman, D. M., Needham, W. E., Berman, R. M., Anand, A., Charney, D. S. 2001; 95 (4): 226-229

  View details for Web of Science ID 000168073200004