Jonathan Shaw

All Publications

• Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data. Health services research Shaw, J. G., Joyce, V. R., Schmitt, S. K., Frayne, S. M., Shaw, K. A., Danielsen, B., Kimerling, R., Asch, S. M., Phibbs, C. S. 2018

  Abstract

  OBJECTIVE: To describe variation in payer and outcomes in Veterans' births.DATA/SETTING: Secondary data analyses of deliveries in California, 2000-2012.STUDY DESIGN: We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.METHODS: We anonymously linked VA administrative data for all female VA enrollees with California birth records.PRINCIPAL FINDINGS: From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).CONCLUSIONS: VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

  View details for DOI 10.1111/1475-6773.13041

  View details for PubMedID 30198185

• Deployment and Preterm Birth Among United States Army Soldiers American Journal of Epidemiology Shaw, J. G., Nelson, D. A., Shaw, K. A., Woolaway-Bickel, K., Phibbs, C. S., Kurina, L. M. 2018: 687–95

  Abstract

  With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.

  View details for DOI 10.1093/aje/kwy003

  View details for PubMedCentralID PMC5889029

• 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

• Social Isolation and Medicare Spending: Among Older Adults, Objective Isolation Increases Expenditures While Loneliness Does Not Journal of Aging and Health Shaw, J. G., Farid, M., Noel-Miller, C., Joseph, N., Houser, A., Asch, S. M., Bhattacharya, J., Flowers, L. 2017; 29 (7): 1119-1143

  Abstract

  Evaluate objective isolation and loneliness' impact on Medicare spending and outcomes.We linked Health and Retirement Study data to Medicare claims to analyze objective isolation (scaled composite of social contacts and network) and loneliness (positive response to 3-item loneliness scale) as predictors of subsequent Medicare spending. In multivariable regression adjusting for health and demographics, we determined marginal differences in Medicare expenditures. Secondary outcomes included spending by setting, and mortality.Objective isolation predicts greater spending, $1,644(p<0.001) per beneficiary annually, whereas loneliness predicts reduced spending, -$768(p<0.001). Increased spending concentrated in inpatient and nursing-home (SNF) care; despite more healthcare, objectively isolated beneficiaries had 31%(p<0.001) greater risk of death. Loneliness did not predict SNF use nor mortality, but predicted slightly less inpatient and outpatient care.Objectively isolated seniors have higher Medicare spending, driven by increased hospitalization and institutionalization, and face greater mortality. Policies supporting social connectedness could reap significant savings.

  View details for DOI 10.1177/0898264317703559

  View details for PubMedCentralID PMC5847278

• THE PREVALENCE OF PELVIC FLOOR DISORDERS IN ACTIVE DUTY FEMALE SOLDIERS: DATA FROM THE STANFORD MILITARY DATA REPOSITORY Rogo-Gupta, L., Nelson, D., Young-Lin, N., Shaw, J., Kurina, L. WILEY. 2018: S567–S568

  View details for Web of Science ID 000427016100082

• Long-Acting Reversible Contraceptive Placement Among Active-Duty U.S. Army Servicewomen. Obstetrics and gynecology Erickson, A. K., Nelson, D. A., Shaw, J. G., Loftus, P. D., Kurina, L. M., Shaw, K. A. 2017; 129 (5): 800-809

  Abstract

  To quantify uptake of long-acting reversible contraceptives (LARC)-intrauterine devices (IUDs) and hormonal implants-among U.S. Army active-duty female soldiers and identify characteristics associated with uptake.This retrospective cohort study used the Stanford Military Data Repository, which includes all digitally recorded health encounters for active-duty U.S. Army soldiers from 2011 to 2014. We analyzed data from women aged 18-44 years to assess rates of LARC initiation using medical billing codes. We then evaluated predictors of LARC initiation using multivariable regression.Among 114,661 servicewomen, 14.5% received a LARC method; among those, 60% received an IUD. Intrauterine device insertions decreased over the study period (38.7-35.9 insertions per 1,000 women per year, β=0.14, 95% confidence interval [CI] -0.23 to -0.05, P<.05), whereas LARC uptake increased, driven by an increase in implant insertions (20.3-35.4/1,000 women per year, β=0.41, CI 0.33-0.48, P<.001). Younger age was a positive predictor of LARC uptake: 32.4% of IUD users and 62.6% of implant users were in the youngest age category (18-22 years) compared with 9.6% and 2.0% in the oldest (36-44 years). The likelihood of uptake among the youngest women (compared with oldest) was most marked for implants (adjusted relative risk 7.12, CI 5.92-8.55; P<.001). A total of 26.2% of IUD users had one child compared with 13.2% among non-LARC users (adjusted relative risk 1.94, CI 1.85-2.04, P<.001). The majority (52.2%) of those initiating IUDs were married, which was predictive of uptake over never-married women (adjusted relative risk 1.52, CI 1.44-1.59, P<.001).Among servicewomen, we observed low but rising rates of LARC insertion, driven by increasing implant use. Unmarried and childless soldiers were less likely to initiate LARC. These findings are consistent with potential underutilization and a need for education about LARC safety and reversibility in a population facing unique consequences for unintended pregnancies.

  View details for DOI 10.1097/AOG.0000000000001971

  View details for PubMedID 28383371

• Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, J. G., Asch, S. M., Katon, J. G., Shaw, K. A., Kimerling, R., Frayne, S. M., Phibbs, C. S. 2017; 31 (3): 185-194

  Abstract

  Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy.This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery).Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery.The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

  View details for DOI 10.1111/ppe.12349

  View details for Web of Science ID 000400170000004

  View details for PubMedID 28328031

• Interpretation of epidemiologic studies very often lacked adequate consideration of confounding. Journal of clinical epidemiology Hemkens, L. G., Ewald, H., Naudet, F., Ladanie, A., Shaw, J. G., Sajeev, G., Ioannidis, J. P. 2017

  Abstract

  Confounding bias is a most pervasive threat to validity of observational epidemiologic research. We assessed whether authors of observational epidemiologic studies consider confounding bias when interpreting the findings.We randomly selected 120 cohort or case-control studies published in 2011 and 2012 by the general medical, epidemiologic, and specialty journals with the highest impact factors. We used Web of Science to assess citation metrics through January 2017.Sixty-eight studies (56.7%, 95% confidence interval: 47.8-65.5%) mentioned "confounding" in the Abstract or Discussion sections, another 20 (16.7%; 10.0-23.3%) alluded to it, and there was no mention or allusion at all in 32 studies (26.7%; 18.8-34.6%). Authors often acknowledged that for specific confounders, there was no adjustment (34 studies; 28.3%) or deem it possible or likely that confounding affected their main findings (29 studies; 24.2%). However, only two studies (1.7%; 0-4.0%) specifically used the words "caution" or "cautious" for the interpretation because of confounding-related reasons and eventually only four studies (3.3%; 0.1-6.5%) had limitations related to confounding or any other bias in their Conclusions. Studies mentioning that the findings were possibly or likely affected by confounding were more frequently cited than studies with a statement that findings were unlikely affected (median 6.3 vs. 4.0 citations per year, P = 0.04).Many observational studies lack satisfactory discussion of confounding bias. Even when confounding bias is mentioned, authors are typically confident that it is rather irrelevant to their findings and they rarely call for cautious interpretation. More careful acknowledgment of possible impact of confounding is not associated with lower citation impact.

  View details for DOI 10.1016/j.jclinepi.2017.09.013

  View details for PubMedID 28943377

• Medicare Spends More on Socially Isolated Older Adults Flowers, L., Houser, A., Noel-Miller, C., Shaw, J., Bhattacharya, J., Schoemaker, L., Farid, M. AARP Public Policy Institute. Washington, DC. 2017 ; Insight on the Issues (125): 1–15
• Contraception in US servicewomen: emerging knowledge, considerations, and needs Current Opinion in Obstetrics and Gynecology Harrington, L. A., Shaw, K. A., Shaw, J. G. 2017; 29 (6): 431–436
• Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth OBSTETRICS AND GYNECOLOGY Shaw, J. G., Asch, S. M., Kimerling, R., Frayne, S. M., Shaw, K. A., Phibbs, C. S. 2014; 124 (6): 1111-1119

  Abstract

  To evaluate the association between antenatal posttraumatic stress disorder (PTSD) and spontaneous preterm delivery.We identified antenatal PTSD status and spontaneous preterm delivery in a retrospective cohort of 16,334 deliveries covered by the Veterans Health Administration from 2000 to 2012. We divided mothers with PTSD into those with diagnoses present the year before delivery (active PTSD) and those only with earlier diagnoses (historical PTSD). We identified spontaneous preterm birth and potential confounders including age, race, military deployment, twins, hypertension, substance use, depression, and results of military sexual trauma screening and then performed multivariate regression to estimate adjusted odds ratio (OR) of spontaneous preterm delivery as a function of PTSD status.Of 16,334 births, 3,049 (19%) were to mothers with PTSD diagnoses, of whom 1,921 (12%) had active PTSD. Spontaneous preterm delivery was higher in those with active PTSD (9.2%, n=176) than those with historical (8.0%, n=90) or no PTSD (7.4%, n=982) before adjustment (P=.02). The association between PTSD and preterm birth persisted, when adjusting for covariates, only in those with active PTSD (adjusted OR 1.35, 95% confidence interval [CI] 1.14-1.61). Analyses adjusting for comorbid psychiatric and medical diagnoses revealed the association with active PTSD to be robust.In this cohort, containing an unprecedented number of PTSD-affected pregnancies, mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries (95% CI 1-4). Posttraumatic stress disorder's health effects may extend, through birth outcomes, into the next generation.

  View details for DOI 10.1097/AOG.0000000000000542

  View details for Web of Science ID 000345341100008

• 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

• Gestational Diabetes and Hypertensive Disorders of Pregnancy Among Women Veterans Deployed in Service of Operations in Afghanistan and Iraq JOURNAL OF WOMENS HEALTH Katon, J., Mattocks, K., Zephyrin, L., Reiber, G., Yano, E. M., Callegari, L., Schwarz, E. B., Goulet, J., Shaw, J., Brandt, C., Haskell, S. 2014; 23 (10): 792-800

  View details for DOI 10.1089/jwh.2013.4681

  View details for Web of Science ID 000343237900005

• To sling or not to sling at time of abdominal sacrocolpopexy: a cost-effectiveness analysis. journal of urology Richardson, M. L., Elliott, C. S., Shaw, J. G., Comiter, C. V., Chen, B., Sokol, E. R. 2013; 190 (4): 1306-1312

  Abstract

  OBJECTIVES: To compare the cost-effectiveness of three strategies for use of a mid-urethral sling (MUS) to prevent occult stress urinary incontinence (SUI) in those undergoing abdominal sacrocolpopexy (ASC). METHODS: Using decision-analysis modeling, we compared cost-effectiveness over a 1 year post-operative time period of three treatment approaches: 1) ASC alone with deferred option for MUS; 2) ASC with universal concomitant MUS; and 3) preoperative urodynamic study (UDS) for selective MUS. Using published data, we modeled probabilities of SUI after ASC with or without MUS, the predictive value of UDS to detect occult SUI, and the likelihood of complications after MUS. Costs were derived from Medicare 2010 reimbursement rates. The main outcome modeled was incremental cost effectiveness ratio (ICER) per quality-adjusted life years (QALY) gained. In addition to base-case analysis, one-way sensitivity analyses were performed. RESULTS: In our model, universally performing MUS at the time of ASC was the most cost-effective approach, with an incremental cost per QALY gained of $2867 when compared to performing ASC alone. Preoperative UDS was more costly and less effective than universally performing intraoperative MUS. The cost-effectiveness of ASC + MUS was robust to sensitivity analysis, with a cost-effectiveness ratio consistently below $20,000 per QALY. CONCLUSIONS: Universal concomitant MUS is the most cost-effective prophylaxis strategy for occult SUI in women undergoing ASC. The use of pre-operative UDS to guide MUS placement at the time of ASC is not cost-effective.

  View details for DOI 10.1016/j.juro.2013.03.046

  View details for PubMedID 23524201

• Attitudes of preclinical and clinical medical students toward interactions with the pharmaceutical industry ACADEMIC MEDICINE Hyman, P. L., Hochman, M. E., Shaw, J. G., Steinman, M. A. 2007; 82 (1): 94-99

  Abstract

  Medical school is a critical time for physicians in training to learn the professional norms of interacting with the pharmaceutical industry, yet little is known about how students' attitudes vary during the course of training. This study sought to determine students' opinions about pharmaceutical industry interactions with medical students and whether these opinions differ between preclinical and clinical students.The authors surveyed medical students at Harvard Medical School (HMS) from November 2003 through January 2004 using a six-question survey. The authors then analyzed how responses differed among the classes.Out of 723 questionnaires, 418 were returned--an overall response rate of 58%. A total of 107 (26%) students believed that it is appropriate for medical students to accept gifts from pharmaceutical companies, and 76 (18%) agreed that the medical school curriculum should include events sponsored by the pharmaceutical industry. Many students--253 (61%)--reported that they do not feel adequately educated about pharmaceutical industry-medical professionals' interactions. Preclinical and clinical students had similar opinions for the majority of their responses. Finally, students who reported feeling better educated about pharmaceutical industry interactions tended to be less skeptical of the industry and more likely to view interactions with the industry as appropriate.Students' opinions about interactions with the pharmaceutical industry were similar between preclinical and clinical students, suggesting that the current medical school experience may have limited impact on students' views about interactions with the pharmaceutical industry.

  View details for Web of Science ID 000243237200013

  View details for PubMedID 17198299