Jonathan Shaw

All Publications

• COVID-19 Community Interventions Task Force: Building Bridges Between EM and Community Health Centers Rajeev, S., Wang, E., Shaw, J. G., Newberry, J. A. Society for Academic Emergency Medicine. 2021 ; SAEM Pulse (Jan-Feb 2021): 40–43

  Abstract

  Working together, the CCI Task Force created a venue for knowledge sharing and identifying community needs, which in turn increased access to testing, personal protective equipment (PPE), and evidence-based protocols, while improving connections with community resources.

• Relationship of socio-demographics, comorbidities, symptoms and healthcare access with early COVID-19 presentation and disease severity. BMC infectious diseases Vaughan, L., Veruttipong, D., Shaw, J. G., Levy, N., Edwards, L., Winget, M. 2021; 21 (1): 40

  Abstract

  COVID-19 studies are primarily from the inpatient setting, skewing towards severe disease. Race and comorbidities predict hospitalization, however, ambulatory presentation of milder COVID-19 disease and characteristics associated with progression to severe disease is not well-understood.We conducted a retrospective chart review including all COVID-19 positive cases from Stanford Health Care (SHC) in March 2020 to assess demographics, comorbidities and symptoms in relationship to: 1) their access point of testing (outpatient, inpatient, and emergency room (ER)) and 2) development of severe disease.Two hundred fifty-seven patients tested positive: 127 (49%), 96 (37%), and 34 (13%) at outpatient, ER and inpatient, respectively. Overall, 61% were age < 55; age > 75 was rarer in outpatient setting (11%) than ER (14%) or inpatient (24%). Most patients presented with cough (86%), fever/chills (76%), or fatigue (63%). 65% of inpatients reported shortness of breath compared to 30-32% of outpatients and ER patients. Ethnic/minority patients had a significantly higher risk of developing severe disease (Asian OR = 4.8 [1.6-14.2], Hispanic OR = 3.6 [1.1-11.9]). Medicare-insured patients were marginally more likely (OR = 4.0 [0.9-17.8]). Other factors associated with developing severe disease included kidney disease (OR = 6.1 [1.0-38.1]), cardiovascular disease (OR = 4.7 [1.0-22.1], shortness of breath (OR = 5.4 [2.3-12.6]) and GI symptoms (OR = 3.3 [1.4-7.7]; hypertension without concomitant CVD or kidney disease was marginally significant (OR = 2.3 [0.8-6.5]).Early widespread symptomatic testing for COVID-19 in Silicon Valley included many less severely ill patients. Thorough manual review of symptomatology reconfirms the heterogeneity of COVID-19 symptoms, and challenges in using clinical characteristics to predict decline. We re-demonstrate that socio-demographics are consistently associated with severity.

  View details for DOI 10.1186/s12879-021-05764-x

  View details for PubMedID 33421991

• Socioeconomic Differences Persist in Use of Permanent versus Long-Acting Reversible Contraception: An Analysis of the National Survey for Family Growth, 2006-2010 versus 2015-2017. Contraception Beshar, I., So, J., Chelvakumar, M., Cahill, E. P., Shaw, K. A., Shaw, J. G. 2020

  Abstract

  OBJECTIVE: Permanent contraception has historically been more prevalent among non-White women with lower education and income. Given increasing popularity of long-acting reversible contraception (LARC), we examine changing sociodemographic patterns of permanent contraception and LARC.STUDY DESIGN: We performed a descriptive analysis of the National Survey of Family Growth (NSFG) from 2006-2017, with multivariable analyses of the 2006-2010 and 2015-2017 cohorts. Using multinomial logistic regression, we investigate predictors of contraceptive category (permanent contraception versus LARC, lower-efficacy contraception versus LARC) in reproductive-aged women.RESULTS: 8,161 respondents were included in two distinct but analogous regression analyses: 1) the most recent survey cohort, 2015-2017, and 2) the cohort a decade prior, 2006-2010. Over this period, the prevalence of LARC increased nearly three-fold (6.2% to 16.7%), while permanent contraception use trended downwards (22% to 18.6%). Yet, in adjusted models, we observed little change in the sociodemographic predictors of permanent contraception: from the early to recent cohort, use of permanent contraception (versus LARC) remained less likely among college graduates (multinomial odds ratio (OR) 0.45[95% CI 0.21, 0.97]) and Hispanic women (OR 0.41[0.21, 0.82]). In addition, high income (>$74,999) and metropolitan residence came to predict less use (OR 0.33[0.13, 0.84] and 0.47[0.23, 0.97]). Multiparity, advanced age (over ≥35), and marital status remained strong predictors of permanent contraception.CONCLUSION: Although use of LARC nearly equals that of permanent contraception in the most recent NSFG survey, socioeconomic differences persist. Continued effort is needed to detect and address structural barriers to accessing the most effective forms of contraception for women.IMPLICATIONS: Comparing 2006-2010 to 2015-2017, reliance on female permanent contraception decreased while LARC use increased, making prevalence more similar. However, significant socioeconomic differences persist in who chooses permanent contraception, with urban, educated, higher-income women more likely to use LARC. Ongoing efforts are needed to understand and reduce economic barriers to LARC.

  View details for DOI 10.1016/j.contraception.2020.12.008

  View details for PubMedID 33359509

• "Racial Bias…I'm Not Sure if It Has Affected My Practice": a Qualitative Exploration of Racial Bias in Team-Based Primary Care. Journal of general internal medicine Brown-Johnson, C., Shankar, M., Taylor, N. K., Safaeinili, N., Shaw, J. G., Winget, M., Mahoney, M. 2020

  View details for DOI 10.1007/s11606-020-06219-w

  View details for PubMedID 32935312

• Building Bridges Between Community Health Centers and Academic Medical Centers in a Pandemic Journal of the American Board of Family Medicine Taylor, N. K., Aboelata, N., Mahoney, M., Seay-Morrison, T., Singh, B., Chang, S., Asch, S. M., Shaw, J. G. 2020; v34 (COVID-19 Ahead-of-Print Subject Collection)
• 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

• Long-acting Reversible Contraception (LARC) Provision by Family Physicians: Low But on the Rise. Journal of the American Board of Family Medicine : JABFM Chelvakumar, M., Jabbarpour, Y., Coffman, M., Jetty, A., Glazer Shaw, J. 2019; 32 (1): 10–12

  Abstract

  Although the fraction of family physicians (FPs) providing Long Acting Reversible Contraceptive (LARC) services increased between 2014 and 2017, the most recent estimates show that less than a quarter of family physicians include provision of LARC in their practice. Increasing the number of FPs providing LARC will help increase patients' access to the most effective forms of birth control currently available.

  View details for DOI 10.3122/jabfm.2019.01.180215

  View details for PubMedID 30610136

• Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim. American journal of medical quality : the official journal of the American College of Medical Quality Brown-Johnson, C. G., Chan, G. K., Winget, M., Shaw, J. G., Patton, K., Hussain, R., Olayiwola, J. N., Chang, S., Mahoney, M. 2018: 1062860618802365

  Abstract

  A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

  View details for PubMedID 30409021

• Deployment and Preterm Birth Among US 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; 187 (4): 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 PubMedID 29370332

• 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

• 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

• 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

• Retaining VA Women's Health Primary Care Providers: Work Setting Matters. Journal of general internal medicine Schwartz, R., Frayne, S. M., Friedman, S., Romodan, Y., Berg, E., Haskell, S. G., Shaw, J. G. 2020

  Abstract

  BACKGROUND: When an experienced provider opts to leave a healthcare workforce (attrition), there are significant costs, both direct and indirect. Turnover of healthcare providers is underreported and understudied, despite evidence that it negatively impacts care delivery and negatively impacts working conditions for remaining providers. In the Veterans Affairs (VA) healthcare system, attrition of women's health primary care providers (WH-PCPs) threatens a specially trained workforce; it is unknown what factors contribute to, or protect against, their attrition.OBJECTIVE: Based on evidence that clinic environment, adequate support resources, and workload affect provider burnout and intent to leave, we explored if such clinic characteristics predict attrition of WH-PCPs in the VA, to identify protective factors.DESIGN: This analysis drew on two waves of existing national VA survey data to examine predictors of WH-PCP attrition, via logistic regression.PARTICIPANTS: All 2,259 providers from 140 facilities VA-wide who were WH-PCPs on September 30, 2016.MAIN MEASURES: The dependent variable was WH-PCP attrition in the following year. Candidate predictors were clinic environment (working in: a comprehensive women's health center, a limited women's health clinic, a general primary care clinic, or multiple clinic environments), availability of co-located specialty support resources (mental health, social work, clinical pharmacy), provider characteristics (gender, professional degree), and clinic workload (clinic sessions per week).KEY RESULTS: Working exclusively in a comprehensive women's health center uniquely predicted significantly lower risk of WH-PCP attrition (adjusted odds ratio 0.40; CI 0.19-0.86).CONCLUSIONS: A comprehensive women's health center clinical context may promote retention of this specially trained primary care workforce. Exploring potential mechanisms-e.g., shared mission, appropriate support to meet patients' needs, or a cohesive team environment-may inform broader efforts to retain front-line providers.

  View details for DOI 10.1007/s11606-020-06285-0

  View details for PubMedID 33063204

• Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience. Neurology Yang, L., Brown-Johnson, C. G., Miller-Kuhlmann, R., Kling, S. M., Saliba-Gustafsson, E. A., Shaw, J. G., Gold, C. A., Winget, M. 2020

  Abstract

  The COVID-19 pandemic has rapidly moved telemedicine from discretionary to necessary. Here we describe how the Stanford Neurology Department: 1) rapidly adapted to the COVID-19 pandemic, resulting in over 1000 video visits within four weeks and 2) accelerated an existing quality improvement plan of a tiered roll out of video visits for ambulatory neurology to a full-scale roll out. Key issues we encountered and addressed were related to: equipment/software, provider engagement, workflow/triage, and training. Upon reflection, the key drivers of our success were provider engagement and a supportive physician champion. The physician champion played a critical role understanding stakeholder needs, including staff and physicians' needs, and creating workflows to coordinate both stakeholder groups. Prior to COVID-19, physician interest in telemedicine was mixed. However, in response to county and state stay-at-home orders related to COVID-19, physician engagement changed completely; all providers wanted to convert a majority of visits to video visits as quickly as possible. Rapid deployment of neurology video visits across all its subspecialties is feasible. Our experience and lessons learned can facilitate broader utilization, acceptance, and normalization of video visits for neurology patients in the present as well as the much anticipated post-pandemic era.

  View details for DOI 10.1212/WNL.0000000000010015

  View details for PubMedID 32611634

• Effect of Delivery Room Postpartum Contraceptive Implant Insertion on Initiation of Breastfeeding Shaw, K. A., Lerma, K., Reyes, G., Gutow, H., Shaw, J. G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 105S

  View details for Web of Science ID 000554572900366

• Sociodemographic Trends in Long Acting Reversible Contraception vs. Female Sterilization, 2006-2017 Beshar, I. B., Chelvakumar, M., So, J., Cahill, E. P., Shaw, K. A., Shaw, J. G. LIPPINCOTT WILLIAMS & WILKINS. 2020: 100S

  View details for Web of Science ID 000554572900348

• Trained and Ready, but Not Serving?-Family Physicians' Role in Reproductive Health Care. Journal of the American Board of Family Medicine : JABFM Chelvakumar, M., Shaw, J. G. 2020; 33 (2): 182–85

  View details for DOI 10.3122/jabfm.2020.02.200033

  View details for PubMedID 32179600

• CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learning health systems Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2020; 4 (1): e10201

  Abstract

  The Consolidated Framework for Implementation Research (CFIR) is a commonly used implementation science framework to facilitate design, evaluation, and implementation of evidence-based interventions. Its comprehensiveness is an asset for considering facilitators and barriers to implementation and also makes the framework cumbersome to use. We describe adaptations we made to CFIR to simplify its pragmatic application, for use in a learning health system context, in the evaluation of a complex patient-centered care transformation.We conducted a qualitative study and structured our evaluation questions, data collection methods, analysis, and reporting around CFIR. We collected qualitative data via semi-structured interviews and observations with key stakeholders throughout. We identified and documented adaptations to CFIR throughout the evaluation process.We analyzed semi-structured interviews with key stakeholders (n = 23) from clinical observations (n = 5). We made three key adaptations to CFIR: (a) promoted "patient needs and resources," a subconstruct of the outer setting, to its own domain within CFIR during data analysis; (b) divided the "inner setting" domain into three layers that account for the hierarchy of health care systems (i. pilot clinic, ii. peer clinics, and iii. overarching health care system); and (c) tailored several construct definitions to fit a patient-centered, primary care setting. Analysis yielded qualitative findings concentrated in the CFIR domains "intervention characteristics" and "outer setting," with a robust number of findings in the new domain "patient needs and resources."To make CFIR more accessible and relevant for wider use in the context of patient-centered care transformations within a learning health system, a few adaptations are key. Specifically, we found success by teasing apart interactions across the inner layers of a health system, tailoring construct definitions, and placing additional focus on patient needs.

  View details for DOI 10.1002/lrh2.10201

  View details for PubMedID 31989028

  View details for PubMedCentralID PMC6971122

• INCIDENCE OF PELVIC FLOOR DISORDERS IN US ARMY FEMALE SOLDIERS. Urology Rogo-Gupta, L. J., Nelson, D. A., Young-Lin, N., Shaw, J. G., Kurina, L. M. 2020

  Abstract

  To determine the incidence of pelvic floor disorders (PFD) among active-duty US Army female soldiers.We studied 102,015 women for incident PFD using the Stanford Military Data Repository, which comprises medical, demographic and service-related information on all soldiers on active duty in the US Army during 2011-14. Cox proportional hazards estimated adjusted associations with PFD diagnoses. In the adjusted models, military-specific characteristics and fitness were evaluated alongside known PFD predictors.Among 102,015 subjects at risk there was a cumulative incidence of 6.4% over a mean of 27 months (median 29, range 1-42). In adjusted models, obese soldiers were more likely to have a PFD compared to those of normal weight (HR 1.23, CI 1.14-1.34, p<0.001) and those with recent weight gain were more likely to have a PFD compared to those without (HR 1.32, CI 1.24-1.40, p<0.05). Women with the lowest physical fitness scores were more likely to have a PFD (HR 1.14, CI 1.04-1.25) compared to those with the highest scores.Over a median follow-up time of 29 months, 1 in 15 women in this active-duty cohort was diagnosed with a PFD. Optimizing risk factors including BMI and physical fitness may benefit the pelvic health of female soldiers, independent of age, children, and years of service.

  View details for DOI 10.1016/j.urology.2020.05.085

  View details for PubMedID 32650018

• Post-traumatic stress disorder in pregnancy: Does treatment impact the risk of preterm birth? Panelli, D. M., Chan, C., Shaw, J. G., Herrero, T., Lyell, D. J., Phibbs, C. S. MOSBY-ELSEVIER. 2020: S328

  View details for DOI 10.1016/j.ajog.2019.11.520

  View details for Web of Science ID 000504997300503

• The Stanford Lightning Report Method: A comparison of rapid qualitative synthesis results across four implementation evaluations. Learning health systems Brown-Johnson, C., Safaeinili, N., Zionts, D., Holdsworth, L. M., Shaw, J. G., Asch, S. M., Mahoney, M., Winget, M. 2020; 4 (2): e10210

  Abstract

  Current evaluation methods are mismatched with the speed of health care innovation and needs of health care delivery partners. We introduce a qualitative approach called the lightning report method and its specific product-the "Lightning Report." We compare implementation evaluation results across four projects to explore report sensitivity and the potential depth and breadth of lightning report method findings.The lightning report method was refined over 2.5 years across four projects: team-based primary care, cancer center transformation, precision health in primary care, and a national life-sustaining decisions initiative. The novelty of the lightning report method is the application of Plus/Delta/Insight debriefing to dynamic implementation evaluation. This analytic structure captures Plus ("what works"), Delta ("what needs to be changed"), and Insights (participant or evaluator insights, ideas, and recommendations). We used structured coding based on implementation science barriers and facilitators outlined in the Consolidated Framework for Implementation Research (CFIR) applied to 17 Lightning Reports from four projects.Health care partners reported that Lighting Reports were valuable, easy to understand, and they implied reports supported "corrective action" for implementations. Comparative analysis revealed cross-project emphasis on the domains of Inner Setting and Intervention Characteristics, with themes of communication, resources/staffing, feedback/reflection, alignment with simultaneous interventions and traditional care, and team cohesion. In three of the four assessed projects, the largest proportion of coding was to the clinic-level domain of Inner Setting-ranging from 39% for the cancer center project to a high of 56% for the life-sustaining decisions project.The lightning report method can fill a gap in rapid qualitative approaches and is generalizable with consistent but flexible core methods. Comparative analysis suggests it is a sensitive tool, capable of uncovering differences and insights in implementation across projects. The Lightning Report facilitates partnered evaluation and communication with stakeholders by providing real-time, actionable insights in dynamic health care implementations.

  View details for DOI 10.1002/lrh2.10210

  View details for PubMedID 32313836

  View details for PubMedCentralID PMC7156867

• 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

• Rapid implementation of video visits in neurology during COVID-19: a mixed methods evaluation. Journal of medical Internet research Saliba-Gustafsson, E. A., Miller-Kuhlmann, R., Kling, S. M., Garvert, D. W., Brown-Johnson, C. G., Lestoquoy, A. S., Verano, M. R., Yang, L., Falco-Walter, J., Shaw, J. G., Asch, S. M., Gold, C. A., Winget, M. 2020

  Abstract

  Telemedicine has been used for decades; yet, despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology's ambulatory subspecialties has been sparse. The SARS-CoV-2 (COVID-19) pandemic however, prompted healthcare systems worldwide to reconsider traditional healthcare delivery. To safeguard healthcare workers and patients many healthcare systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care.To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess the adoption, acceptability, appropriateness, and perceptions of potential sustainability.Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semi-structured interviews with providers (n=30) completed between March and May 2020.Video visits were adopted rapidly; 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted satisfaction. Video visits were reported to be more convenient for patients, families, and/or caregivers than in-person visits; however, access to technology, the patient's technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination.Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

  View details for DOI 10.2196/24328

  View details for PubMedID 33245699

• "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

• CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system LEARNING HEALTH SYSTEMS Safaeinili, N., Brown-Johnson, C., Shaw, J. G., Mahoney, M., Winget, M. 2019

  View details for DOI 10.1002/lrh2.10201

  View details for Web of Science ID 000487784900001

• Role definition is key-Rapid qualitative ethnography findings from a team-based primary care transformation. Learning health systems Brown-Johnson, C., Shaw, J. G., Safaeinili, N., Chan, G. K., Mahoney, M., Asch, S., Winget, M. 2019; 3 (3): e10188

  Abstract

  Purpose: Implementing team-based care into existing primary care is challenging; understanding facilitators and barriers to implementation is critical. We assessed adoption and acceptability of new roles in the first 6months of launching a team-based care model focused on preventive care, population health, and psychosocial support.Methods: We conducted qualitative rapid ethnography at a community-based test clinic, including 74hours of observations and 28 semi-structured interviews. We identified implementation themes related to team-based care and specifically the integration of three roles purposively designed to enhance coordination for better patient outcomes, including preventive screening and mental health: (1) medical assistants as care coordinators; (2) extended care team specialists, including clinical pharmacist and behavioral health professional; and (3) advanced practice providers (APPs)-ie, nurse practitioners and physician assistants.Results: All stakeholders (ie, patients, providers, and staff) reported positive perceptions of care coordinators and extended care specialists; these roles were well defined and quickly implemented. Care coordinators effectively managed care between visits and established strong patient relationships. Specialist colocation facilitated patient access and well-supported diabetes services and mental health care. We also observed unanticipated value: Care coordinators relayed encounter-relevant chart information to providers while scribing; extended care specialists supported informal continuing medical education. In contrast, we observed uncertain definition and expectations of the APP role across stakeholders; accordingly, adoption and acceptability of the role varied.Conclusions: Practice redesign can redistribute responsibility and patient connection throughout a team but should emphasize well-defined roles. Ethnography, conducted early in implementation with multistakeholder perspectives, can provide rapid and actionable insights about where roles may need refinement or redefinition to support ultimate physical and mental health outcomes for patients.

  View details for DOI 10.1002/lrh2.10188

  View details for PubMedID 31317071

• 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

• Improving contraceptive choice for military servicewomen: better provision serves both women and deployment planning BMJ SEXUAL & REPRODUCTIVE HEALTH Shaw, J. G., Shaw, K. A. 2019; 45 (2): 86–87

  View details for DOI 10.1136/bmjsrh-2018-200238

  View details for Web of Science ID 000471856700002

• 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

• Obstetric Outcomes in U.S. Veterans: Emerging Knowledge, Considerations, and Gaps. Seminars in reproductive medicine Hugin, M., Shaw, J. G. 2019

  Abstract

  In the post-9/11 era, the number of young women serving, and deploying, in the military grew rapidly; as they exit service, there is tremendous increase in reproductive-aged women Veterans. Here, we review the limited but growing research regarding Veterans' pregnancy and obstetric outcomes. U.S. women Veterans returning from deployment carry a high burden of physical and mental health conditions, and often trauma. As poor mental health is known to predict poorer maternal and infant sequelae, there are unique concerns around perinatal outcomes in Veterans. Accordingly, there is new attention to their reproductive risks and needs-evidenced by recent research and programmatic efforts within the VA. Emerging research suggests that the unique health profiles of pregnant Veterans, including prevalent posttraumatic stress disorder, predict increased risk of preterm birth, preeclampsia, and gestational diabetes. In the most contemporary large study, relying on California birth data, Veterans who relied on VA for their health care coverage were high risk, with increased rates of preeclampsia and Cesarean delivery. Additionally, Veterans' infants (compared with non-Veterans') were more likely to require NICU care. Additional research is needed to explore upstream factors leading to these poorer outcomes. Current effort to coordinate VA and non-VA care for Veteran mothers is warranted.

  View details for DOI 10.1055/s-0039-1692128

  View details for PubMedID 31185514

• Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Contraception Cahill, E. P., Henkel, A., Shaw, J. G., Shaw, K. A. 2019

  Abstract

  Misoprostol as an Adjunct to Overnight Osmotic Dilators Prior to Second Trimester Dilation and Evacuation: A Systematic Review and Meta-Analysis. Cahill EP, Henkel AG, Shaw JG, Shaw KA OBJECTIVE: To understand effect of adjunct misoprostol with overnight osmotic dilators for dilation and evacuation for cervical preparation after 16 weeks gestation on procedure time and dilation, complication rate, and side effects.We searched PubMed, ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, dilators and reviewed reference lists of published reports. Randomized controlled trials of cervical preparation for second trimester D&E using overnight osmotic dilators comparing adjunct misoprostol to placebo were included. Weighted mean and standard deviation (SD) and pooled binary outcomes were compared with two sample t-test or chi-square respectively.Among 84 articles identified, three met inclusion criteria of randomized controlled trials comparing adjunct misoprostol to placebo with overnight osmotic dilators prior to second trimester abortion with 457 total subjects at 16-24 weeks gestation (misoprostol n=228; placebo n=229). In the meta-analysis, misoprostol as compared to placebo did not significantly decrease mean procedure times (8.5 + 4.6 vs 9.6 + 5.8 minutes, p=0.78) or need for manual dilation (18% vs 28%, p=0.23). There was no difference in total complications (p=0.61), major complications (hemorrhage, uterine perforation, hospitalization, p=0.44), or cervical lacerations (p=0.87).Current limited evidence suggests that use of adjunctive misoprostol with osmotic dilators after 16 weeks does not affect procedure time or need for manual dilation. Further research is needed to determine if adjunctive misoprostol affects major complications and blood loss.Adjunctive misoprostol does not affect procedure time or need for manual dilation in mid to late second trimester abortion. Further research is needed to determine the effect of adjunctive misoprostol on major complications and blood loss.

  View details for DOI 10.1016/j.contraception.2019.09.005

  View details for PubMedID 31811840

• 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 PubMedID 30198185

• 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

• 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

• Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017. Seminars in reproductive medicine Katon, J. G., Zephyrin, L., Meoli, A., Hulugalle, A., Bosch, J., Callegari, L., Galvan, I. V., Gray, K. E., Haeger, K. O., Hoffmire, C., Levis, S., Ma, E. W., Mccabe, J. E., Nillni, Y. I., Pineles, S. L., Reddy, S. M., Savitz, D. A., Shaw, J. G., Patton, E. W. 2018; 36 (6): 315–22

  Abstract

  The literature on the reproductive health and healthcare of women Veterans has increased dramatically, though there are important gaps. This article aims to synthesize recent literature on reproductive health and healthcare of women Veterans. We updated a literature search to identify manuscripts published between 2008 and July 1, 2017. We excluded studies that were not original research, only included active-duty women, or had few women Veterans in their sample. Manuscripts were reviewed using a standardized abstraction form. We identified 52 manuscripts. Nearly half (48%) of the new manuscripts addressed contraception and preconception care (n = 15) or pregnancy (n = 10). The pregnancy and family planning literature showed that (1) contraceptive use and unintended pregnancy among women Veterans using VA healthcare is similar to that of the general population; (2) demand for VA maternity care is increasing; and (3) women Veterans using VA maternity care are a high-risk population for adverse pregnancy outcomes. A recurrent finding across topics was that history of lifetime sexual assault and mental health conditions were highly prevalent among women Veterans and associated with a wide variety of adverse reproductive health outcomes across the life course. The literature on women Veterans' reproductive health is rapidly expanding, but remains largely observational. Knowledge gaps persist in the areas of sexually transmitted infections, infertility, and menopause.

  View details for PubMedID 31003246

• Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4: Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution. Frayne, S. M., Phibbs, C. S., Saechao, F., Friedman, S. A., Shaw, J. G., Romodan, Y., Berg, E., Lee, J., Ananth, L., Iqbal, S., Hayes, P., Haskell, S. Women’s Health Evaluation Initiative, Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs. Washington DC. 2018

  Abstract

  https://www.womenshealth.va.gov/WOMENSHEALTH/docs/WHS_Sourcebook_Vol-IV_508c.pdf

• Contraception in US servicewomen: emerging knowledge, considerations, and needs CURRENT OPINION IN OBSTETRICS & GYNECOLOGY Harrington, L. A., Shaw, K. A., Shaw, J. G. 2017; 29 (6): 431–36

  Abstract

  We describe current literature regarding contraceptive use among women serving in the military. We explore the state of contraceptive use by female servicewomen, gaps in knowledge, special considerations, and evidence of unmet needs.Recent data on US servicewomen show that overall rates of contraceptive use remain low. Data highlight disparities and suggest barriers to contraceptive uptake persist, with contraceptive use being lower around the time of deployment. Methods that do not require daily use or prescription refills, such as long-acting reversible contraception (LARC) - intrauterine devices and contraceptive implants - may be distinctly well suited for service and deployment. Two contemporary studies document growing popularity of LARC methods among female members of the military, possibly driven by a surge in contraceptive implant use. Nonetheless, LARC appears to remain underutilized.Despite no-cost provision, the importance of preventing unplanned pregnancy, and the potential benefits of cycle control during service, emerging data about the US military suggest barriers to and underutilization of contraception, particularly LARC. Research is needed to explore preferences and tailor contraceptive counseling to servicewomen. Existing and future work can inform efforts to standardize military provider training and ensure all servicewomen are appropriately counseled and have timely access to any method they may choose.

  View details for PubMedID 28915159

• 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

• 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 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
• Adjunct mifepristone for cervical preparation prior to dilation and evacuation: a randomized trial CONTRACEPTION Shaw, K. A., Shaw, J. G., Hugin, M., Velasquez, G., Hopkins, F. W., Blumenthal, P. D. 2015; 91 (4): 313-319

  Abstract

  The objective was to investigate mifepristone as a potential adjunct to cervical preparation for surgical abortion after 19weeks of gestation, with the aim of improving procedure access, convenience and comfort.This is a site-stratified, block-randomized, noninferiority trial of 50 women undergoing surgical abortion between 19 and 23 6/7weeks of gestation randomized to receive either one set of osmotic dilators plus mifepristone the day prior to procedure (mifepristone group) or two sets of osmotic dilators (placed 18-24 h apart) in the 2 days prior to procedure (control group). All subjects received preprocedure misoprostol. Primary outcome was procedure time. Secondary outcomes included preoperative cervical dilation, ease of procedure, and side effects and pain experienced by subjects.Mean gestational age was similar between groups (20weeks); more nulliparous subjects were randomized to the mifepristone group (46% vs. 12%, p=.009). Mean procedure times were similar: mifepristone group 11:52 (SD 5:29) vs. control group 10:56 (SD 5:08); difference in means -56s, with confidence interval (95% CI -4:09 to +2:16) not exceeding the 5-min difference we a priori defined as clinically significant. Preprocedure cervical dilation did not differ and was >3cm for the majority of subjects in both groups. There was no difference (p=.6) in ease of procedure reported by providers. Preoperative (postmisoprostol) pain and postoperative pain levels were greater with mifepristone (p = 0.02 and p= 0.04 respectively). Overall subject experience was not different (p=0.80), with most reporting a "better than expected" experience.Mifepristone with one set of osmotic dilators and misoprostol did not result in longer procedure times or less cervical dilation than serial (two sets) of osmotic dilators and misoprostol, and has the potential to improve access to second trimester abortion without compromising safety.Use of mifepristone for cervical preparation before surgical abortion after 19weeks allows for fewer visits and fewer osmotic dilators without compromising cervical dilation or increasing procedure time.

  View details for DOI 10.1016/j.contraception.2014.11.014

  View details for Web of Science ID 000351190700009

  View details for PubMedID 25499589

• 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

• Mifepristone-misoprostol dosing interval and effect on induction abortion times: a systematic review. Obstetrics and gynecology Shaw, K. A., Topp, N. J., Shaw, J. G., Blumenthal, P. D. 2013; 121 (6): 1335-1347

  Abstract

  To examine the effect of the interval between mifepristone and misoprostol administration on induction time (first misoprostol dose to abortion), total procedure time (mifepristone administration to abortion), and safety and efficacy in second-trimester induction abortion (13-24 weeks).We searched MEDLINE (1966-2012), ClinicalTrials.gov, POPLINE, and the Cochrane Controlled Trials Register using search terms for second trimester, abortion, misoprostol, and mifepristone and reviewed reference lists of published reports.Our search revealed 138 articles of which 29 met inclusion criteria: 20 randomized controlled trials and nine observational studies. Studies were included if, in any study arm, mifepristone and misoprostol were used for medical abortion in the second trimester.Two authors independently reviewed the articles and abstracted the data using standardized data abstraction templates to summarize data. Discrepancies were resolved by consensus. Three studies directly compared a 1-day to 2-day mifepristone-misoprostol interval; they showed small differences in median induction times (weighted average 7.3 hours, range 7-8.5 for a 1-day interval; weighted average 6.8 hours, range 6.3-7.2 for a 2-day interval) and no significant difference in percent expelled by 12 hours or 24 hours. When all randomized studies using mifepristone and misoprostol were pooled by comparable mifepristone-misoprostol interval and misoprostol dose, induction times (first misoprostol dose to expulsion) were only 1-2 hours longer for a 12- to 24-hour interval compared with a 36-48-hour interval, whereas total abortion times (mifepristone to expulsion) were at least 18 hours longer in the 36- to 48-hour group. Induction times varied by misoprostol dosing, with 400-microgram misoprostol protocols resulting in shorter induction times than 200-microgram protocols.Shortening the mifepristone-misoprostol interval, thereby reducing total abortion time, does not compromise the safety or efficacy of second-trimester medication abortion and may be used to accommodate patient or health care provider preference.

  View details for DOI 10.1097/AOG.0b013e3182932f37

  View details for PubMedID 23812471

• 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